The effect of cyproheptadine hydrochloride (periactin) and megestrol acetate (megace) on weight in children with cancer/treatment-related cachexia

Spectroscopic Screening of Dexamethasone and Cyproheptadine Adulteration in Weight Gaining Products Marketed in Aden, Yemen

Background

Weight-gaining (WG) products are either medicine or herbal products that have been used intensively by the young and adolescents in Yemen. These products may contain undeclared potentially toxic ingredients that can lead to several health problems and diseases on long-term usage. This study was intended to evaluate the presence of some undeclared pharmaceuticals, dexamethasone (DX) and cyproheptadine (CPR), in WG products in Aden, Yemen.

Methods

The detection of DX & CPR in WG products was evaluated using UV& Fourier transform infrared (FT-IR) spectroscopy. Also, phytochemical analysis was carried out for herbal products.

Findings

The study indicated the presence of CPR in Tab-II, honey mixture, and capsules in the range between 0.10%-102.6%. A lower percentage was detected in the honey mixture and a higher percentage in Tab-2. DX was only detected in Tab-I (102.87%).

Conclusion

It can be concluded that WG products may contain undeclared amounts of DX and CPR. Stricter regulations must be implemented for the usage and distribution of these products to avoid potential long-term adverse consequences.

Electrical Stimulation of Acupuncture Points Helps Resolve a Child's Failure to Thrive

Background

Failure to thrive (FTT) is a challenging childhood condition that may lead to developmental delays and requires immediate therapeutic strategies. Children are diagnosed with FTT when their weight or rate of weight gain is significantly below that of other children of similar age and sex. A Pub Med literature search revealed no published acupuncture treatments for failure to thrive or faltering growth.

Case

A 2 year, 4 month-old female was presented with FTT and a history of multiple severe congenital medical conditions. Western medical treatment with optimization of tube feeds achieved weight scores in the third-to-fifth percentile range. Acupuncture points were electrically stimulated for the child once monthly for 30 seconds with a Pointer Plus™ at each of 12 traditional Chinese/Shu Mu points and at several auricular points: Appetite, Stomach, Small Intestine, and Large Intestine bilateral.

Results

The patient gained weight during the treatment, increasing monthly as shown on fully naked weight measurements to the 25th percentile, 28th percentile, 32nd percentile, 40th percentile, 46th percentile, 61st percentile, and 65th percentile. Her treatment was spaced to every 2.5 months after the 46th percentile measurement, and her weight started to level off when it reached the 61st percentile.

Conclusions

In this particular case, electroacupuncture (EA) stimulation may have facilitated a weight gain in this female child. EA (nonneedle) research should be explored for FTT.

Avoidant restrictive food intake disorder and pediatric feeding disorder: the pediatric gastroenterology perspective

PURPOSE OF REVIEW

Avoidant/restrictive food intake disorder (ARFID) and pediatric feeding disorder (PFD) are the newest evolutions of frameworks for dysfunctional feeding and share overlapping features but maintain notable differences. This review will compare the two frameworks, highlighting some of the latest advances in diagnosis and management.

RECENT FINDINGS

Dysfunctional feeding, particularly withing the PFD definition, benefits from multidisciplinary care with equal attention to medical, nutritional, skill-based, and behavioral domains. Management requires medical attention, often with functional gastrointestinal disease and anxiety. Pharmacologic appetite stimulation may play a role. A single empirically proved behavioral approach has not been described and multiple options exist regarding type, location, and intensity of feeding therapy.

SUMMARY

ARFID and PFD not only share areas of overlap, but also differ, likely based on the origins of each framework. Ultimately, both frameworks describe dysfunctional feeding and require input from medical providers. The more effective approaches tend to be multidisciplinary, addressing medical, nutritional, skill-based, and/or behavioral aspects of the disorder (the PFD model). Future evolution of both ARFID and PFD frameworks is likely to generate refinement in their defining criteria, hopefully generating a structured link between the two.

Children's Oncology Group's 2023 blueprint for research: Cancer control and supportive care

The objective of the Cancer Control and Supportive Care (CCL) Committee in the Children's Oncology Group (COG) is to reduce the overall morbidity and mortality of therapy-related toxicities in children, adolescents, and young adults with cancer. We have targeted five major domains that cause clinically important toxicity: (i) infections and inflammation; (ii) malnutrition and metabolic dysfunction; (iii) chemotherapy-induced nausea and vomiting; (iv) neuro- and oto-toxicty; and (v) patient-reported outcomes and health-related quality of life. Subcommittees for each domain prioritize randomized controlled trials and biology aims to determine which strategies best mitigate the toxicities. The findings of these trials are impactful, informing clinical practice guidelines (CPGs) and directly leading to changes in the standard of care for oncology practice. With the development of new therapies, there will be new toxicities, and the COG CCL Committee is dedicated to developing interventions to minimize acute and delayed toxicities, lessen morbidity and mortality, and improve quality of life in pediatric and young adult patients with cancer.

The effect of oral nutrition supplements and appetite stimulants on weight status among pediatric cancer patients: A systematic review

The objective of this study was to identify the use and impact of oral nutrition supplements (ONSs) and appetite stimulants on weight status among pediatric patients diagnosed with malignancy. We performed a literature search of trials using Medline PubMed, CINAHL, Web of Science Core Collection, Scopus, and Cochrane Database of Systematic Reviews and included all prospective studies except review articles and case-reports/series that assessed ONSs or appetite stimulants among patients (0-20 years old) diagnosed with a pediatric malignancy. Databases were searched through May 17, 2022. There were six trials included with three studies related to ONS and the remaining on appetite stimulants. No studies that compared both ONS and appetite stimulants were found. To assess quality, we used the Risk of Bias in Nonrandomized Studies of Interventions and the Revised Cochrane Risk of Bias Tool for Randomized Trials depending on the study design. The studies all had pediatric patients diagnosed with a variety of malignancy types. All studies demonstrated improvement of weight status in the treatment group across various malignancy types. However, none of the studies addressed nutrition intakes outside of ONS consumption, compliance to ONSs, or frequency of ONS use. Despite the short durations (3-6 months) and significant differences in the timing of intervention initiation (ONS or appetite stimulants), these treatment modalities can improve weight status. Further research is needed to identify the best intervention for improving weight status.

Cyproheptadine hydrochloride inhibits African swine fever viral replication in vitro

African swine fever (ASF) is an infectious disease caused by the African swine fever virus (ASFV), and has a high mortality rate. It has caused serious socioeconomic consequences worldwide. Currently, there are no available commercial vaccines or antiviral drug interventions. D1133L is one of the key genes for ASFV replication and antiviral drug screening. In this study, a virtual screening software program, PyRx, was used to screen libraries of compounds against the potential drug target D1133L. Twelve compounds with a high affinity for ASFV D1133L were screened, and cyproheptadine hydrochloride (periactin) was identified as a candidate drug. The periactin has little cytotoxicity, and which dose-dependently inhibited ASFV replication in vitro. Further research indicated that periactin could significantly down-regulate D1133L at the transcriptional and protein levels with RT-qPCR and western blot methods. This study has provided important candidate drugs for the prevention and treatment of ASF, as well as biological materials and new fields of view for the research and development of vaccines and drugs for ASFV.

Malnutrition screening and treatment in pediatric oncology: a scoping review

BACKGROUND

Malnutrition and cachexia during pediatric cancer treatment worsen toxicity and quality-of-life. Clinical practice varies with lack of standard malnutrition definition and nutrition interventions. This scoping review highlights available malnutrition screening and intervention data in childhood cancer and the need for standardizing assessment and treatment.

METHODS

Ovid Medline, CINAHL, and Cochrane Library were searched for studies containing malnutrition as the primary outcome with anthropometric, radiographic, or biochemical measurements. Secondary outcomes included validated nutritional assessment or screening tools. Two authors reviewed full manuscripts for inclusion. Narrative analysis was chosen over statistical analysis due to study heterogeneity.

RESULTS

The search yielded 234 articles and 17 articles identified from reference searching. Nine met inclusion criteria with six nutritional intervention studies (examining appetite stimulants, nutrition supplementation, and proactive feeding tubes) and three nutritional screening studies (algorithms or nutrition support teams) each with variable measures and outcomes. Both laboratory evaluations (albumin, prealbumin, total protein) and body measurement (weight loss, mid-upper arm circumference) were used. Studies demonstrated improved weight, without difference between formula or appetite stimulant used. Screening studies yielded mixed results on preventing weight loss, weight gain, and survival.

CONCLUSION

Our review demonstrated a paucity of evidence for malnutrition screening and intervention in pediatric cancer treatment. While a variety of malnutrition outcomes, interventions, and screening tools exist, nutritional interventions increased weight and decreased complications. Screening tools decreased malnutrition risk and may improve weight gain. Potential age- and disease-specific nutritional benefits and toxicities also exist, further highlighting the benefit of standardizing malnutrition definitions, screening, and interventions.

Targeting cancer cachexia: Molecular mechanisms and clinical study

Cancer cachexia is a complex systemic catabolism syndrome characterized by muscle wasting. It affects multiple distant organs and their crosstalk with cancer constitute cancer cachexia environment. During the occurrence and progression of cancer cachexia, interactions of aberrant organs with cancer cells or other organs in a cancer cachexia environment initiate a cascade of stress reactions and destroy multiple organs including the liver, heart, pancreas, intestine, brain, bone, and spleen in metabolism, neural, and immune homeostasis. The role of involved organs turned from inhibiting tumor growth into promoting cancer cachexia in cancer progression. In this review, we depicted the complicated relationship of cancer cachexia with the metabolism, neural, and immune homeostasis imbalance in multiple organs in a cancer cachexia environment and summarized the treatment progress in recent years. And we discussed the molecular mechanism and clinical study of cancer cachexia from the perspective of multiple organs metabolic, neurological, and immunological abnormalities. Updated understanding of cancer cachexia might facilitate the exploration of biomarkers and novel therapeutic targets of cancer cachexia.

A Systematic Review and Meta-Analysis of the Clinical Use of Megestrol Acetate for Cancer-Related Anorexia/Cachexia

Cancer-related anorexia/cachexia is known to be associated with worsened quality of life and survival; however, limited treatment options exist. Although megestrol acetate (MA) is often used off-label to stimulate appetite and improve anorexia/cachexia in patients with advanced cancers, the benefits are controversial. The present meta-analysis aimed to better elucidate the clinical benefits of MA in patients with cancer-related anorexia/cachexia. A systematic search of PubMed, EMBASE, OVID Medline, Clinicaltrials.gov, and Google Scholar databases found 23 clinical trials examining the use of MA in cancer-related anorexia. The available randomized, controlled trials were appraised using Version 2 of the Cochrane risk-of-bias tool (RoB 2) and they had moderate-to-high risk of bias. A total of eight studies provided sufficient data on weight change for meta-analysis. The studies were divided into high-dose treatment (>320 mg/day) and low-dose treatment (≤320 mg/day). The overall pooled mean change in weight among cancer patients treated with MA, regardless of dosage was 0.75 kg (95% CI = −1.64 to 3.15, τ2 = 9.35, I2 = 96%). Patients who received high-dose MA tended to have weight loss rather than weight gain. There were insufficient studies to perform a meta-analysis for the change in tricep skinfold, midarm circumference, or quality of life measures. MA was generally well-tolerated, except for a clear thromboembolic risk, especially with higher doses. On balance, MA did not appear to be effective in providing the symptomatic improvement of anorexia/cachexia in patients with advanced cancer.

When Reality and Research Collide: Guidelines Are Essential for Optimal Nutrition Care in Pediatric Oncology

Nutritional problems are common in pediatric oncology due to the side effects of the disease and treatment. Nutrition intervention can be challenging, and little is known about the current clinical practice of registered dietitian nutritionists. An online questionnaire emailed to members of the pediatric, oncology nutrition, and clinical manager practice groups of the Academy of Nutrition and Dietetics, consisted of items related to current nutrition practice. Our questionnaire results suggest that the field of pediatric oncology is employed with relatively new dietitians (62% had <5 y of experience). Many registered dietitian nutritionists (60%) are providing care across the cancer care continuum (standard therapy, transplant, and survivorship) versus specializing in a particular area. Approximately half (52%) felt that their center had inadequate staffing, many reporting little in the outpatient setting. Barriers to providing optimal patient care included inadequate staffing, lack of time for research initiatives, and lack of evidence-based guidelines. Future studies should determine follow-up guidelines and appropriate staffing ratios for nutrition care in pediatric oncology. Approaches should be developed to support less experienced dietitians. Collaboration between dietitians at different facilities will likely be key in developing essential evidence-informed guidelines.

Efficacy and Tolerability of Cyproheptadine in Poor Appetite: A Multicenter, Randomized, Double-blind, Placebo-controlled Study

PURPOSE

Cyproheptadine, an antihistamine and antiserotonergic agent, is an appetite stimulant that is efficacious in promoting weight gain in children and adults with poor appetite. Despite numerous studies showing that cyproheptadine achieved positive outcomes, studies documenting its effectiveness on appetite are limited. This study evaluated the efficacy and tolerability of cyproheptadine in adults with poor appetite in South Korea.

METHODS

Patients aged 19 to 64 years with poor appetite were randomly assigned to receive either cyproheptadine or placebo for 8 weeks. The primary end point was the difference between the groups in change in appetite, as measured by the Korean version of the Edmonton Symptom Assessment System from the beginning to the end of the study period. The secondary end points included effects on weight, anthropometrics, body composition, Simplified Nutritional Appetite Questionnaire-measured appetite, and toxicities. A total of 375 patients were randomly assigned to the two groups (189 cyproheptadine, 186 placebo).

FINDINGS

The cyproheptadine group experienced a mean (SD) change in appetite score of -2.42 (0.12) compared with -2.03 (0.13) in the placebo arm, representing a statistically significant appetite gain in the cyproheptadine group (difference, +0.38 [0.18]; 95% CI, -0.73 to -0.04; P = 0.0307). Patients in the cyproheptadine group experienced significant increases in weight and body mass index. The most common adverse event was somnolence, as predicted. Cyproheptadine was well tolerated, with one serious adverse event (colitis) which was classified as a moderate adverse effect unlikely to be related to the study drug.

IMPLICATIONS

We present the largest randomized, double-blind, placebo-controlled clinical trial of cyproheptadine versus placebo in healthy adults with poor appetite using the lowest effective dosage of cyproheptadine. Cyproheptadine is a safe treatment option in patients with poor appetite. Our findings provide important information for the use of cyproheptadine to ameliorate poor appetite in adults. Further randomized studies focused on the effect of cyproheptadine in older populations are needed.

Recent advances and new discoveries in the pipeline of the treatment of primary spinal tumors and spinal metastases: A scoping review

The field of spinal oncology has substantially evolved over the past decades. This review synthesizes and appraises what was learned and what will potentially be discovered from the recently completed and ongoing clinical studies related to the treatment of primary and secondary spinal neoplasms. This scoping review included all clinical studies on the treatment of spinal neoplasms registered in the ClinicalTrials.gov website from February/2000 to December/2020. The terms "spinal cord tumor", "spinal metastasis", and "metastatic spinal cord compression" were used. Of the 174 registered clinical studies on primary spinal tumors and spinal metastasis, most of the clinical studies registered in this American registry were interventional studies led by single institutions in North America (n=101), Europe (n=43), Asia (n=24) or other continents (n=6). The registered clinical studies mainly focused on treatment strategies for spinal neoplasms (90.2%) that included investigating stereotactic radiosurgery (n=33), radiotherapy (n=21), chemotherapy (n=20), and surgical technique (n=11). Of the 69 completed studies, the results from 44 studies were published in the literature. In conclusion, this review highlights the key features of the 174 clinical studies on spinal neoplasms that were registered from 2000 to 2020. Clinical trials were heavily skewed towards the metastatic population as opposed to the primary tumours which likely reflects the rarity of the latter condition and associated challenges in undertaking prospective clinical studies in this population. This review serves to emphasize the need for a focused approach to enhancing translational research in spinal neoplasms with a particular emphasis on primary tumors.

Cyproheptadine as an appetite stimulant in children with cystic fibrosis

BACKGROUND

Cystic fibrosis (CF) is a multi-organ genetically inherited disease that leads to progressive lung disease and nutrient malabsorption. The aim of this study was to assess the effectiveness of cyproheptadine (CH) (Periactin®) as an appetite stimulant on improving the nutrition status of paediatric patients with CF.

METHODS

We conducted a retrospective study of 15 patients with a suboptimal nutrition status prescribed CH for ≥12 months from 2013 to 2018. Change in Body Mass Index (BMI) z-score and lung function before vs. after treatment with CH were measured as well as dose-response relationship.

RESULTS

The mean change in BMI z-score over 12 months of treatment with CH was +0.91 compared to -0.52 in the previous 12 months (p∗∗∗ = 0.0002). There was also a trend towards an improvement in lung function over the 12 months of CH treatment compared to the 12 months prior (+2.79 vs -6.2% (p = 0.07)). No dose-response relationship was observed.

CONCLUSION

These results suggest that CH is effective at improving the nutrition status of paediatric CF patients with suboptimal nutrition.

iKanEat: protocol for a randomized controlled trial of megestrol as a component of a pediatric tube weaning protocol

Background

Although tube feeding routinely saves the lives of children who do not eat by mouth, chronic tube feeding can be a burden to patients, caregivers, and families. Very few randomized trials exist regarding the best methods for weaning children from their feeding tubes.

Methods

The current paper describes a randomized controlled trial of an empirically supported outpatient treatment protocol for moving children from tube to oral eating called iKanEat. Specifically, we describe the methods of randomized double-blind, placebo-controlled trial which includes a 4-week course of megestrol, the only medication used in the iKanEat protocol, to determine whether the addition of megestrol results in improved child outcomes. The primary and secondary aims are to assess the safety and efficacy of megestrol as part of the iKanEat protocol. The third aim is to provide critical information about the impact of the transition from tube to oral feeding on parent stress and parent and child quality of life.

Discussion

This trial will provide data regarding whether megestrol is a safe and effective component of the iKanEat tube weaning protocol, as well as important data on how the tube weaning process impacts parent stress and parent and child quality of life.

Trial registration

ClinicalTrials.gov NCT#03815019. Registered on January 17, 2019

Gastrointestinal Symptoms in Children With Life-Limiting Conditions Receiving Palliative Home Care

Context: Children with life-limiting diseases suffer from gastrointestinal (GI) symptoms. Since the introduction of specialized palliative home care (SPHC) in Germany, it is possible to care for these children at home. In phase 1 of care the aim is to stabilize the patient. In phase 2, terminal support is provided. Objectives: Analysis were performed of the differences between these phases. The causes and modalities/outcome of treatment were evaluated. Methods: A retrospective study was performed from 2014 to 2020. All home visits were analyzed with regard to the abovementioned symptoms, their causes, treatment and results. Results: In total, 149 children were included (45.9% female, mean age 8.17 ± 7.67 years), and 126 patients were evaluated. GI symptoms were common in both phases. Vomiting was more common in phase 2 (59.3 vs. 27.1%; p < 0.001). After therapy, the proportion of asymptomatic children in phase 1 increased from 40.1 to 75.7%; (p < 0.001). Constipation was present in 52.3% (phase 1) and 54.1% (phase 2). After treatment, the proportion of asymptomatic patients increased from 47.3 to 75.7% in phase 1 (p < 0.001), and grade 3 constipation was reduced from 33.9 to 15% in phase 2 (p < 0.05). Conclusion: Painful GI symptoms occur in both palliative care phases but are more common in phase 2. The severity and frequency can usually be controlled at home. The study limitations were the retrospective design and small number of patients, but the study had a representative population, good data quality and a unique perspective on the reality of outpatient pediatric palliative care in Germany.

Safety of Cyproheptadine, an Orexigenic Drug. Analysis of the French National Pharmacovigilance Data-Base and Systematic Review

Objectives: Cyproheptadine is a first-generation H1-antihistamine drug first that was distributed in the 1960s. While its orexigenic effect was observed early, cyproheptadine is not yet authorized for this indication in all countries today. There is an increasing medical interest and demand for the orexigenic effect of cyproheptadine, especially in children with poor appetite. As cyproheptadine might be evaluated in future clinical trials, we wanted to assess its safety profile. Methods: Using the French national pharmacovigilance database, we retrospectively analyzed all pediatric and adult reports of adverse effects of cyproheptadine recorded since its first distribution in France. Next, we performed a systematic review of the literature of cyproheptadine adverse effects. Results: Since 1985, 93 adverse effects were reported in the French pharmacovigilance database (adults 81.7%, children 18.3%); these were mainly neurological symptoms (n = 38, adults 71%, children 28.9%), and hepatic complications (n = 15, adults 86.7%, children 13.3%). In the literature, the most frequent adverse effect reported was drowsiness in adults or children, and five case reports noted liver complications in adults. We estimated the frequency of hepatic adverse effects at 0.27 to 1.4/1000, regardless of age. Conclusion: Cyproheptadine can be considered a safe drug. Mild neurological effects appear to be frequent, and hepatotoxicity is uncommon to rare. Randomized controlled trials are needed to evaluate the safety and efficacy of cyproheptadine before authorization for appetite stimulation, especially in young children as studies at this age are lacking. Possible hepatic complications should be monitored, as very rare cases of liver failure have been reported.

The Paradoxical Effect of PARP Inhibitor BGP-15 on Irinotecan-Induced Cachexia and Skeletal Muscle Dysfunction

Simple Summary

Both cancer and the chemotherapy used to treat it are drivers of cachexia, a life-threatening body-wasting condition which complicates cancer treatment. Poly-(ADP-ribose) polymerase (PARP) inhibitors are currently being investigated as a treatment against cancer. Here, we present paradoxical evidence that they might also be useful for mitigating the skeletal muscle specific side-effects of anti-cancer chemotherapy or exacerbate them. BGP-15 is a small molecule PARP inhibitor which protected against irinotecan (IRI)-induced cachexia and loss of skeletal muscle mass and dysfunction in our study. However, peculiarly, BGP-15 adjuvant therapy reduced protein synthesis rates and the expression of key cytoskeletal proteins associated with the dystrophin-associated protein complex and increased matrix metalloproteinase activity, while it increased the propensity for fast-twitch muscles to tear during fatiguing contraction. Our data suggest that both IRI and BGP-15 cause structural remodeling involving proteins associated with the contractile apparatus, cytoskeleton and/or the extracellular matrix which may be only transient and ultimately beneficial or may paradoxically onset a muscular dystrophy phenotype and be detrimental if more permanent.

Abstract

Chemotherapy-induced muscle wasting and dysfunction is a contributing factor to cachexia alongside cancer and increases the risk of morbidity and mortality. Here, we investigate the effects of the chemotherapeutic agent irinotecan (IRI) on skeletal muscle mass and function and whether BGP-15 (a poly-(ADP-ribose) polymerase-1 (PARP-1) inhibitor and heat shock protein co-inducer) adjuvant therapy could protect against IRI-induced skeletal myopathy. Healthy 6-week-old male Balb/C mice (n = 24; 8/group) were treated with six intraperitoneal injections of either vehicle, IRI (30 mg/kg) or BGP-15 adjuvant therapy (IRI+BGP; 15 mg/kg) over two weeks. IRI reduced lean and tibialis anterior mass, which were attenuated by IRI+BGP treatment. Remarkably, IRI reduced muscle protein synthesis, while IRI+BGP reduced protein synthesis further. These changes occurred in the absence of a change in crude markers of mammalian/mechanistic target of rapamycin (mTOR) Complex 1 (mTORC1) signaling and protein degradation. Interestingly, the cytoskeletal protein dystrophin was reduced in both IRI- and IRI+BGP-treated mice, while IRI+BGP treatment also decreased β-dystroglycan, suggesting significant remodeling of the cytoskeleton. IRI reduced absolute force production of the soleus and extensor digitorum longus (EDL) muscles, while IRI+BGP rescued absolute force production of the soleus and strongly trended to rescue force output of the EDL (p = 0.06), which was associated with improvements in mass. During the fatiguing stimulation, IRI+BGP-treated EDL muscles were somewhat susceptible to rupture at the musculotendinous junction, likely due to BGP-15’s capacity to maintain the rate of force development within a weakened environment characterized by significant structural remodeling. Our paradoxical data highlight that BGP-15 has some therapeutic advantage by attenuating IRI-induced skeletal myopathy; however, its effects on the remodeling of the cytoskeleton and extracellular matrix, which appear to make fast-twitch muscles more prone to tearing during contraction, could suggest the induction of muscular dystrophy and, thus, require further characterization.

Cancer Cachexia: Definition, Staging, and Emerging Treatments

Cachexia is a multifactorial disease characterized by weight loss via skeletal muscle and adipose tissue loss, an imbalance in metabolic regulation, and reduced food intake. It is caused by factors of catabolism produced by tumors in the systemic circulation as well as physiological factors such as the imbalanced inflammatory activation, proteolysis, autophagy, and lipolysis that may occur with gastric, pancreatic, esophageal, lung cancer, liver, and bowel cancer. Cancer cachexia not only negatively affects the quality of life of patients with cancer but also reduces the effectiveness of anti-cancer chemotherapy and increases its toxicity, leading to increased cancer-related mortality and expenditure of medical resources. Currently, there are no effective medical interventions to completely reverse cachexia and no approved drugs. Adequate nutritional support is the main method of cachexia treatment, while drugs that target the inhibition of catabolism, cell damage, and excessive activation of inflammation are under study. This article reviews recent advances in the diagnosis, staging, and evaluation of cancer cachexia.

The importance of enteral nutrition to prevent or treat undernutrition in children undergoing treatment for cancer

Nutrition therapy is a therapeutic approach to treating medical conditions and symptoms via diet, which can be done by oral, enteral or parenteral routes. It is desirable to include nutritional interventions as a standard of care in pediatric cancer units (PCUs) at all levels of care. The interventions are dependent on available resources and personnel across all clinical settings. Enteral nutrition is easy, inexpensive, uses the gastrointestinal tract, maintains gut mucosal integrity, and allows for individualized nutritional strategies. This narrative review describes enteral nutritional interventions for children undergoing cancer treatment and is aimed at PCUs of all levels of care located in a low- and middle-income country.

Gastric electrical stimulation: An emerging therapy for children with intractable gastroparesis

Management of gastroparesis remains challenging, particularly in pediatric patients. Supportive care and pharmacological therapies for symptoms remain the mainstay treatment. Although they are effective for mild and some moderately severe cases, often time they do not work for severe gastroparesis. There are a few prokinetics available, yet the use of these drugs is limited by a lack of persistent efficacy and/or safety concerns. Currently, the only modality for adult patients with severe intractable gastroparesis is surgery, e.g., pyloroplasty and partial gastrectomy, however, this option is generally considered too radical for a growing child. Novel therapeutic approaches, particularly those which are less invasive, are needed. This article explores gastric electrical stimulation (GES), a new therapy for gastroparesis. Unlike others, it neither needs medications nor gastrectomy; rather, it treats through the use of microelectrodes to deliver high-frequency low energy electric stimulation to the pacemaker area of the stomach. Thus, it is tolerated and safe in children. Like in adult patients, GES appears to work in releasing symptoms, improving nutrition, and enhancing the quality of life; it also helps wean off medications and eliminate many needs for hospitalization. Considering the transient nature of gastroparesis in children in many occasions, GES is considered a “bridging” therapy after failed medical interventions and before surgery.

Is Neuronal Histamine Signaling Involved in Cancer Cachexia? Implications and Perspectives

In this paper, we present evidence in support of our hypothesis that the neuronal histaminergic system might be involved in cancer cachexia¹. To build our premise, we present the research and the reasonable inferences that can be drawn from it in a section by section approach starting from one of the key issues related to cachexia, increased resting energy expenditure (REE), and progressing to the other, anorexia. Based on an extensive survey of the literature and our own deliberations on the abovementioned topics, we investigate whether histamine signaling might be the mechanism used by a tumor to hijack the body's thermogenic machinery. Our hypothesis in short is that hypothalamic histaminergic neurons are stimulated by inputs from the parasympathetic nervous system (PSNS), which senses tumor traits early in cancer development. Histamine release in the preoptic area of the hypothalamus primarily activates brown adipose tissue (BAT), triggering a highly energy demanding mechanism. Chronic activation of BAT, which, in this context, refers to intermittent and/or low grade activation by the sympathetic nervous system, leads to browning of white adipose tissue and further enhances thermogenic potential. Aberrant histamine signaling not only triggers energy-consuming processes, but also anorexia. Moreover, since functions such as taste, smell, and sleep are governed by discrete structures of the brain, which are targeted by distinct histaminergic neuron populations even relatively minor symptoms of cachexia, such as sleep disturbances and taste and smell distortions, also might be ascribed to aberrant histamine signaling. In late stage cachexia, the sympathetic tone in skeletal muscle breaks down, which we hypothesize might be caused by a reduction in histamine signaling or by the interference of other cachexia related mechanisms. Histamine signaling thus might delineate distinct stages of cachexia progression, with the early phase marked by a PSNS-mediated increase in histamine signaling, increased sympathetic tone and symptomatic adipose tissue depletion, and the late phase characterized by reduced histamine signaling, decreased sympathetic tone and symptomatic muscle wasting. To support our hypothesis, we review the literature from across disciplines and highlight the many commonalities between the mechanisms underlying cancer cachexia and current research findings on the regulation of energy homeostasis (particularly as it relates to hypothalamic histamine signaling). Extrapolating from the current body of knowledge, we develop our hypothetical framework (based on experimentally falsifiable assumptions) about the role of a distinct neuron population in the pathophysiology of cancer cachexia. Our hope is that presenting our ideas will spark discussion about the pathophysiology of cachexia, cancer's devastating and intractable syndrome.

A novel treatment for height growth in patients with growth hormone insensitivity syndrome by cyproheptadine hydrochloride

BACKGROUND

Cyproheptadine HCl (CyproH) is an appetite-stimulating drug and while it was prescribed for a patient with growth hormone insensitivity syndrome (GHIS) for increasing appetite, his height growth was surprisingly increased. Therefore, the aim of this study was to investigate the effect of CyproH on growth parameters of the patients with GHIS.

PATIENTS AND DESIGN

Twenty patients were enrolled in two prospective cohorts at two different times. Fifteen cases were observed for 1.17 ± 1.3 years without treatment (observation period, OP). Then, CyproH was administered for 2.2 ± 2.7 years (treatment period, TP), and growth parameters were compared within these two periods. Five patients who did not receive any treatment for 1-8.24 years (4 ± 2.9) were the control group.

RESULTS

Height velocity (HV) increased from 1.88 ± 0.7 to 6.1 ± 0.8 cm/year and HV-SDS reached from -4.5 ± 0.74 to -0.21 ± 1.2 in OP and TP, respectively (P < .001), whereas HV and HV-SDS were 2.2 ± 1.1 cm/yr and -4.2 ± 1.2, respectively, in controls (P < .001). Height SDS was -7.0 ± 1.7 and increased to -6 ± 2.2 after treatment (P = .002). Gain in height was 2.3 ± 0.6 SDS in 5 patients who were treated for 5.4 ± 2.8 years. BMI-SDS was not significantly changed within two time periods and also in cases and controls.

CONCLUSION

CyproH caused height growth in the patients with GHIS, and therefore, this treatment can be considered as an alternative option to IGF-I injection.

Cancer cachexia: Diagnosis, assessment, and treatment

Cancer cachexia is a multi-factorial syndrome, which negatively affects quality of life, responsiveness to chemotherapy, and survival in advanced cancer patients. Our understanding of cachexia has grown greatly in recent years and the roles of many tumor-derived and host-derived compounds have been elucidated as mediators of cancer cachexia. However, cancer cachexia remains an unmet medical need and attempts towards a standard treatment guideline have been unsuccessful. This review covers the diagnosis, assessment, and treatment of cancer cachexia; the elements impeding the formulation of a standard management guideline; and future directions of research for the improvement and standardization of current treatment procedures.

Effect of cyproheptadine on weight gain in malnourished children: a randomized, controlled trial

Background: Cyproheptadine has been used therapeutically as an appetite stimulant in various chronic illnesses. However, no clinical data are available on the therapeutic effect of cyproheptadine in malnourished children without underlying pathological conditions. Objective: Investigate the short-term effect of cyproheptadine on weight gain in malnourished children who appear otherwise normal on physical examination. Methods: Seventy malnourished children who were otherwise normal on physical examination were recruited to participate in a randomized, double-blind, placebo-controlled trial. Thirty-seven children were randomized to a treatment regimen of cyproheptadine (0.1 mg/kg/dose, three times/day for eight weeks), and 33 children were randomized to receive placebo over a period of eight weeks. Subjects were evaluated at a baseline visit and at four visits at two-week intervals. Parameters assessed included baseline demographics, anthropometrics (weight, height, skin-fold thickness, waist and hip circumferences, and fat composition by bioelectric impedance analysis), adverse events, and pill counts. Data were analyzed by Student’s t-test and Chi-square test; a p- value < 0.05 was considered significant. Results: No significant differences were observed in baseline demographic characteristics and anthropometric parameters between the groups. The cyproheptadine-treated group showed a significantly greater weight gain over the baseline compared with the control group. The absolute weight gain was significantly higher in the cyproheptadine-treated group than in the control group at the end of study. No significant difference was observed in the change in the body fat percentage between the groups. No serious adverse events were reported. Adverse events included mild sedation, nausea, diarrhea, abdominal pain, and headache. No significant differences in the frequency of adverse events were observed between the groups. Conclusions: Cyproheptadine treatment was well tolerated and resulted in significant weight gain in malnourished children, without increasing the body fat percentage.

Effect of Cyproheptadine on Weight and Growth Velocity in Children With Silver-Russell Syndrome

OBJECTIVES

Nutritional management of children with Silver-Russell syndrome (SRS) is crucial, especially before initiating growth hormone therapy. Since cyproheptadine (CYP) has been reported to be orexigenic, we retrospectively investigated the effects of CYP on changes in weight and height in patients with SRS.

METHODS

Anthropometric parameters (weight [W], length or height [H], weight on expected weight for height [W/H], and body mass index) were recorded for 34 children with SRS receiving CYP. We specifically analyzed the anthropometric parameters (expressed in median) in a group of 23 patients treated with CYP at baseline (M0-CYP) and every 3 months (M3 to M12-CYP) after the initiation of CYP treatment.

RESULTS

The 23 children with SRS treated by CYP only had weight stagnation during the months preceding the start of treatment. Anthropometric parameters, especially the weight, differed significantly between M0-CYP and all other times (M3, M6, M9, M12-CYP). After 1 year of treatment, a gain in overall length/height and weight was observed (W: +1.1 standard deviations from the mean [SDS]; H: +0.5 SDS). At M3, significant improvements in W/H (74.9% vs 79.3% [P = 0.01]) and body mass index (-3.4 vs -2.4 SDS [P = 0.001]) were also observed. Twenty-one patients (91%) improved their weight by at least +0.5 SDS, and 12 (52%) by at least +1 SDS.

CONCLUSIONS

Our results show that CYP can be effective in patients with SRS with significant improvements in growth velocity and nutritional status before initiation of growth hormone therapy. Further prospective studies are required to confirm these results.

Appetite-Inducing Effects of Homoeriodictyol: Two Randomized, Cross-Over Interventions

SCOPE

Anorexia of aging, characterized by a decrease in appetite and/or food intake, is a major risk factor of under-nutrition and adverse health outcomes in elderly people. Recent in vitro evidence suggests homoeriodictyol (HED), a naturally occurring, bitter-masking flavanone, as a promising agent to increase appetite and food intake.

METHODS AND RESULTS

In two cross-over intervention trials, 30 mg NaHED, either solely (n = 10, Study I) or in combination with a 75 g glucose load (n = 17, study II) were administered to healthy adult subjects. Ratings of hunger were assessed at fasting and either 30 min (Study I) or 120 min (Study II) post intervention. Ad libitum energy intake from a standardized breakfast and plasma changes in hunger-/satiety-associated hormones PYY, GLP-1, ghrelin and serotonin were determined after blood drawings. Effects were more pronounced when NaHED was administered in combination with 75 g glucose since ad libitum energy (+ 9.52 ± 4.60%) and protein (+ 7.08 ± 7.97%) intake as well as plasma ΔAUC ghrelin values increased in study II solely, whereas plasma serotonin concentrations decreased after both interventions.

CONCLUSIONS

NaHED demonstrated appetizing effects in healthy adults when administered with a glucose load. Long-term intervention studies are warranted to verify these effects in compromised subjects.

Novel targeted therapies for cancer cachexia

Anorexia and metabolic alterations are the main components of the cachectic syndrome. Glucose intolerance, fat depletion, muscle protein catabolism and other alterations are involved in the development of cancer cachexia, a multi-organ syndrome. Nutritional approach strategies are not satisfactory in reversing the cachectic syndrome. The aim of the present review is to deal with the recent therapeutic targeted approaches that have been designed to fight and counteract wasting in cancer patients. Indeed, some promising targeted therapeutic approaches include ghrelin agonists, selective androgen receptor agonists, β-blockers and antimyostatin peptides. However, a multi-targeted approach seems absolutely essential to treat patients affected by cancer cachexia. This approach should not only involve combinations of drugs but also nutrition and an adequate program of physical exercise, factors that may lead to a synergy, essential to overcome the syndrome. This may efficiently reverse the metabolic changes described above and, at the same time, ameliorate the anorexia. Defining this therapeutic combination of drugs/nutrients/exercise is an exciting project that will stimulate many scientific efforts. Other aspects that will, no doubt, be very important for successful treatment of cancer wasting will be an optimized design of future clinical trials, together with a protocol for staging cancer patients in relation to their degree of cachexia. This will permit that nutritional/metabolic/pharmacological support can be started early in the course of the disease, before severe weight loss occurs. Indeed, timing is crucial and has to be taken very seriously when applying the therapeutic approach.

Interventions for managing weight change following paediatric acquired brain injury: a systematic review

OBJECTIVE

To systematically review literature reporting interventions for weight change following paediatric acquired brain injury (ABI).

METHOD

A systematic search of the literature was conducted using advanced search techniques. The retrieval identified 1562 papers, of which 30 were relevant. The total number of paediatric participants was 759.

RESULTS

There is a paucity of higher quality evidence to support the use of weight change interventions following paediatric ABI. Substantial variation in screening, outcome measures, intervention, and reporting were demonstrated. Some support was found for the use of hypothalamic-sparing surgery as a method to prevent obesity following craniopharyngioma resection.

INTERPRETATION

There is a need for further study in this area to inform clinical and research practice; recommendations are given.

A Framework for Adapted Nutritional Therapy for Children With Cancer in Low- and Middle-Income Countries: A Report From the SIOP PODC Nutrition Working Group

The utilization of adapted regimens for the treatment of pediatric malignancies has greatly improved clinical outcomes for children receiving treatment in low- and middle-income countries (LMIC). Nutritional depletion has been associated with poorer outcomes, increased abandonment of therapy, and treatment-related toxicities. Surveys have found that nutritional intervention is not incorporated routinely into supportive care regimens. Establishing nutritional programs based upon institutional resources may facilitate the incorporation of nutritional therapy into clinical care in a way that is feasible in all settings. We present a framework for establishing and monitoring of nutritional care based on the infrastructure of institutions in LMIC.

Failure to Thrive: A Prospective Study in a Pediatric Gastroenterology Clinic

OBJECTIVES

We aimed to describe the clinical characteristics, diagnostic work-up, interventions, and outcomes of children referred to a pediatric gastroenterology clinic with the diagnosis of failure to thrive (FTT).

METHODS

We prospectively enrolled 110 children seen for the first time in our pediatric gastroenterology clinic for FTT. Standard demographic information, history, and anthropometric data were collected at initial and follow-up visits. We also obtained data about diagnostic workup, therapeutic interventions, and growth outcomes.

RESULTS

Seventy patients (63.6%) were boys with a median age of 0.79 years (interquartile range 0.36-1.98). Of the 91 children with follow-up data, 81 (89%) were found to have nonorganic etiologies of their FTT. The majority of children (56.4%) underwent laboratory evaluation. Imaging and endoscopic evaluations were performed in fewer patients (29.6 and 10.2%, respectively). Endoscopic intervention yielded a diagnosis in 16.7% of patients while the positive result rates for laboratory testing and imaging were 3.2% and 3.1%, respectively. The most common therapeutic interventions included increasing calories (71.8%), avoiding grazing (71.8%), and structuring meals and snacks (67.3%). Compared with nonadherent children, children who were adherent with standard behavioral and nutritional interventions showed a higher positive change in z scores for weight (0.36 vs -0.01, P = 0.001) and body mass index (0.58 vs -0.18, P = 0.031).

CONCLUSIONS

The majority of children in a pediatric gastroenterology clinic with FTT have nonorganic etiologies of their failure to thrive. Laboratory, imaging, and endoscopic evaluation are rarely positive and should be judiciously performed. Adherence to standardized interventions leads to improved growth.

A Randomized Controlled Trial of an Outpatient Protocol for Transitioning Children from Tube to Oral Feeding: No Need for Amitriptyline

OBJECTIVE

To assess the role of amitriptyline in the effectiveness of an outpatient protocol for weaning medically complicated children from tube to oral feeding.

STUDY DESIGN

Twenty-one children seen in multidisciplinary outpatient feeding teams across 4 sites were recruited to a randomized placebo-controlled trial of a 6-month outpatient treatment protocol with behavioral, oral-motor, nutrition, and medication components.

RESULTS

All of the children who completed the 6-month program (73%) were weaned to receive only oral feeding, regardless of group assignment. The transition from tube to oral feeding resulted in decreases in body mass index percentile and pain, some improvements in quality of life, and no statistically significant changes in cost.

CONCLUSIONS

Amitriptyline is not a key component of this otherwise effective outpatient, interdisciplinary protocol for weaning children from tube to oral feeding.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT01206478.

The misuse of Cyproheptadine: a non-communicable disease risk behaviour in Kinshasa population, Democratic Republic of Congo

Background

Obesity is one of the main risk factors of non-communicable diseases (NCDs) worldwide, especially in sub-Saharan Africa. The use of Cyproheptadine increases body weight and the risk of becoming obese. The aim of this study is to determine the prevalence of Cyproheptadine misuse in the Kinshasa population and to describe its characteristics.

Methods

A cross-sectional study was conducted in two town sectors of Kinshasa, Democratic Republic of Congo (DRC), over a 4 month period (May 2011 to August 2011). Data from 499 participants, aged between 13 and 55 years were collected and analyzed. Mean and standard deviation were used for quantitative variables and frequency and percentage for categorical variables. In order to determine the relationship between socio-demographic status and Cyproheptadine use the Chi-square test was conducted. Student’s t-test was used to compare means age of Cyproheptadine users and non-users. Logistic regression was used to determine predictors of Cyproheptadine use. A p-value of <0.05 was considered statistically significant.

Results

Overall, 499 participants were enrolled (352 females, 147 males, mean age ± standard deviation 24.9 ± 9.7 years) in the study. The majority of the study participants (72.9 %) had used Cyproheptadine as an appetite stimulant. Females were 11 times more likely to use Cryproheptadine (OR = 11.9; 95 % CI: 7.1–20.1) than males. People aged between 36 and 55 were three times less likely to use Cryproheptadine (OR = 0.3; 95 % CI: 0.2–0.8) compared to teenagers. More than half of the participants (69.0 %) declared to take daily Cyproheptadine. Half of the study participants (50.0 %) used Cyproheptadine for more than a year and also declared to combine it with Dexamethasone (87.6 %).

Conclusion

This study shows that the Kinshasa population is significantly misusing Cyproheptadine and is highly exposed to its risk, including obesity.

Cyproheptadine significantly improves the overall and progression-free survival of sorafenib-treated advanced HCC patients

Objective

Sorafenib is a recommended treatment for advanced hepatocellular carcinoma. The study is to evaluate the efficacy of sorafenib plus cyproheptadine compared with sorafenib alone in patients with advanced hepatocellular carcinoma.

Methods

A retrospective cohort study reviewed all consecutive advanced hepatocellular carcinoma cases with Child-Pugh Class A disease starting sorafenib treatment at our hospital from August 2012 to March 2013. They were followed up until 31 December 2013. A total of 52 patients were enrolled: 32 patients in the combination (sorafenib–cyproheptadine) group and 20 patients in the control (sorafenib alone) group. The response to treatment, overall survival and progression-free survival were compared.

Results

The median overall survival was 11.0 months (95% confidence interval: 6.8–15.1 months) in the combination group compared with 4.8 months (95% confidence interval: 3.1–6.6 months) in the control group (crude hazard ratio = 0.45, 95% confidence interval: 0.22–0.82). The median progression-free survival time was 7.5 months (95% confidence interval: 5.1–10.0 months) in the combination group compared with 1.7 months (95% confidence interval: 1.4–2.1 months) in the control group (crude hazard ratio = 0.43, 95% confidence interval: 0.22–0.86). Kaplan–Meier survival analysis revealed that both overall survival and progression-free survival in the combination group were significantly longer than that in the control group. The multivariate model found patients in the combination group were 76% less likely to die (adjusted hazard ratio = 0.24, 95% confidence interval: 0.10–0.58) and 82% less likely to have progression (adjusted hazard ratio = 0.18, 95% confidence interval: 0.08–0.44) during the 17 months of follow-up.

Conclusion

Cyproheptadine may significantly improve survival outcomes of sorafenib-treated advanced hepatocellular carcinoma patients.

Beneficial effect of cyproheptadine on body mass index in undernourished children: a randomized controlled trial

OBJECTIVE

Cyproheptadine hydrochloride (CH) is a first-generation antihistamine which is used as an appetite stimulant. This study was designed to identify the role of CH therapy on weight gain, linear growth and body mass index in children with mild to moderate undernutrition.

METHODS

Eighty-nine patients were enrolled. The present randomized, double-blinded controlled trial included 77 evaluable patients, aged 24-64 months with undernutrition. The patients were randomized to receive cyproheptadine with multivitamin, or multivitamin over a period of four weeks. The weight, height and body mass index were measured at the baseline, four weeks after intervention and four weeks after discontinuation.

FINDINGS

A significant higher body mass index was observed among CH-treated patients after 8 weeks intervention with cyproheptadine compared with the control group (P<0.041). Mean weight gain after eight weeks was 0.11 kg in the control group and 0.60 kg in the CH group. There were no significant differences in changes of weight and height velocity across the study between CH-treated and control group at the end of study.

CONCLUSION

In our study, cyproheptadine promotes increase in body mass index in children with mild to moderate undernutrition after four weeks treatment.

Use of cyproheptadine in young children with feeding difficulties and poor growth in a pediatric feeding program

OBJECTIVE

The aim of this study was to assess the efficacy and safety of cyproheptadine (CY) use in infants and young children with poor growth treated at our multidisciplinary pediatric feeding program, and to describe changes in their weight and feeding behaviors.

METHODS

A retrospective chart review of children treated with CY from January 2007 to July 2011 was performed. Demographic data, medical diagnosis, adverse effects of the drug, and changes in mealtime behaviors were extracted from the patients' medical records. For each patient who received the CY, weight-for-age z scores (WtZ) were calculated before and during treatment. Repeated-measures mixed model was used to analyze the pattern of change in WtZ over time and between groups. Differences in mean WtZ were tested between patients regularly receiving CY and a naturally conceived comparison group.

RESULTS

Of the 127 patients in treatment owing to poor weight gain who received the CY, 82 took the medication regularly as prescribed in combination with our interventional program. For these patients, the majority of the parents (96%) reported a positive change in mealtime and feeding behaviors. A significant improvement in mean WtZ was observed after starting CY when compared with the WtZ before treatment for those patients regularly receiving the medication. This effect was independent of patients' age and/or presence of an underline medical problem. No significant differences in mean WtZ were observed over time within the comparison group.

CONCLUSIONS

In our experience, the use of CY in combination with a specialized multidisciplinary interventional program is a safe and effective therapy in infants and young children with low appetite and poor growth.

A randomized, double-blind, placebo-controlled clinical trial of megestrol acetate as an appetite stimulant in children with weight loss due to cancer and/or cancer therapy

BACKGROUND

Megestrol acetate (MA) is an appetite stimulant with efficacy in promoting weight gain in adults with cancer-associated anorexia-cachexia. Studies documenting MA efficacy in children, however, are limited. We present the first randomized, double-blind, placebo-controlled clinical trial of MA versus placebo in children with cancer and weight loss.

METHODS

Subjects <18 years of age with weight loss (minimum 5% from highest previous weight; or %ideal body weight <90%) due to cancer and/or cancer therapy were randomized to either MA (7.5 mg/kg/day) or placebo for a planned study duration of 90 days. Primary outcome was the difference between groups in mean percent weight change from beginning to end of the study period. Secondary outcomes included effects on anthropometrics, body composition, need for tube feeding or parenteral nutrition, and toxicities.

RESULTS

Twenty-six patients were randomly assigned (13 MA, 13 placebo). The MA group experienced a mean weight gain of +19.7% compared to a mean weight loss of -1.2% in the placebo group, for a difference of +20.9% (95%CI: +11.3% to +30.5%, P = 0.003) in favor of MA over placebo. MA subjects experienced significant increases in weight for age z-scores, body mass index z-scores, and mid upper arm circumference compared to placebo. DXA scanning suggested disproportionate increases in fat accrual. Adrenal suppression was the main toxicity of MA.

CONCLUSION

In children with high-risk malignancies, MA resulted in significant increases in mean percent weight change compared to placebo. Further studies of MA should be pursued to better delineate the effect on nutritional status.

Impact of caffeine on weight changes due to ketotifen administration

PURPOSE

Prescription of ketotifen as an effective antihistamine in asthma and allergic conditions is associated with side effect of weight gain. Caffeine is an agent which increases thermogenesis and improves energy expenditure and also effective in asthma. The aim of current study was to evaluate caffeine impact in reducing weight gain side effect of ketotifen.

METHODS

Male mice at the weight limit of 20-30 gr in 8 groups were randomly chosen and injected following drug dosages for 45 days intraperitoneally: control group (normal saline 10 ml/kg), three groups of ketotifen (4, 8, 16 mg/kg), three groups of caffeine (4, 8, 16 mg/kg) and one group of ketotifen (4 mg/kg) in combination with caffeine (4 mg/kg). Weight changes have been recorded and assessed every 3 days for 45 days.

RESULTS

The results showed that in all dosages of the two drugs, significant weight loss occurred in comparison with the control group.

CONCLUSION

The effect of caffeine on weight loss according to our results, matches with human studies, while ketotifen contradictory to our assumption, resulted in weight loss which probably was related to the difference in metabolic pathways in mice and humans, or maybe the used doses of ketotifen in this study were insufficient to reduce TNF-α production or influence in serotonin release and be effective on appetite or weight gain.

Treatment Options for Medulloblastoma and CNS Primitive Neuroectodermal Tumor (PNET)

OPINION STATEMENT

Medulloblastoma and central nervous system (CNS) primitive neuroectodermal tumor (PNET) are primary pediatric brain tumors that require multidisciplinary therapies. Although often treated similarly in clinical trials, they are biologically different diseases. Even within medulloblastomas and CNS PNETs, there are molecularly distinct subgroups with differing presentations and prognoses. Overall, prognosis is better for medulloblastomas. Specific treatments for these types of cancer are continuously evolving to maximize survival and minimize long-term sequelae of treatment. Patients should be treated on a clinical trial, if eligible, as they may gain benefit with minimal risk over current standard of care. The amount of residual disease after surgery better correlates with survival for medulloblastomas than for CNS PNETs. Maximal surgical resection of tumor should be done, only if additional permanent, neurologic deficits can be spared. Patients should have a staging work-up to assess the extent of disease. This includes postoperative magnetic resonance imaging (MRI) of the brain, MRI of the entire spine and lumbar cerebrospinal fluid (CSF) sampling for cytological examination, if deemed safe. Radiation therapy to the entire CNS axis is required, with a greater dose (boost) given to the region of the primary site or any bulky residual disease for older children. Adjuvant chemotherapy must be given even if no evidence of disease after radiation therapy exists, as the risk of relapse is substantial after radiation alone. Subsets of younger children with medulloblastoma, arbitrarily defined as those younger than 3 years of age in some studies and 4 or even 5 years in other studies, can be effectively treated with chemotherapy alone. Recent genomic studies have revealed further subtypes of disease than previously recognized. Clinical trials to exploit these biologic differences are required to assess potential efficacy of targeted agents. The treatment of medulloblastoma and CNS PNET can cause significant impairment in neurologic function. Evaluations by physical therapy, occupational therapy, speech therapy and neurocognitive assessments should be obtained, as needed. After therapy is completed, survivors need follow-up of endocrine function, surveillance scans and psychosocial support.

Clinical evaluation and optimal management of cancer cachexia

Cancer anorexia-cachexia syndrome (CACS) is a complex metabolic syndrome, different from malnutrition and sarcopenia, which is very common in cancer patients. Treatment for CACS is based on nutritional support and CACS pathophysiology-modulating drugs. The most commonly used are megestrol acetate (MA) and corticosteroids. The efficacy of MA has been confirmed by multiple clinical trials and meta-analyses. Glucocorticoids are also effective but should only be used for short periods and in selected cases. Future strategies should include intensified research into potentially effective drugs (ω-3 fatty acids, thalidomide, cannabinoids, ghrelin, bortezomib, and COX-2 inhibitors), combined treatment and new drugs (anti-IL-6 monoclonal antibodies, melanocortin, β-2 antagonists, and androgen receptor-modulating analogues). We propose a review based on the literature on the pathophysiology of CACS, the diagnostic criteria and treatment, and future strategies.

Children's Oncology Group's 2013 blueprint for research: cancer control and supportive care

In cancer control research, the objective is to reduce overall morbidity and mortality by decreasing acute and delayed treatment-related toxicities in all children with cancer. To date, the Children's Oncology Group (COG) has focused on infection, neurocognition, quality of life (QoL), and nutrition/antiemetics. COG is conducting randomized controlled trials (RCTs) to determine prophylaxis strategies that will reduce infections in high-risk populations. Two RCTs are determining if modafinil or computerized cognitive training improve cognitive functioning in pediatric brain tumor patients. QoL is being assessed in acute leukemia patients. Improved supportive care outcomes will only occur when the most effective interventions are established.

Antisecretory effect of prescribed appetite stimulator drug cyproheptadine in rat intestine

Cyproheptadine (Cph) is an antiserotoninergic and antihistaminergic agent with alpha-blocking activity and central sedative effect. Cph has been found to be effective in stimulating appetite, but to our knowledge, its direct effects on the intestine have not been documented. We aimed to assess the antisecretory effects of Cph in rat proximal colon using Ussing chambers' technique. In basal and serotonin (5-HT)-stimulated conditions, Cph induced a dose-dependent reduction in short-circuit current (Isc). This effect was different in fed vs. fasted rats (EC50 = 1.9 × 10(-5 ) m and 4.9 × 10(-5 ) m, respectively). As expected, Cph induced a marked dose-dependent rightward shift of the concentration-response curve to 5-HT (pA2 = 5.4). The effect of Cph was found to be close to that of antisecretory agents in the following sequence: peptide YY > somatostatin > clonidine > Cph > C7-sorbin. To our knowledge, this is the first demonstration that Cph has a direct effect on the inhibition of electrogenic ionic secretion in intestinal epithelium in vitro. Our results indicate that Cph can modulate the intestinal transport of electrolytes and provide a new insight into the peripheral effects of this drug, which is frequently prescribed as appetite stimulator in developing countries.

Malnutrition and obesity in pediatric oncology patients: causes, consequences, and interventions

In children with cancer, suboptimal nutrition states are common consequences of the disease and its treatment. These nutrition states have been attributed to a number of etiologies dependent on the patient's tumor type and treatment, and are associated with increased morbidity and mortality. Interventions vary from psychosocial to pharmacological and surgical management. Further research is necessary to understand the epidemiology and etiology of these nutrition states. Of great importance is the development and implementation of effective interventions to optimize nutritional status among children with cancer during and after therapy.

Nutritional Screening and Early Intervention in Children, Adolescents, and Young Adults With Cancer

Children and adolescents with cancer who receive chemotherapy and/or radiation treatments are at risk for malnutrition due to side effects such as nausea, vomiting, anorexia, and mouth sores. Malnutrition during treatment for childhood cancer increases the risk of infection, decreases tolerance to treatment, and even affects overall survival. A retrospective analysis of 79 children, adolescents, and young adults was conducted to evaluate nutritional screening at baseline and for the first 6 months of treatment. Interventions were also documented. Forty-nine participants had a positive screen for risk of malnutrition. In the patients with a positive screen, 78% had intervention within 24 hours of the identified risk for malnutrition. Thirty-five patients had a nutritional referral, which resulted in a full nutritional assessment and plan. Key independent variables were analyzed to determine if they were associated with an increased risk of malnutrition. In addition, individual risk factors were analyzed to determine their association with malnutrition. Future studies should find whether early intervention is effective in reversing the risk of malnutrition during treatment for childhood cancer.

Nutrition in infants and very young children with chronic kidney disease

Provision of adequate nutrition is a cornerstone of the management of infants and very young children with chronic kidney disease (CKD). Very young children with CKD frequently have poor spontaneous nutritional intake. Because growth depends strongly on nutrition during early childhood, growth in very young children with CKD is often suboptimal. In this review we will consider the mechanisms and manifestations of inadequate nutritional status in very young children with CKD, mechanisms mediating inadequate nutritional intake, and the optimal nutritional management of this special population. In addition, we suggest an approach to the assessment of nutritional status, including the use of body mass index in infants. Five major nutritional components are considered: energy, macronutrients, fluids and electrolytes, micronutrients, and calcium/phosphorus/vitamin D. The use of adjunctive therapies, including appetite stimulants, treatment of gastroesophageal reflux and gastric dysmotility, enhanced dialytic clearance, and growth hormone, is also briefly discussed.

Decompensated septic shock in the setting of megace-induced severe adrenal suppression in an otherwise healthy pediatric patient: a case report

A previously healthy 4-year-old boy presented to the emergency department at the Children's Hospital of Alabama with pneumonia caused by Pneumococcus infection and rapid progression to circulatory collapse. He was described as previously healthy except for being a "picky eater" and has been taking Megace (megestrol acetate) as an appetite stimulant for the past 2 years. We believe that the severity of his presentation was due in part to severe adrenal suppression from long-term Megace use. We were able to successfully resuscitate him with the addition of stress dose hydrocortisone, and he went on to have a complete recovery without any permanent disability. Previous literature has reported the adverse effect of Megace in suppressing adrenal function in patients with cancer and acquired immunodeficiency syndrome. This is the first report of this adverse effect in an otherwise healthy child. As the use of Megace becomes more widespread as an appetite stimulant in children, we hope to raise awareness of this important, potentially life-threatening adverse effect among physicians.

A comparative study of loratadine syrup and cyproheptadine HCL solution for treating perennial allergic rhinitis in Taiwanese children aged 2-12 years

We assessed the efficacy of loratadine syrup compared with cyproheptadine HCl solution for treating children aged from 2 to 12 years with perennial allergic rhinitis (PAR) in Taiwan. Sixty children with mite-induced PAR were enrolled and randomly placed into two treatment groups: loratadine syrup or cyproheptadine HCl solution. Treatment efficacy and symptom changes from baseline to post-treatment were evaluated by total symptom scores and visual analogue scales (VAS) during a 2-week period. There were no differences in age, gender, height, or weight between the two groups. After 2 weeks of treatment, there was a significantly greater reduction in symptom scores in the loratadine group than in the cyproheptadine group (p&#x003C;0.001). Clinical and subjective VAS showed significant differences in percentage changes from baseline between the loratadine and cyproheptadine groups at all time points (all p&#x003C;0.001, in favor of loratadine). Clinical VAS change at week 1: 95.1 vs 11.3; subjective VAS change at week 1: 88.6 vs 13.6; clinical VAS change at week 2: 125.5 vs 18.3; subjective VAS change at week 2: 101.4 vs 7.1. Thus, loratadine was superior to cyproheptadine for alleviating both nasal and non-nasal symptoms of perennial allergic rhinitis in Taiwanese children aged 2-12 years.