Systematic review of antimicrobials, mucosal coating agents, anesthetics, and analgesics for the management of oral mucositis in cancer patients and clinical practice guidelines

PURPOSE

To update the clinical practice guidelines for the use of antimicrobials, mucosal coating agents, anesthetics, and analgesics for the prevention and/or treatment of oral mucositis (OM).

METHODS

A systematic review was conducted by the Mucositis Study Group of the Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology (MASCC/ISOO). The body of evidence for each intervention, in each cancer treatment setting, was assigned an evidence level. The findings were added to the database used to develop the 2014 MASCC/ISOO clinical practice guidelines. Based on the evidence level, the following guidelines were determined: Recommendation, Suggestion, and No Guideline Possible.

RESULTS

A total of 9 new papers were identified within the scope of this section, adding to the 62 papers reviewed in this section previously. A new Suggestion was made for topical 0.2% morphine for the treatment of OM-associated pain in head and neck (H&N) cancer patients treated with RT-CT (modification of previous guideline). A previous Recommendation against the use of sucralfate-combined systemic and topical formulation in the prevention of OM in solid cancer treatment with CT was changed from Recommendation Against to No Guideline Possible. Suggestion for doxepin and fentanyl for the treatment of mucositis-associated pain in H&N cancer patients was changed to No Guideline Possible.

CONCLUSIONS

Of the agents studied for the management of OM in this paper, the evidence supports a Suggestion in favor of topical morphine 0.2% in H&N cancer patients treated with RT-CT for the treatment of OM-associated pain.

Systematic review of natural and miscellaneous agents for the management of oral mucositis in cancer patients and clinical practice guidelines-part 1: vitamins, minerals, and nutritional supplements

PURPOSE

To update the clinical practice guidelines for the use of natural and miscellaneous agents for the prevention and/or treatment of oral mucositis (OM).

METHODS

A systematic review was conducted by the Mucositis Study Group of the Multinational Association of Supportive Care in Cancer / International Society of Oral Oncology (MASCC/ISOO). The body of evidence for each intervention, in each cancer treatment setting, was assigned an evidence level. The findings were added to the database used to develop the 2014 MASCC/ISOO clinical practice guidelines. Based on the evidence level, the following guidelines were determined: Recommendation, Suggestion, and No Guideline Possible.

RESULTS

A total of 78 papers were identified within the scope of this section, out of which 29 were included in this part, and were analyzed with 27 previously reviewed studies. A new Suggestion was made for oral glutamine for the prevention of OM in head and neck (H&N) cancer patients receiving radiotherapy with concomitant chemotherapy. The previous Recommendation against the use of parenteral glutamine for the prevention of OM in hematopoietic stem cell transplantation (HSCT) patients was re-established. A previous Suggestion for zinc to prevent OM in H&N cancer patients treated with radiotherapy or chemo-radiotherapy was reversed to No Guideline Possible. No guideline was possible for other interventions.

CONCLUSIONS

Of the vitamins, minerals, and nutritional supplements studied for the management of OM, the evidence supports a Recommendation against parenteral glutamine in HSCT patients and a Suggestion in favor of oral glutamine in H&N cancer patients for the management of OM.

Oxygen and parenteral nutrition two main oxidants for extremely preterm infants: 'It all adds up'

OBJECTIVES

To assess the effect of early exposure to O2 and parenteral nutrition (PN) on oxidative stress at 36 weeks post-menstrual age (PMA) and on bronchopulmonary dysplasia (BPD) in extremely preterm infants.

STUDY DESIGN

A prospective observational study including 116 infants <29 weeks of gestation. Baseline clinical characteristics, FiO2 on day 7, duration of PN and clinical outcomes data were collected. In 39 infants, whole blood glutathione (GSH) and oxidized glutathione (GSSG) at 36 weeks PMA were measured and the redox potential was calculated using Nernst equation. Student's t-test, Chi-square, Spearman correlation, ANOVA, and logistic regression analyses were used as appropriate. P <  0.05 was considered significant.

RESULTS

FiO2 ≥25% was associated with higher level of GSSG (0.29 ± 0.04 versus 0.18 ± 0.02 nmol/mg of protein), a more oxidized redox potential (-191 ± 2 versus -198 ± 2 mV) and more BPD (90% versus 45%). PN duration >14 days was also associated with higher level of GSSG (0.26 ± 0.03 versus 0.13 ± 0.02 nmol/mg of protein), a more oxidized redox potential (-193 ± 5 versus -203 ± 2 mV) and more BPD (89% versus 24%). In logistic regression model, each 1% increase in FiO2 and each day increase in PN duration resulted in an increase in the OR for BPD by 1.57 (1.09 -2.28) and 1.17 (1.03 -1.33) respectively.

CONCLUSION

Early O2 supplement and PN have additive effects that were associated with prolonged oxidative stress and increased risk of BPD. Strategies targeting judicious use of O2 and decreasing the duration or developing a safer formulation of PN can be targeted to decrease BPD.

Meta-analysis of cardiovascular toxicity risks in cancer patients on selected targeted agents

PURPOSE

The purpose was to estimate the risk and severity of cardiovascular toxicities associated with selected targeted agents.

METHODS

We searched English-language literature for randomized clinical trials published between January 1, 2000 and November 30, 2013 of targeted cancer therapy drugs approved by the FDA by November 2010. One hundred ten studies were eligible. Using meta-analytic methods, we calculated the relative risks of several cardiovascular toxicities [congestive heart failure (CHF), decreased left ventricular ejection fraction (DLVEF), myocardial infarction (MI), arrhythmia, and hypertension (HTN)], adjusting for sample size using the inverse-variance technique. For each targeted agent and side effect, we calculated the number needed to harm.

RESULTS

Regarding CHF, trastuzumab showed significantly greater risk of all-grade and high-grade CHF. There was significant increased risk of all-grade DLVEF with sorafenib, sunitinib, and trastuzumab and high-grade DLVEF with bevacizumab and trastuzumab. Sorafenib was associated with significant increased all-grade risk of MI based on one study. None was associated with high-grade risk of MI or increased risk of arrhythmia. Bevacizumab, sorafenib, and sunitinib had significant increased risk of all-grade and high-grade HTN.

CONCLUSIONS

Several of the targeted agents were significantly associated with increased risk of specific cardiovascular toxicities, CHF, DLVEF, and HTN. Several had significant increased risk for high-grade cardiovascular toxicities (CHF, DLVEF, and HTN). Patients receiving such therapy should be closely monitored for these toxicities and early and aggressive treatment should occur. However, clinical experience has demonstrated that some of these toxicities may be reversible and due to secondary effects.

Meta-analysis: Risk of congestive heart failure (CHF) in selected targeted agents

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Background: Congestive heart failure (CHF) is among the most serious cardiovascular side effects of targeted agents (TA) impacting the clinical outcomes (including survival) of cancer patients on this therapy. Although clinical trials have reported this toxicity, often sample sizes are small and systemic evaluations are lacking. The objective of this study is to estimate risk and severity of CHF due to selected TAs. Methods: We identified 110 English language studies of 26 TA’s approved by the Food and Drug Administration as of November 2013 via MEDLINE. Of those, 8 studies including nearly 8000 patients provided TA-related data on the incidence and severity of CHF. Using meta-analytic methods, we calculated the relative risks of CHF, adjusting for sample size using the inverse variance technique. For each TA, we also determined the number needed to harm. Results: See table. Conclusions: In 5 studies including more than 7,000 patients, trastuzumab showed significantly greater risk of CHF. For every 9 patients treated with trastuzumab, there was 1 additional case of CHF compared to control regimens. A careful patient selection before therapy and early detection of CHF by judicious monitoring of patients on this therapy may prevent serious complications and allow maintenance of cancer treatment. [Table: see text]

Receipt of dental care and barriers encountered by persons with disabilities

A study was conducted to describe the receipt of dental care by patients with disabilities and to understand their perspective with regard to barriers to dental care. Subjects for this study were recruited among patients with disabilities seen at Carolinas Rehabilitation's outpatient clinic. A questionnaire consisting of 66 questions was completed by 344 subjects; with the topics related to both medical and dental care. Among the study population, 57.2% of subjects reported being seen by a dentist within the last 12 months, versus 67.3% before they became disabled. The last dental appointment was a routine examination for 59.5% of the respondents. Since becoming disabled, 16.6% of subjects reported problems receiving dental care. Financial challenges were the primary problem followed by physical accessibility issues. Further research is required to discover how barriers to care can be overcome to assure that those with disabilities receive adequate dental care.

Photoprotection of solutions of parenteral nutrition decreases the infused load as well as the urinary excretion of peroxides in premature infants

Light exposure and multivitamins are contributing factors to the generation of peroxides in solutions of parenteral nutrition. This article verifies if peroxides infused with parenteral nutrition are of biological significance in neonates. The mechanisms responsible for the generation of peroxides in total parenteral nutrition solutions are reviewed. The consequences of infused peroxides on an index of oxidant stress and on levels of a central antioxidant are evaluated in an animal model. The effect of photoprotection of parenteral nutrition on a biological marker of redox imbalance is evaluated in the urine of premature infants. Parenteral multivitamins produce a drop in glutathione and an oxidant stress similar to peroxides in the lungs of newborn guinea pigs. Infused peroxides elicited an increased urinary peroxide excretion in infants receiving parenteral nutrition exposed to light. Photoprotection reduced levels of infused and excreted peroxides. The results suggest that peroxides infused with total parenteral nutrition are not fully quenched by premature infants.

Parenteral multivitamin supplementation induces both oxidant and antioxidant responses in the liver of newborn guinea pigs

BACKGROUND

The multivitamin solution is a major component of photo-induced generation of peroxides in parenteral nutrition. The aim of this study was to determine whether the parenteral multivitamin preparation induces in the liver a peroxide-induced oxidant challenge or an antioxidant protection associated with the antiradical components of the solution.

METHODS

Newborn guinea pigs were infused with dextrose supplemented with peroxides (250 micromol/L H2O2 or 350 micromol/L tert-butylhydroperoxide) or with a multivitamin preparation (MVP, 1% vol/vol). After 4 days, total glutathione and a free radical-sensitive eicosanoid marker (prostaglandin I2 [PGI2]/total prostaglandins) were measured in livers.

RESULTS

There was a significant decrease in the PGI2/total prostaglandin ratio (mean +/- SEM) [dextrose: 0.068 +/- 0.007 vs. (dextrose + H2O2: 0.048 +/- 0.001, dextrose + TBH: 0.043 +/- 0.001)] and glutathione concentrations decreased [dextrose: 55 +/- 7 vs. (dextrose + H2O2: 37 +/- 7, dextrose + TBH: 18 +/- 7 nmol/mg protein)] after infusion of peroxides. Despite the peroxide load in the multivitamin solution, it did not alter the measured variables as prostanoid ratio remained at control concentrations (dextrose: 0.066 +/- 0.008 vs. dextrose + MVP: 0.065 +/- 0.006), as did glutathione levels (dextrose: 52 +/- 6 vs. dextrose + MVP: 45 +/- 7 nmol/mg prot).

CONCLUSION

In the liver of guinea pig pups, infused peroxides cause oxidation of membrane-derived prostanoids. The decrease in glutathione in response to administration of peroxides suggests consumption rather than a response to a free radical attack. Despite the oxidant load associated with peroxides generated in MVP, the multivitamin preparation protected membranes as the prostanoid ratio, and glutathione levels remained at control levels.

Peroxide-like oxidant response in lungs of newborn guinea pigs following the parenteral infusion of a multivitamin preparation

The multivitamin solution is a major component responsible for the photo-induced generation of peroxides in parenteral nutrition. The lung is a target of oxidant injury; however, the specific role of infused peroxides is unknown. The aim of this study was to determine if parenteral multivitamins induce in the lung an oxidant challenge similar to that of peroxides. Newborn guinea pigs were infused with dextrose plus relevant concentrations of H(2)O(2) (0,250,500 microM) or multivitamins (0,1%), as well as parenteral nutrition supplemented with multivitamins (0,1%). After 4 days, total glutathione, glutathione-related enzymes, and oxidant-sensitive eicosanoids were measured in the lungs. Peroxides as well as multivitamins led to a significant decrease in glutathione and the activity of glutathione synthase, indicating that infused peroxides were not entirely transformed into free radicals, which would have stimulated glutathione synthesis. The multivitamin solution induced a response in oxidant-sensitive eicosanoids similar to the response to peroxides, suggesting an oxidant stress that was not alleviated by the antiradical properties of its components. The effects on prostaglandins occurred independently from the stimulation in glutathione levels induced by parenteral nutrition. The multivitamin solution carries an oxidant load and causes effects similar to those of peroxides in the lungs of newborn guinea pigs.

Modulation of apo A-IV transcript levels and synthesis by n-3, n-6, and n-9 fatty acids in CACO-2 cells

It has been postulated that apolipoprotein (apo) A-IV plays various significant roles in lipid transport and lipoprotein metabolism. Although it is controlled by fat feeding, so far little else is known about its regulation by specific fatty acids. In this study, we focused on the modulation of apo A-IV mRNA levels, mass, and biogenesis by mono- and polyunsaturated fatty acids (FA) in the human intestinal Caco-2 cell line. In confluent cells incubated with 1 mM oleic (n-9), linoleic (n-6), alpha-linolenic (n-3), or docosahexaenoic (n-3) acids for a long-term period, both apo A-IV protein levels and de novo synthesis were increased. The induction resulted from the up-regulation of apo A-IV mRNA transcripts. In contrast, an inhibitory effect was evident with short-term incubation. FA chain length and degree of unsaturation had little effect altering apo A-IV transcript and biogenesis. These data offer evidence that isolated fatty acids regulate gene expression and the production of apo A-IV in the enterocyte.

Impact of essential fatty acid deficiency on hepatic sterol metabolism in rats

The major aim of the current investigation was to define whether essential fatty acid (EFA) deficiency modifies the intrahepatic metabolism and biliary output of sterols in rats. EFA-deficient diet caused an impoverishment in linoleic, arachidonic, and docosahexaenoic acids, and a marked enrichment in the eicosatrienoic acid of the plasma, liver, and hepatic microsomes. During a short term of biliary drainage, a significant decline of the pool size of biliary sterols was noted in EFA-deficient rats compared with control rats. To assess the biosynthesis of biliary components, the common bile duct was cannulated and the pool size depleted (24 hours). Subsequently, a 6-hour bile collection disclosed a significant decrease (nmoles/min/g liver) in bile acids (4.8 +/- 0.3 vs. 8.4 +/- 0.7, P < .005), cholesterol (0.26 +/- 0.01 vs. 0.34 +/- 0.02, P < .05), and phospholipids (1.49 +/- 0.11 vs. 2.82 +/- 0.32, P < .005) in EFA-deficient rats compared with controls (n = 6/group). When cholesterogenesis was measured by the incorporation of [14C]acetate and 3H20 into cholesterol, using liver slices, it was also found to be significantly (P < .001) reduced in EFA-deficient rats. The activity of hepatic 3-hydroxy-3-methylglutaryl coenzyme A reductase, the rate-limiting enzyme in cholesterol biosynthesis, was consistently lower (80 percent, P < .001) in EFA-deficient rats. In parallel experiments, the direct measurement of microsomal acyl-CoA:cholesterol acyl-transferase (ACAT) showed a decrease averaging 52 percent (P < .001). This is in striking contrast to the elevated activity (157 percent, P < .005) of cholesterol 7 alpha-hydroxylase, the rate-limiting enzyme in bile acid biosynthesis. Current experiments also suggest that the enzyme regulation involving phosphorylation and dephosphorylation is modified by EFA deficiency. Among the structural alterations observed in the morphology of hepatocytes in EFA-deficient rats, the lumen of bile canaliculi was reduced in size. These results underline the importance of EFA in the major mechanisms involved in the maintenance of hepatocyte sterol balance.

Significance of transported glycine in the conjugation of sodium benzoate in spf mutant mice with ornithine transcarbamylase deficiency

3H-glycine and 14C-serine were injected intraperitoneally, during treatment of spf mutant mice with 2% sodium benzoate in drinking water. Urinary hippurate was separated by thin layer chromatography and counted for 3H and 14C labels representing transported and newly synthesized glycine, respectively. The specific activity of 3H-hippurate increased significantly in mutant and normal groups, while the increase of 14C was seen only in mutants. The ratio of specific activity 3H:14C showed significant increases in normal (0.99 to 1.93; p less than 0.01) and mutant (1.53 to 3.05; p less than 0.05) groups, which shows that glycine transported from body pools played a significantly greater role in the conjugation of benzoate, compared to glycine synthesized de novo from serine. In spf mice, benzoate treatment also resulted in a decrease in orotate excretion, indicating amelioration of the hyperammonemic state. It is postulated that the elimination of glycine transported from body pools may be the primary mechanism for the reduction of ammoniagenicity in benzoate therapy, and that the de novo synthesis of glycine may have a secondary effect.