Erythropoiesis-stimulating agents in oncology: a study-level meta-analysis of survival and other safety outcomes

BACKGROUND: Cancer patients often develop the potentially debilitating condition of anaemia. Numerous controlled studies indicate that erythropoiesis-stimulating agents (ESAs) can raise haemoglobin levels and reduce transfusion requirements in anaemic cancer patients receiving chemotherapy. To evaluate recent safety concerns regarding ESAs, we carried out a meta-analysis of controlled ESA oncology trials to examine whether ESA use affects survival, disease progression and risk of venous-thromboembolic events.

METHODS: This meta-analysis included studies from the 2006 Cochrane meta-analysis, studies published/updated since the 2006 Cochrane report, and unpublished trial data from Amgen and Centocor Ortho Biotech. The 60 studies analysed (15 323 patients) were conducted in the settings of chemotherapy/radiochemotherapy, radiotherapy only treatment or anaemia of cancer. Data were summarised using odds ratios (ORs) with 95% confidence intervals (CIs).

RESULTS: Results indicated that ESA use did not significantly affect mortality (60 studies: OR=1.06; 95% CI: 0.97–1.15) or disease progression (26 studies: OR=1.01; 95% CI: 0.90–1.14), but increased the risk for venous-thromoboembolic events (44 studies: OR=1.48; 95% CI: 1.28–1.72).

CONCLUSION: Though this meta-analysis showed no significant effect of ESAs on survival or disease progression, prospectively designed, future randomised clinical trials will further examine the safety and efficacy of ESAs when used according to the revised labelling information.

Loss-of-function mutations in growth differentiation factor-1 (GDF1) are associated with congenital heart defects in humans

Congenital heart defects (CHDs) are among the most common birth defects in humans (incidence 8-10 per 1,000 live births). Although their etiology is often poorly understood, most are considered to arise from multifactorial influences, including environmental and genetic components, as well as from less common syndromic forms. We hypothesized that disturbances in left-right patterning could contribute to the pathogenesis of selected cardiac defects by interfering with the extrinsic cues leading to the proper looping and vessel remodeling of the normally asymmetrically developed heart and vessels. Here, we show that heterozygous loss-of-function mutations in the human GDF1 gene contribute to cardiac defects ranging from tetralogy of Fallot to transposition of the great arteries and that decreased TGF- beta signaling provides a framework for understanding their pathogenesis. These findings implicate perturbations of the TGF- beta signaling pathway in the causation of a major subclass of human CHDs.

Computational method to assign microbial genes to pathways

We present techniques that mine fully sequenced microbial genomes for functional relationships between genes. We show that genes related by one of four techniques are more likely to belong to the same cellular pathways. Furthermore, we demonstrate that the pathway of an uncharacterized gene may be inferred from those of its functionally related partners. Therefore, we are now able to assign most of the genes within bacteria to cellular pathways.

Loss-of-function mutations in the EGF-CFC gene CFC1 are associated with human left-right laterality defects

All vertebrates display a characteristic asymmetry of internal organs with the cardiac apex, stomach and spleen towards the left, and the liver and gall bladder on the right. Left-right (L-R) axis abnormalities or laterality defects are common in humans (1 in 8,500 live births). Several genes (such as Nodal, Ebaf and Pitx2) have been implicated in L-R organ positioning in model organisms. In humans, relatively few genes have been associated with a small percentage of human situs defects. These include ZIC3 (ref. 5), LEFTB (formerly LEFTY2; ref. 6) and ACVR2B (encoding activin receptor IIB; ref. 7). The EGF-CFC genes, mouse Cfc1 (encoding the Cryptic protein; ref. 9) and zebrafish one-eyed pinhead (oep; refs 10, 11) are essential for the establishment of the L-R axis. EGF-CFC proteins act as co-factors for Nodal-related signals, which have also been implicated in L-R axis development. Here we identify loss-of-function mutations in human CFC1 (encoding the CRYPTIC protein) in patients with heterotaxic phenotypes (randomized organ positioning). The mutant proteins have aberrant cellular localization in transfected cells and are functionally defective in a zebrafish oep-mutant rescue assay. Our findings indicate that the essential role of EGF-CFC genes and Nodal signalling in left-right axis formation is conserved from fish to humans. Moreover, our results support a role for environmental and/or genetic modifiers in determining the ultimate phenotype in humans.

Left-right axis malformations associated with mutations in ACVR2B, the gene for human activin receptor type IIB

Targeted disruption of the mouse activin receptor type IIB gene (Acvr2b) results in abnormal left-right (LR) axis development among Acvr2b-/- homozygotes [Oh and Li, 1997: Genes Dev 11:1812-1826]. The resulting malformations include atrial and ventricular septal defects, right-sided morphology of the left atrium and left lung, and spleen hypoplasia. Based on these results, we hypothesized that mutations in the type IIB activin receptor gene are associated with some cases of LR axis malformations in humans. We report here characterization of the ACVR2B genomic structure, analysis of ACVR2B splice variants, and screening for ACVR2B mutations among 112 sporadic and 14 familial cases of LR axis malformations. Two missense substitutions have been identified, one of which appears in two unrelated individuals. Neither of these nucleotide changes has been found in 200 control chromosomes. We conclude that ACVR2B mutations are present only rarely among human LR axis malformation cases.

Courtship behaviour of ostriches (Struthio camelus) towards humans under farming conditions in Britain

1. The courtship behaviour of adult male and female ostriches was observed in the presence and absence of human beings. 2. Courtship behaviours in both males and females were more prevalent in the presence of humans. 3. Exposure to a human for a short period did not stimulate courtship behaviour in the period immediately after the human had withdrawn. 4. Courtship behaviour towards humans may be important in the reproductive success of ostriches in a farming environment.

Delayed hemopericardium and cardiac tamponade after unrecognized chest trauma

Delayed hemopericardium after blunt chest wall trauma in children is rare and difficult to recognize before overt signs of cardiac tamponade. We present a 21-month-old girl who developed a late hemopericardium with cardiac tamponade after initially unrecognized blunt chest wall injury.

Effect of patient characteristics and disease manifestations on the outcome of acute otitis media at 2 months

BACKGROUND

Optimal therapy for acute otitis media (AOM) is controversial and there is no consensus regarding which antibiotic to use, how long to administer it, or whether antibiotics are effective at all. Knowledge of the effects of patient characteristics and disease manifestations is needed to individualize treatment and to evaluate large-scale trials.

METHODS

Data originated from 2251 patients with AOM, aged newborn to 15 years, who participated in a prospective primary care study in eight countries. At the initial visit, medical history, symptoms, physical findings, and treatment data were recorded. Follow-up 2 months later identified changes in treatment and outcome.

RESULTS

Patients younger than 13 months were less likely to have recovered than those aged 13 months to 15 years (P = .05). Using univariate analysis for infants aged 12 months or younger, male sex, prior episodes of AOM, and serous otitis media were associated with poor outcome. For older patients, poor outcome was associated with initial history of ear tubes, prophylactic antibiotic use, ear discharge, decreased hearing, serous otitis media; and past episodes of AOM; the symptom of decreased hearing; and the finding of pus exuding from the tympanic membrane. Using multivariate analysis for infants aged 12 months or younger, a history of serous otitis media (odds ratio [OR], 2.3; 95% confidence interval [CI], 0.95-5.7), past episodes of AOM (OR, 1.9; 95% CI, 0.82-4.5), and male sex (OR, 1.7; 95% CI, 1.0-3.0) made independent contributions to poor outcome. For children aged 13 months to 15 years, significant variables included pus drainage (OR, 2.2; 95% CI, 1.5-3.3), a history of ear tubes (OR, 2.3; 95% CI, 1.5-3.6), past episodes of AOM (OR, 1.8; 95% CI, 1.3-2.34), and a history of serous otitis media (OR, 1.4; 95% CI, 1.0-1.9).

CONCLUSIONS

Patient characteristics and disease manifestations are significant determinants of AOM outcome.

Acute otitis media in adults: a report from the International Primary Care Network

BACKGROUND

Of 22 million visits annually to United States physicians for acute otitis media, almost 4 million are by patients 15 years old or older. Yet the clinical spectrum and variables related to recovery have not been reported for adults.

METHOD

Data originated from 3224 primary care patients with acute otitis media, of whom 500 were 15 years old or older, who were enrolled in a prospective study in eight countries. At the initial visit, history, symptoms, physical findings, and treatment were recorded. At a 2-month follow-up visit, changes in treatment and recovery were recorded.

RESULTS

Compared with children, adults sought care more quickly after symptom onset; were more likely to have had a tonsillectomy or adenoidectomy; and were more likely to complain of ear pain, decreased hearing, sore throat, and ear discharge. Children were more likely to have a history of recent upper respiratory tract infection, serous otitis media, and ear tubes; symptoms of fever, diarrhea, and vomiting; and tympanic membrane findings of redness, bulging, and ear tubes in place. History of reduced hearing, allergy, prophylactic antibiotics, and tympanic membrane findings characterized as opaque or dull, fluid, draining pus, perforation, and not visualized were equally frequent in both age groups. For adults, neither type nor duration of antibiotic affected outcome. Patients receiving antibiotics had lower rates of recovery than those who did not. The likelihood of a poor outcome increased with an increasing number of past episodes of acute otitis media and with increasing age.

CONCLUSION

Although history and symptoms differ in adults and children, the similarity of tympanic membrane findings is consistent with previous reports of a similar bacterial spectrum in both groups. Recovery is related more to individual patient characteristics and history than to antibiotic therapy. Adults have an increased rate of poor outcome at 2 months compared with children.

Analysis of skull anthropometric measurements in patients with neurofibromatosis type-1

RATIONALE AND OBJECTIVES

The authors studied selected anthropometric measurements of plain postero-anterior and lateral skull roentgenograms to ascertain whether these were useful in distinguishing patients with clinically probable neurofibromatosis type-1 from controls.

METHODS

A retrospective review of medical records of patients for whom skull roentgenograms were available was conducted. Patients were assigned to one of three groups: definite neurofibromatosis type-1 (DNF), probable neurofibromatosis type-1 (PNF), and controls. A blinded analysis of 29 measurements, 9 qualitative assessments, and 3 area/volume calculations was performed.

RESULTS

There were 58 patients (29 controls, 14 DNF, and 15 PNF). The majority (75%) of all predetermined landmarks could be ascertained in 43 of these subjects. After age and gender were held constant, analysis of covariance showed that both DNF and PNF subjects could be distinguished from controls, but not from each other when comparing the mean: sella turcica height (P < .001), sella turcica depth (P < .005), skull width (P < .001), skull length (P < .002), skull height (P < .003), and skull volume (P < .0001).

CONCLUSIONS

Anthropometric analysis of skull roentgenograms coupled with results of clinical examination improves the ability to distinguish between patients with DNF and PNF from controls.

Diagnosis and antibiotic treatment of acute otitis media: report from International Primary Care Network

STUDY OBJECTIVE

The relation between a history of disorders suggestive of acute otitis media, symptoms, and findings of an examination of the tympanic membrane and doctors' certainty of diagnosis. Also, to examine differences in prescribing habits for acute otitis media among doctors from different countries.

DESIGN

Questionnaires were completed by participating doctors for a maximum of 15 consecutive patients presenting with presumed acute otitis media.

SETTING

General practices in Australia, Belgium, Great Britain, Israel, The Netherlands, New Zealand, Canada, Switzerland, and the United States.

PATIENTS

3660 Children divided into the three age groups 0-12 months, 13-30 months, and greater than or equal to 31 months.

MAIN OUTCOME MEASURES

General practitioners' responses to questions on their diagnostic certainty and resolution of patients' symptoms after two months.

RESULTS

The diagnostic certainty in patients aged 0-12 months was 58.0%. This increased to 66.0% in those aged 13-30 months and 73.3% in those aged greater than or equal to 31 months. In all age groups diagnostic certainty was positively associated with the finding of a tympanic membrane that was discharging pus or bulging. Redness of the membrane and pain were also associated with certainty in patients aged 13-30 months, and a history of decreased hearing or recent upper respiratory infection was positively associated in patients aged greater than or equal to 31 months. The proportion of patients prescribed antibiotics varied greatly among the countries, from 31.2% in The Netherlands to 98.2% in both Australia and New Zealand, as did the duration of treatment. Patients who did not take antibiotics had a higher rate of recovery than those who did; the rate of recovery did not differ between different types of antibiotic.

CONCLUSIONS

Doctors' certainty of diagnosis of acute otitis media was linked to patient's age. Improved criteria or techniques for diagnosing acute otitis media, especially in very young children, need to be developed. Antibiotic treatment did not improve the rate of recovery of patients in this study.

The effects of 6-azacholest-4-en-3 beta-ol-7-one, an inhibitor of cholesterol 7 alpha-hydroxylase, on cholesterol metabolism and bile acid synthesis in primary cultures of rat hepatocytes

6-Azacholest-4-en-3 beta-ol-7-one (azacholesterol) was shown to be a specific inhibitor of cholesterol 7 alpha-hydroxylase. It inhibited cholesterol hydroxylation by a rat liver microsomal preparation with non-competitive kinetics and a Ki of 4 microM. No evidence was found for a time-dependent inhibition of activity. Azacholesterol did not inhibit acyl-CoA: cholesterol acyltransferase or 3-hydroxy-3-methylglutaryl coenzyme A reductase in rat liver microsomal preparations, or cholesterol esterification and synthesis in primary cultures of rat hepatocytes. The synthesis of bile acids was inhibited by azacholesterol in these cells in a dose-dependent way. When bile acid synthesis was inhibited by azacholesterol, newly-synthesized cholesterol from exogenous mevalonate was secreted by the hepatocyte cultures into the cell culture medium in several-fold excess over control incubations. No changes in the secretion of cholesteryl ester occurred in the presence of azacholesterol. This observation suggests that newly synthesised cholesterol that has entered the substrate pool for hydroxylation is no longer accessible to the substrate pool for esterification. This is further evidence for the compartmentation of cholesterol metabolism in the hepatocyte.

The role of acyl-CoA: cholesterol acyltransferase in the metabolism of free cholesterol to cholesteryl esters or bile acids in primary cultures of rat hepatocytes

Sandoz compound 58-035 has been shown to inhibit acyl-CoA: cholesterol acyltransferase activity in a variety of cell types. We have shown that it does not inhibit rat liver microsomal cholesterol 7 alpha-hydroxylase, the rate-limiting enzyme of bile-acid synthesis, but it does inhibit acyl-CoA: cholesterol acyltransferase in both the microsomal fraction and in rat hepatocyte monolayers. To test the role of acyl-CoA: cholesterol acyltransferase in these cells, monolayers were incubated over 5 h in the presence and absence of 58-035 and in the presence of increasing amounts of mevalonic acid to provide a source of cholesterol. The addition of mevalonic acid increased the secretion of bile acids by the cells, and this was further increased by the addition of 58-035. The secretion of cholesteryl esters was conversely inhibited by the addition of 58-035. The results help define the role of acyl-CoA: cholesterol acyltransferase in determining the fate of intracellular cholesterol.

EEG "maturational lag" profiles: follow-up analyses

Nineteen children who had EEG diffuse slow frequency profiles suggesting a maturational lag were retested 1 to 2 years later receiving both EEG and psychometric assessments. They were compared to 18 children who also had been tested previously but did not have the slow frequency profile. Children with the maturational lag profile displayed varying degrees of EEG developmental change upon retest; i.e., some showed the expected developmental change while others remained the same. Within this group, there were significant relationships between the degree of EEG change and psychometric scores. Those that demonstrated the most EEG change had higher psychometric indices, and these relationships were not obtained in the comparison group. These findings suggest developmental heterogeneity with respect to brain maturation as measured by the EEG and also suggest that test-retest EEG data can clarify a maturational lag diagnosis.

A comparative study of 99mTc and 131I in thyroid scanning

Thyroid scans performed with both 99mTc pertechnetate (99mTcO4) and (131I) were compared in 46 patients with palpable thyroid nodules to determine whether 131I scanning is any longer a necessary procedure. A discrepancy between the two types of scan existed in only three cases, in one of which the thyroid nodule showed uptake of 99mTcO4 but not of 131I. Subsequent surgery revealed a thyroid malignancy in this patient. In each of the other two discrepancies a nodule "cold" on 99mTcO4 scanning was apparently functioning on 131I scanning, and was found to be benign at surgery. As the convenience and lower radiation absorbed dose of 99mTcO4 patients compared with 131I make it a better scanning agent, it is recommended that 99mTcO4 scans of the thyroid be first nodules. If these nodules prove to be functioning equally with paranodular tissue, a 131I scan should also be performed to help exclude a possible thyroid malignancy.