Registry-derived stage (RD-Stage) for capturing cancer stage at diagnosis for endometrial cancer

BACKGROUND

Capture of cancer stage at diagnosis is important yet poorly reported by health services to population-based cancer registries. In this paper we describe current completeness of stage information for endometrial cancer available in Australian cancer registries; and develop and validate a set of rules to enable cancer registry medical coders to calculate stage using data available to them (registry-derived stage or 'RD-Stage').

METHODOLOGY

Rules for deriving RD-stage (Endometrial carcinoma) were developed using the American Joint Commission on Cancer (AJCC) TNM (tumour, nodes, metastasis) Staging System (8th Edition). An expert working group comprising cancer specialists responsible for delivering cancer care, epidemiologists and medical coders reviewed and endorsed the rules. Baseline completeness of data fields required to calculate RD-Stage, and calculation of the proportion of cases for whom an RD stage could be assigned, was assessed across each Australian jurisdiction. RD-Stage (Endometrial cancer) was calculated by Victorian Cancer Registry (VCR) medical coders and compared with clinical stage recorded by the patient's treating clinician and captured in the National Gynae-Oncology Registry (NGOR).

RESULTS

The necessary data completeness level for calculating RD-Stage (Endometrial carcinoma) across various Australian jurisdictions varied from 0 to 89%. Three jurisdictions captured degree of spread of cancer, rendering RD-Stage unable to be calculated. RD-Stage (Endometrial carcinoma) could not be derived for 64/485 (13%) cases and was not captured for 44/485 (9%) cases in NGOR. At stage category level (I, II, III, IV), there was concordance between RD-Stage and NGOR captured stage in 393/410 (96%) of cases (95.8%, Kendall's coefficient = 0.95).

CONCLUSION

A lack of consistency in data captured by, and data sources reporting to, population-based cancer registries meant that it was not possible to provide national endometrial carcinoma stage data at diagnosis. In a sample of Victorian cases, where surgical pathology was available, there was very good concordance between RD-Stage (Endometrial carcinoma) and clinician-recorded stage data available from NGOR. RD-Stage offers promise in capturing endometrial cancer stage at diagnosis for population epidemiological purposes when it is not provided by health services, but requires more extensive validation.

Impulsivity and Treatment Outcomes in Individuals with Cocaine Use Disorder: Examining the Gap between Interest and Adherence

Background: Impulsivity is implicated in the development and maintenance of Cocaine Use Disorder (CUD). Less work has examined impulsivity's role on interest in initiating treatment, treatment adherence, or treatment response. No pharmacotherapies are approved for CUD, so efforts to understand and bolster the effects of psychotherapy are important in guiding and refining treatment. The present study examined the impact of impulsivity on interest in treatment, treatment initiation, treatment adherence, and treatment outcomes in individuals with CUD. Methods: Following the completion of a larger study on impulsivity and CUD participants were offered 14 sessions of (12 weeks) Cognitive Behavioral Relapse Prevention (CBT-RP). Before starting treatment, participants completed seven self-report and four behavioral measures of impulsivity. Sixty-eight healthy adults (36% female) with CUD (aged 49.4 ± 7.9) expressed an interest in treatment. Results: Greater scores on several self-report measures of impulsivity, and fewer difficulties with delayed gratification were associated with increased interest in treatment in both males and females. 55 participants attended at least 1 treatment session, while 13 participants did attend a single session. Individuals who attended at least one treatment session scored lower on measures of lack of perseverance and procrastination. Still, measures of impulsivity did not reliably predict session attendance nor the frequency of cocaine-positive urine samples throughout treatment. Males attended nearly twice as many treatment sessions as females despite nonsignificant associations between impulsivity in males and the number of sessions attended. Conclusions: Greater impulsivity in individuals with CUD was associated with expressing an interest in treatment, but not treatment adherence or response.

Global survival trends for brain tumors, by histology: analysis of individual records for 556,237 adults diagnosed in 59 countries during 2000-2014 (CONCORD-3)

BACKGROUND

Survival is a key metric of the effectiveness of a health system in managing cancer. We set out to provide a comprehensive examination of worldwide variation and trends in survival from brain tumors in adults, by histology.

METHODS

We analyzed individual data for adults (15-99 years) diagnosed with a brain tumor (ICD-O-3 topography code C71) during 2000-2014, regardless of tumor behavior. Data underwent a 3-phase quality control as part of CONCORD-3. We estimated net survival for 11 histology groups, using the unbiased nonparametric Pohar Perme estimator.

RESULTS

The study included 556,237 adults. In 2010-2014, the global range in age-standardized 5-year net survival for the most common sub-types was broad: in the range 20%-38% for diffuse and anaplastic astrocytoma, from 4% to 17% for glioblastoma, and between 32% and 69% for oligodendroglioma. For patients with glioblastoma, the largest gains in survival occurred between 2000-2004 and 2005-2009. These improvements were more noticeable among adults diagnosed aged 40-70 years than among younger adults.

CONCLUSIONS

To the best of our knowledge, this study provides the largest account to date of global trends in population-based survival for brain tumors by histology in adults. We have highlighted remarkable gains in 5-year survival from glioblastoma since 2005, providing large-scale empirical evidence on the uptake of chemoradiation at population level. Worldwide, survival improvements have been extensive, but some countries still lag behind. Our findings may help clinicians involved in national and international tumor pathway boards to promote initiatives aimed at more extensive implementation of clinical guidelines.

Gabapentin increases the abuse liability of alcohol alone and in combination with oxycodone in participants with co-occurring opioid and alcohol use disorder

BACKGROUND

People who have co-occurring Alcohol Use Disorder (AUD) and Opioid Use Disorder (OUD) carry a higher risk of adverse outcomes, including drug overdose. Early clinical and preclinical studies suggested that gabapentin may be effective in treating both disorders. The present study was designed to assess the effects of gabapentin on the subjective and physiological effects of oxycodone (OXY) and alcohol (ALC), alone and in combination.

METHODS

During an 8-week, inpatient, within-subject, randomized, double-blind, placebo-controlled crossover study, non-treatment seeking participants (N = 13; 12 M/1F; 44.1 ± 3 years of age) with OUD and AUD were maintained on oral morphine (120 mg daily). Under gabapentin (1800 mg/day) and placebo (0 mg/day) maintenance, participants completed nine separate test sessions (three sessions per week) during which they received an oral solution containing 0, 15, or 30 mg/70 kg OXY in combination with 0, 0.5, or 0.75 g/kg ALC. During test sessions, subjective effects and physiological responses were assessed repeatedly on 100-mm visual analog scales (VAS). The primary outcome variable was the VAS rating of drug liking after receiving the drug challenge.

RESULTS

Alcohol alone (but not oxycodone alone) produced dose-related increases in several positive subjective responses, including drug liking. Gabapentin significantly increased drug liking when given in combination with ALC and OXY + ALC (p < 0.05). Gabapentin did not clinically compromise respiration or other vital functions.

CONCLUSIONS

Gabapentin may increase the abuse liability of ALC and OXY + ALC in those with co-occurring OUD and AUD.

Realizing a learning health system through process, rigor and culture change

While many healthcare organizations strive to achieve the patient care benefits of being a learning health system (LHS), myriad challenges stand in the way of successful implementation. The reality of creating a true LHS requires top-to-bottom commitment to culture change with the necessary vision, leadership, and investment. The Center for Outcomes Research and Evaluation (CORE) is a multidisciplinary research unit embedded within a large, vertically integrated healthcare system in the southeastern United States. We used a two-pronged approach to: a) methodically recruit a team of experts, while generating early wins that demonstrated real success; and b) build relationships and buy-in across organizational leadership. Building out a team with diverse expertise created the ability to deploy pragmatic, data-driven research designs that fit seamlessly into real-world care delivery, resulting in agile study execution that aligns with health system timelines. Case study examples from hospital readmissions and antibiotic stewardship illustrate how our LHS operationalizes practice-informed research and research-informed practice. Lessons from this experience can serve as a blueprint for other healthcare systems or networks seeking to expand the promise of the LHS framework to improve health for patients and communities.

(Dis)concordance of comorbidity data and cancer status across administrative datasets, medical charts, and self-reports

Background

Benchmarking outcomes across settings commonly requires risk-adjustment for co-morbidities that must be derived from extant sources that were designed for other purposes. A question arises as to the extent to which differing available sources for health data will be concordant when inferring the type and severity of co-morbidities, how close are these to the “truth”. We studied the level of concordance for same-patient comorbidity data extracted from administrative data (coded from International Classification of Diseases, Australian modification,10th edition [ICD-10 AM]), from the medical chart audit, and data self-reported by men with prostate cancer who had undergone a radical prostatectomy.

Methods

We included six hospitals (5 public and 1 private) contributing to the Prostate Cancer Outcomes Registry-Victoria (PCOR-Vic) in the study. Eligible patients from the PCOR-Vic underwent a radical prostatectomy between January 2017 and April 2018.Health Information Manager’s in each hospital, provided each patient’s associated administrative ICD-10 AM comorbidity codes. Medical charts were reviewed to extract comorbidity data. The self-reported comorbidity questionnaire (SCQ) was distributed through PCOR-Vic to eligible men.

Results

The percentage agreement between the administrative data, medical charts and self-reports ranged from 92 to 99% in the 122 patients from the 217 eligible participants who responded to the questionnaire. The presence of comorbidities showed a poor level of agreement between data sources.

Conclusion

Relying on a single data source to generate comorbidity indices for risk-modelling purposes may fail to capture the reality of a patient’s disease profile. There does not appear to be a ‘gold-standard’ data source for the collection of data on comorbidities.

Biopsychosocial barriers affecting recovery after a minor transport-related injury: A qualitative study from Victoria

Objective

The aim of the study was to understand the recovery phenomena and to explore participants' perspectives on the biopsychosocial facilitators and barriers affecting their recovery after a minor transport injury.

Methods

A qualitative method was used involving semi‐structured interviews with 23 participants who sustained a minor transport injury. Interviews and analysis were guided by the biopsychosocial model (BPS) of health. The outcomes were themes capturing biopsychosocial barriers to, and personal experiences of, recovery using a previously defined framework.

Results

The themes indicate that recovery is a multifaceted phenomenon affected by comorbidities such as chronic pain, depression and anxiety. A range of subsequent complexities such as the inability to self‐care and undertaking daily domestic duties, and incapacity to participate in recreational activities were major barriers to recovery. These barriers were found to be an on‐going source of frustration, dissatisfaction and a perceived cause of depressive symptomatology in many participants. Most participants reported mixed feelings of the care received. Other common issues raised included a lack of understanding of the assessment time, regular follow‐up, guidance and on‐going support.

Conclusion

This study revealed that recovery after a minor transport‐related injury was a challenging, complex, demanding and a long‐term process for the individuals in this study. Findings from this limited cohort suggested that, for participants to return to their pre‐accident health status, a more coordinated approach to information and care delivery may be required.

Management of low-risk prostate cancer in a population-based cohort of Australian men between 2008 and 2016

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Background: The aim of this study is to evaluate the practice pattern of management of NCCN low-risk prostate cancer (LRPC) in a population-based cohort of Australian men. Methods: This is prospective cohort of men captured in Prostate Cancer Outcomes Registry Victoria (PCOR-Vic), who were diagnosed with LRPC between Aug 2008 and Dec 2016. Conservative management was defined as no active treatment (surgery, radiotherapy, or other local therapy) within 12-month of LRPC diagnosis. Chi-squared test for trend was used to evaluate change in practice over time. Multivariate logistics regressions were used to patient-, tumour- and institutional factors influencing the likelihood of conservative management for LRPC. Results: A total of 3238 men with LRPC were identified in the PCOR-Vic database. The median age was 62.6 (range:37-94). The median PSA level was 5.1ng/mL (range: 0.01-9.96). Overall, 1934 (60%) had conservative management, of which 1668 (86%) were documented as being on active surveillance. Of the 1304 (40%) men who active treatment within 12-month of diagnosis, 977 (30%) had surgeries, 289 (9%) had radiotherapy, and 38 (1%) had other local treatment. Overall, there is increasing trend in conservative management for LRPC from 52% in 2009 to 73% in 2016 (P<0.001). In multivariate analyses, age, PSA, clinical stage, institutions and year of diagnosis were all independently associated with conservative management. Men diagnosed in private and regional centres were 26% (95%CI=0.63-0.88, P=0.001) and 40% (95% CI=0.51-0.72, P<0.001) less likely to have conservative management for LRPC. Conclusions: This is the largest Australian series on management of LRPC to date. We observe increasing use of conservative management for LRPC over time, however, there is large institutional variations in care with men diagnosed in private and regional centres more likely to have active local management for LRPC.

"Prostate cancer is far more hidden…": Perceptions of stigma, social isolation and help-seeking among men with prostate cancer

The purpose of this study was to provide in-depth insight into men's experiences of prostate cancer, specifically: perceived stigma and self-blame, social isolation, unmet need and help-seeking. A qualitative descriptive approach was used. Semi-structured interviews were undertaken with 20 men diagnosed with prostate cancer, and thematic analysis was undertaken. Some participants perceived a stigma associated with prostate cancer and cancer in general, which sometimes acted as a barrier to disclosure. Self-blame and internalisation of cause was not a prominent issue. Participants' descriptions of emotional distress, social isolation and anxiety demonstrated the impact of prostate cancer. Social isolation was most commonly reported as a physical consequence of treatment and/or side effects. Participants felt both support and ongoing care were limited at post-treatment. Most did not seek or receive help for emotional or psychosocial problems from a formal source due to anticipated awkwardness, autonomous coping, not burdening others, unwanted sympathy and retaining privacy. Prostate cancer can cause considerable emotional and social burden for some men, and many are unlikely to seek or receive help. Men, and their support networks, require active encouragement throughout diagnosis, treatment and follow-up to overcome barriers and access additional support, particularly for sexual, emotional and psychosocial issues.

Oncological outcomes in an Australian cohort according to the new prostate cancer grading groupings

Background

A new 5-tiered grading grouping system has recently been endorsed for reporting of prostate cancer (PCa) grade to better reflect escalating risk of progression and cancer death. While several validations of the new grade groupings have been undertaken, most have involved centralised pathological review by specialist urological pathologists.

Methods

Participants included 4268 men with non-metastatic PCa diagnosed between 2006 and 2013 from the multi-institutional South Australia Prostate Cancer Clinical Outcomes Collaborative registry. PCa-specific survival and biochemical recurrence-free survival were compared across the five grade groups using multivariable competing risk regression.

Results

For the entire cohort, risk of PCa death increased with increasing grade groups (at biopsy) Adjusted subdistribution-hazard ratios [sHR] and 95% confidence intervals [95%CI] were: 2.2 (1.5–3.6); 2.5 (1.6–4.2); 4.1 (2.6–6.7) and 8.7 (4.5–14.0) for grade groups II (pattern 3 + 4), III (pattern 4 + 3), IV (total score 8) and V (total score 9–10) respectively, relative to grade group I (total score < =6). Clear gradients in risk of PCa death were observed for radical prostatectomy (RP), but were less clear for those who had radiotherapy (RT) with curative intent and those who were managed conservatively. Likewise, risk of biochemical recurrence increased across grade groups, with a strong and clear gradient for men undergoing RP [sHR (95%CI): 2.0 (1.4–2.8); 3.8 (2.9–5.9); 5.3 (3.5–8.0); 11.2 (6.5–19.2) for grade groups II, III, IV and V respectively, relative to grade group I], and a less clear gradient for men undergoing RT.

Conclusion

In general, the new five-tiered grade groupings distinguished PCa survival and recurrence outcomes for men with PCa. The absence of a clear gradient for RT may be due to heterogeneity in this patient group.

Ergonomics@Ford.Com: Using the Intranet to Enhance Program Effectiveness

Ford Motor Company's Automated Evidence Book, known as ErgoRx, is a Web-browser-based application that permits plant-level Local Ergonomics Committees (LECs) to manage the process for identifying, tracking, resolving and sharing ergonomic concerns with reduced administrative burden. The Intranet application also allows Corporate and Division ergonomics personnel to view LEC concern data remotely and obtain measures of program effectiveness directly.

A Personalized Service to Academic Researchers: the Experimental Information Service in the Social Sciences at the University of Bath

Between 1969 and 1971 Bath University Library experimented with a personalized information service to social science researchers at the Universities of Bath and Bristol. The principal service offered was a manunl current awareness service, based mainly on the scanning of primary and abstracting journals. The service was evaluated by feedback slips returned by clients for each reference notified, and by a questionnaire at the end of the experiment. The relevance performance was good, and few references had been seen before; some precision could have been sacrificed to ensure comprehensive recall. The whole service was rated highly by nearly all users and considered to be a high priority among the various possible claims on university resources. Those who had the closest contact with the infor mation officers had the best scores on most aspects evaluated and rated the service most highly. Some general observations on the place and value of an information service in a university library are given in conclusion.

Need for a roadmap for development of a coordinated national registry programme

Clinical quality registries are an overlooked and under-funded arm of clinical research in Australia. Registries are databases for patients with a particular disease, or who undergo a procedure, or use a health resource. Registries, where properly funded and universally adopted, have provided substantial benefits to the quality of healthcare and, in some cases, have had demonstrable effect in reducing costs. There is a lack of a coordinated programme for both funding and development of registries in Australia. A coordinated effort is required to address key gaps in registry coverage and ensure registries comply with appropriate technical and operating principles, and target areas where registries can add value to the health system. This will ensure that Australia is competitive with its international peers in this dynamic environment.

Quality-of-life outcomes for prostate cancer treatment in Australia

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Background: We aimed to use a population based quality registry established in Australia, to review patient-reported health-related QOL after the diagnosis of Prostate Cancer (PCa). Methods: Prospective registry of men with PCa from statutory notifications to the canonical population-based cancer registry in Victoria. An "opt-off" mechanism used. Coverage expanded from 30%-80% of State population over time. Demographics and disease features, management, and outcomes from medical record; men phoned at 12 and 24 months (m), interviewed with script including SF12 and items from standard form (UCLA PCI) for specific QOL outcomes. Urinary, rectal, and sexual function bother (UB, RB, and SB) scores where analysed by univariate and multivariable modelling for relationship of these with presentation or management factors, adjusting for risk. Results: Men from 8/2008 - 2/2011; 1.9% of eligible opted out. Followed 1172 to 12 & 24 m. Median diagnosis age 65 yr; median PSA 6.8 ng/mL; 97.3% clinically localised with 47.7% having NCCN intermediate risk. 520 had treatment with Radical Prostatectomy (RP) (89 also with external beam-EBRT), 171 had EBRT (with or without HDR brachy), and 211 seed implant (SI). 226 had no treatment (NT) in the first 12 m. 52.5% managed in public hospitals, rest private. Univariate analysis: UB associated with management type, and hospital type, and RB and SB associated with these factors, as well as age and disease stage. On multivariate regression SB at 12 m was associated with increasing age (p=0.002) and radical treatment types (RP and EBRT/HDR, p<0.001 and 0.003 respectively)—except SI—compared to NT; RB was associated with SI (0.02) and EBRT/HDR (0.007) and treatment in a public hospital (0.006); and UB was associated with public hospital (<0.001). All associations at 12 m remained significant at 24 m. SF12 physical score had a positive association with RP vs NT (0.014), hospital type (0.001) and younger age. SF12 mental health also showed associations. Conclusions: A large scale registry in Australia assessing patient-reported quality of life outcomes after prostate cancer treatment shows patterns similar to that seen in North American reports.

Measurements of hypoxia ([(18)F]-FMISO, [(18)F]-EF5) with positron emission tomography (PET) and perfusion using PET ([(15)O]-H(2)O) and power Doppler ultrasonography in feline fibrosarcomas*

Abstract The aim of this study was to evaluate if hypoxia in feline fibrosarcomas can be detected. This was done using positron emission tomography (PET), two hypoxia tracers and polarographic pO(2) measurements. Of the seven cats included, five received [(18)F]-fluoromisonidazole and two 2-(2-nitro-1H-imidazol-1-yl)-N-(2,2,3,3,3-pentafluoropropyl) acetamide. Perfusion was evaluated with [(15)O]-H(2)O (n = 4) and with contrast-enhanced power Doppler ultrasonography (n = 5). Hypoxia was detected in three cats. Polarographic pO(2) measurements did not confirm PET results. In the ultrasonographic evaluation, low vascularity and low perfusion were seen with a peripheral vascular pattern and no perfusion in the centre of the tumour. This was in contrast to the [(15)O]-H(2)O scans, where central perfusion of the tumour was also found. In conclusion, it appears that hypoxia exists in this tumour type. The presence of tumour necrosis and heterogeneous hypoxia patterns in these tumours may explain the found discrepancies between the applied techniques.

Measuring the quality of hospital care: an inventory of indicators

BACKGROUND

Development of indicators to measure health-care quality has progressed rapidly. This development has, however, rarely occurred in a systematic fashion, and some aspects of care have received more attention than others. The aim of this study is to identify and classify indicators currently in use to measure the quality of care provided by hospitals, and to identify gaps in current measurement.

METHODS

A literature search was undertaken to identify indicator sets. Indicators were included if they related to hospital care and were clearly being collected and reported to an external body. A two-person independent review was undertaken to classify indicators according to aspects of care provision (structure, process or outcome), dimensions of quality (safety, effectiveness, efficiency, timeliness, patient-centredness and equity), and domain of application (hospital-wide, surgical and non-surgical clinical specialities).

RESULTS

383 discrete indicators were identified from 22 source organizations or projects. Of these, 27.2% were relevant hospital-wide, 26.1% to surgical patients and 46.7% to non-surgical specialities, departments or diseases. Cardiothoracic surgery, cardiology and mental health were the specialities with greatest coverage, while nine clinical specialities had fewer than three specific indicators. Processes of care were measured by 54.0% of indicators and outcomes by 38.9%. Safety and effectiveness were the domains most frequently represented, with relatively few indicators measuring the other dimensions.

CONCLUSION

Despite the large number of available indicators, significant gaps in measurement still exist. Development of indicators to address these gaps should be a priority. Work is also required to evaluate whether existing indicators measure what they purport to measure.

Measuring quality

It is no longer sufficient for health care professionals to provide high quality health care, they must also be able to demonstrate that they are meeting and often exceeding quality targets. Quality indicators (QIs) provide a means of measuring and assessing quality, however there are advantages and disadvantages of indicator measurement. Further, the clinical perspective needs to be balanced against managerial control when developing valid, reliable, sensitive and specific QIs. While indicators do not represent a perfect measurement device, they may provide a useful tool for improving patient safety and meeting community expectations.

Cardiovascular development: towards biomedical applicability

The LIM-homeodomain transcription factor Islet-1 (Isl1) marks a cell population which makes a substantial contribution to the embryonic heart. Isl1 expression is downregulated as soon as the cells adopt a differentiated phenotype, suggesting that this transcription factor delineates a cardiogenic progenitor cell population. Taking advantage of this developmental lineage marker, we have identified in the postnatal heart a novel cardiac cell type, which is capable of self-renewal and readily differentiates into mature cardiomyocytes. Utilization of embryonic stem (ES) cells that harbour knock-ins of reporter genes into the endogenous Isl1 locus will enable us to isolate Isl1+ cardiac progenitors from mouse and human ES cell systems during in vitro cardiogenesis. These genetic cell-based systems should allow the direct identification of signalling pathways which guide formation, renewal and diversification of Isl1+ cardiogenic progenitors into distinct heart cell lineages, and would complement in vitro studies in the mouse embryo during cardiac development.

Attitudes and barriers to incident reporting: a collaborative hospital study

OBJECTIVES

To assess awareness and use of the current incident reporting system and to identify factors inhibiting reporting of incidents in hospitals.

DESIGN, SETTING AND PARTICIPANTS

Anonymous survey of 186 doctors and 587 nurses from diverse clinical settings in six South Australian hospitals (response rate = 70.7% and 73.6%, respectively).

MAIN OUTCOME MEASURES

Knowledge and use of the current reporting system; barriers to incident reporting.

RESULTS

Most doctors and nurses (98.3%) were aware that their hospital had an incident reporting system. Nurses were more likely than doctors to know how to access a report (88.3% v 43.0%; relative risk (RR) 2.05, 95% CI 1.61 to 2.63), to have ever completed a report (89.2% v 64.4%; RR 1.38, 95% CI 1.19 to 1.61), and to know what to do with the completed report (81.9% v 49.7%; RR 1.65, 95% CI 1.27 to 2.13). Staff were more likely to report incidents which are habitually reported, often witnessed, and usually associated with immediate outcomes such as patient falls and medication errors requiring corrective treatment. Near misses and incidents which occur over time such as pressure ulcers and DVT due to inadequate prophylaxis were least likely to be reported. The most frequently stated barrier to reporting for doctors and nurses was lack of feedback (57.7% and 61.8% agreeing, respectively).

CONCLUSIONS

Both doctors and nurses believe they should report most incidents, but nurses do so more frequently than doctors. To improve incident reporting, especially among doctors, clarification is needed of which incidents should be reported, the process needs to be simplified, and feedback given to reporters.

Osteoporosis screening in people with airways disease

We tested associations between risk factors and bone mineral density in airways disease subjects, and developed a clinical screening tool to identify people who could benefit from bone mineral density testing. Subjects were recruited through hospital outpatients and pharmacies (Newcastle, n = 172). With survey refinement, we then tested a revised tool in a second sample (Adelaide, n = 317). Study factors included oral/inhaled corticosteroid use, asthma severity, respiratory admissions, physical activity, percent predicted forced expiratory volume in one second (FEV1), body mass index, and smoking history. Outcomes were bone mineral density of lumbar vertebra (L2-4) and total (or neck of) femur. Analysis was logistic regression with generation of a simple screening algorithm based upon coefficients. Scoring algorithm risk factors for T-score of < - 2.0: age > or = 68 = 10 points, bone mineral density < 20 = 25, weight < 60 kg = 20, 60-69 kg = 10, > or = 80 cigarette pack years = 15, low-level leisure activity = 5, area under receiver operator curve 0.83. For a cut-off score of 10, sensitivity was 91.2%, specificity 53.9%, positive and negative predictive values 52.3 and 91.7%, and 67.2% were correctly classified. In conclusions, our model has acceptable sensitivity, although limited specificity. Use of this tool may reduce unnecessary referrals for bone mineral density measurement.

Randomized controlled trial of alendronate in airways disease and low bone mineral density

BACKGROUND

Patients with airways disease have been demonstrated to be at risk of osteoporosis, and this is likely to be multifactorial. Our aim was to identify patients with low bone mineral density (BMD) using a screening program, and then evaluate the benefit of daily alendronate.

METHOD

Subjects with hip or lumbar spine baseline T-scores < - 2.5, or Z-score < - 1.0 commenced on alendronate/calcium (10 mg/600 mg day) or placebo/calcium, in a double blind randomized controlled trial. BMD by dual emission X-ray absorptiometry (lumbar vertebrae 2-4, neck of femur, total femur) was repeated after 12 months, with adverse events recorded.

RESULTS

145 subjects (74 male, 71 female, mean age 67, median FEV1 1.0 litres = 43% of predicted) were enrolled; 66 alendronate/calcium, 79 placebo/calcium with 24 and 26 withdrawals, respectively. Per protocol but not intention to treat analysis of covariance demonstrated statistically significant improvements in T and Z scores for lumbar spine bone mineral density (P = 0.035, P = 0.040), with no improvement demonstrated at the hip.

CONCLUSIONS

Improvement in bone mineral density has been demonstrated at the lumbar spine, but not hip, by per protocol analysis, with daily alendronate, at 12 months.

Fluid for thought: availability of drinks in primary and secondary schools in Cardiff, UK

OBJECTIVE

While adequate hydration is undoubtedly essential for health, well-being, performance and learning, it is important to recognize that drinks may also have significant detrimental effects on both general and dental health. Since, on weekdays, at least half of a child's recommended daily fluid intake must be imbibed at school, this study sought to examine the provision of drinks in that setting.

SUBJECTS AND METHODS

A self-administered postal questionnaire study was sent to the head teachers of all 107 state primary and all 20 state secondary schools in Cardiff, South Wales, UK.

RESULTS

A response rate of 81.9% was achieved. Children had access to fresh drinking water from at least one drinking fountain in 69 (66.4%) of the 104 schools who responded to the questionnaire. Milk was available in 69 (80.2%) of the 86 responding primary schools. Sixteen (88.9%) of the 18 responding secondary schools had drink vending machines selling a variety of drinks.

CONCLUSIONS

While primary schools appear largely to restrict the availability of drinks to those conducive to the maintenance of good general and dental health, secondary schools appear to foster the use of vending machines. Guidelines should be developed on the use and content of vending machines in schools in order to both meet school objectives and promote healthy choices.

Differential response to alcohol in light and moderate female social drinkers

Individuals who are moderate drinkers are at increased risk to abuse alcohol. Moreover, women are more vulnerable than men to the adverse consequences of alcohol consumption and recent data indicate that the drinking pattern in women is becoming more similar to that of men. However, few studies have determined whether female moderate drinkers (MD) show a differential response to the subjective and performance effects of alcohol, compared to female light drinkers (LD). Fifteen female MD who consumed an average of 34.7 drinks/month were compared to 15 female LD who consumed an average of 6.7 drinks/month. None of the participants had a first-degree family history of alcoholism or substance abuse. The acute effects of alcohol (0, 0.25, 0.50, 0.75 mg/kg) were evaluated using a double-blind, placebo-controlled outpatient design. Drug effects were assessed using a full range of performance measures, subjective-effects questionnaires and observer ratings. Alcohol impaired performance in a dose-related manner on all performance tasks for both groups of females. However, MD were less impaired than LD on balance and Digit Symbol Substitution Test (DSST). This reduced response was also evident from the observer ratings, with MD being viewed as less impaired by alcohol than LD. While ratings of Drug Liking increased in both groups of women on the ascending limb of the breath alcohol curve, alcohol was disliked by LD on the descending limb and LD reported increased ratings of Bad Drug Effects following the high dose of alcohol. The reduced performance impairment, coupled with the positive subjective effects and relative absence of adverse subjective effects, suggestive of behavioral tolerance, could result in a progression towards increased alcohol consumption among moderate female social drinkers.

Noninvasive imaging of tumor hypoxia in rats using the 2-nitroimidazole 18F-EF5

Tumor hypoxia is an important prognostic indicator for cancer therapy outcome. EF5 [2-(2-nitro-1[ H]-imidazol-1-yl)- N-(2,2,3,3,3-pentafluoropropyl)-acetamide] has been employed to measure tumor hypoxia in animals and humans using immunohistochemical methods. EF5 is a lipophilic molecule designed to have a very uniform biodistribution, a feature of obvious benefit for use in PET imaging. The present study represents the first demonstration of noninvasive PET imaging of rat tumors using fluorine-18 labeled EF5. Because of the small tumor size, partial volume effects may result in underestimation of concentration of the compound. Therefore, validation of the PET data was performed by gamma counting of the imaged tissue. The tumor models studied were the Morris 7777 (Q7) hepatoma (n=5) and the 9L glioma (n=2) grown subcutaneously in rats. Our previous studies have demonstrated that early passage 9L tumors are not severely hypoxic and that Q7 tumors are characterized by heterogeneous regions of tumor hypoxia (i.e., Q7 tumors are usually more hypoxic than early passage 9L tumors). The seven rats were imaged in the HEAD Penn-PET scanner at various time points after administration of 50-100 micro Ci (18)F-EF5 in 30 mg/kg carrier nonradioactive EF5. The carrier was used to ensure drug biodistribution comparable to prior studies using immunohistochemical methods. (18)F-EF5 was excreted primarily via the urinary system. Images obtained 10 min following drug administration demonstrated that the EF5 distributed evenly to all organ systems, including brain. Later images showed increased uptake in most Q7 tumors compared with muscle. Liver uptake remained relatively constant over the same time periods. Tumor to muscle ratios ranged from 0.82 to 1.73 (based on PET images at 120 min post injection) and 1.47 to 2.95 (based on gamma counts at approximately 180 min post injection). Tumors were easily visible by 60 min post injection when the final tumor to muscle ratios (based on gamma counts) were greater than 2. Neither of the 9L tumors nor the smallest Q7 tumor met this criterion, and these tumors were not seen on the PET images. These preliminary results suggest that (18)F-EF5 is a promising agent for noninvasive assessment of tumor hypoxia. Plans are underway to initiate a research project to determine the safety and preliminary evidence for the efficacy of this preparation in patients with brain tumors.

Prevalence and treatment of hypercholesterolaemia in patients with peripheral vascular disease

Background

Hypercholesterolaemia is a recognized risk factor for the development of arteriosclerosis. There is compelling evidence to support the use of lipid-lowering strategies in all hypercholesterolaemic patients with arteriosclerotic disease. In peripheral arterial disease (PAD), national guidelines recommend treatment if total cholesterol exceeds 5·0 mmol l−1. The prevalence of hypercholesterolaemia in patients with PAD was determined and the adequacy of lipid management before vascular referral was examined.

Methods

This was a prospective study of 233 consecutive patients admitted electively to this vascular surgery unit between December 1997 and December 1998. Some 68 patients were admitted with carotid disease, 81 with an aneurysm and 84 with intermittent claudication. A fasting venous blood sample was obtained from each patient.

Results

There were 175 men and 58 women, of median age 67 (range 37–85) and 68 (range 47–85) years respectively. Only 35 patients (15 per cent) were previously known to be hypercholesterolaemic; all but one were receiving treatment (one dietary, 33 statin). Of the remaining 198 patients, 124 (63 per cent) had a serum cholesterol level above 5·0 mmol l−1. A further 17 patients (9 per cent) had total cholesterol/high-density lipoprotein: cholesterol ratio greater than 5·0; these patients may also benefit from lipid-lowering therapy. In total, 141 (80 per cent) of 176 hypercholesterolaemic patients were undiagnosed at the time of hospital admission.

Conclusion

Hypercholesterolaemia is an important and correctable risk factor found in the majority of patients with PAD, but despite national guidelines and clear evidence from randomized controlled trials it is simply not being diagnosed in primary care. All elective patients with PAD should be screened for hypercholesterolaemia during their admission.

Infrainguinal bypass grafting for critical ischaemia in the hands of trainees

Background

Changes in surgical training mean that operative experience must be gained more efficiently. However, it is important to demonstrate that increasing training opportunities are not associated with inferior patient outcome. The immediate and long-term outcomes of patients undergoing infrainguinal bypass surgery by consultants and trainees were compared.

Methods

A prospectively gathered database of 1077 infrainguinal bypasses performed on 1003 patients for chronic critical limb ischaemia between 1 January 1983 and 31 December 1998 in a single regional vascular unit was evaluated.

Results

Consultants performed 733 operations (68·1 per cent), 347 (47·3 per cent) above-knee, 257 (35·1 per cent) below-knee popliteal, 121 (16·5 per cent) crural and eight (1·1 per cent) other procedures. Of 344 trainee operations, 170 (49·4 per cent) were above-knee, 122 (35·5 per cent) below-knee, 48 (14·0 per cent) crural and four (1·2 per cent) other operations. There was no significant difference in 30-day mortality rate between consultant (2·8 per cent) and trainee (2·0 per cent) operations, nor was there any significant difference in patency or limb salvage rates at 36 months (Table). There was a trend towards reduced graft patency in trainee crural bypasses but this was not statistically significant (35·9 versus 56·2 per cent; P = 0·14, log rank test).

Conclusion

These data suggest that, with appropriate case selection and supervision, training in femoropopliteal and crural bypass grafting does not compromise early or long-term outcome.

Exercise in claudicants is associated with systemic fibrinolysis

Background

Claudicants have been shown to mount a potentially harmful systemic inflammatory response to exercise, characterized by vascular endothelial activation and thrombin generation. However, the fibrinolytic response to exercise remains unknown. This study aimed to determine the nature of the fibrinolytic response to exercise in claudicants and normal controls.

Methods

Peripheral venous blood was drawn from 18 claudicants and eight age- and sex-matched controls before, immediately and 1, 5, 10, 20, 40 and 60 min after treadmill exercise (Gardner protocol). Claudicants exercised to the point of maximal ischaemic pain and controls to the point of fatigue. Plasma tissue plasminogen activator (tPA) activity and plasminogen activator inhibitor (PAI) 1 activity were measured by ‘Coaset’ PAI and ‘Coatest’ tPA assays (Chromogenix, Sweden).

Results

There was no significant difference in tPA or PAI-1 activity between the groups at baseline. tPA activity increased significantly immediately after exercise in all claudicants (median (interquartile range) 2·8 (1·6–4·0) versus 5·6 (3·5–7·7) units ml−1; P = 0·003, Wilcoxon test) and remained significantly raised for 10 min. This was accompanied by an immediate significant fall in PAI-1 activity (8·5 (4·3–12·7) versus 8·3 (5·0–11·6) units ml−1; P = 0·04) which normalized by 10 min. Neither tPA activity or PAI-1 levels changed significantly in the control group.

Conclusion

These data indicate that exercise in claudicants is associated with systemic fibrinolysis. The immediacy and short-lived nature of the response suggests that it occurs as a consequence of muscle ischaemia rather than reperfusion.

Human esophageal cancer is distinguished from adjacent esophageal tissue by tissue cysteine concentrations

Recent studies have suggested that cysteine, in addition to glutathione, may play a role in the genesis, pathobiology, and treatment response of rodent and human cancers. We examined the relative concentrations of cysteine and glutathione in human esophageal cancer and adjacent, minimally involved esophageal tissue. Small biopsies from tumors and adjacent esophageal tissues were placed into cold acid to allow extraction of low-molecular-mass compounds and simultaneous precipitation of macromolecules. Supernatants were analyzed by high-performance liquid chromatography with electrochemical detection for thiol content. While there was no statistically significant difference between the glutathione content of tumor versus adjacent tissue (2.2 mM vs 2.1 mM, respectively), tumor tissue had significantly higher levels of cysteine than adjacent tissue (0.21 mM vs 0.13 mM, respectively). In conclusion, cysteine content distinguishes tumor from adjacent more normal tissue.

The effects of alprazolam and buspirone in light and moderate female social drinkers

Individuals who are moderate/heavy drinkers are at increased risk to abuse benzodiazepines and this risk is increased in women compared to men. However, no studies have determined whether female moderate drinkers (MD) show a differential response to the subjective and performance effects of benzodiazepines compared to female light drinkers (LD). Fourteen female MD who consumed an average of 36 drinks/month were compared to 14 female LD who consumed an average of 4.2 drinks/month. None of the participants had either a first- or second-degree family history of alcoholism. The acute effects of placebo, alprazolam (0.25, 0.50, 0.75 mg) and buspirone (5, 10, 15 mg) were evaluated using a double-blind, placebo-controlled outpatient design. Drug effects were assessed using a full range of performance measures and subjective-effects questionnaires. Alprazolam impaired performance in a dose-related manner on all performance tasks for both groups of females, whereas buspirone had minimal effects on performance. There were few differences between LD and MD with respect to subjective response or performance impairment following either alprazolam or buspirone. Although MD reported greater ratings of Good Drug Effect and Drug Liking than LD, this was neither dose-related, nor specific to alprazolam. The results of the present study suggest that female MD without a family history of alcoholism experience the same level of performance impairment as female LD, although they tend to report greater positive subjective effects from alprazolam.

Re-colonisation and recovery of populations of dogwhelks Nucella lapillus (L.) on shores formerly subject to severe TBT contamination

Dogwhelks Nucella lapillus became locally extinct on some shores adjacent to areas of high shipping/boating activity during the period of high tributyltin (TBT) contamination in the 1980s and early 1990s. However, the species has now re-colonised sites at which extinction occurred on the Isle of Cumbrae, the northeast coast of England, the Shetland Isles and southwest England. There have also been substantial declines in the severity of imposex on adjacent shores where the species has persisted during this period. Re-colonisation and recovery can be attributed to two measures: regulations prohibiting the use of TBT-based paints on vessels < 25 m in length and the development of slow-releasing, self-polishing copolymer paints. Nevertheless, the International Maritime Organisation has now imposed a total ban on the use of TBT-based paints as antifoulants. This is almost certain to result in the use of paints containing alternative biocides and there is widespread concern that there is relatively little information on which to assess their likely environmental impacts. They could cause substantial environmental damage.

Effects of hyperglycemia on oxygenation, radiosensitivity and bioenergetic status of subcutaneous RIF-1 tumors

Since tissue oxygen tension is a balance between delivery and consumption of oxygen, considerable effort has been directed at increasing the former and/or decreasing the latter. Techniques to decrease the rate of cellular oxygen consumption (increasing the distance oxygen can diffuse into tissues) include increasing glycolysis by administering supra-physiologic levels of glucose. We have examined the effect of hyperglycemia produced by intravenous glucose infusion on the tissue oxygenation and radiation response of subcutaneously implanted murine radiation induced fibrosarcomas (RIF-1). A 0.3 M glucose solution was delivered via tail vein injection according to a protocol that maintained glucose at a plasma concentration of 17+/-1 mM. The effect of this treatment on radiation response (clonogenic and growth delay studies), tumor oxygenation (needle electrode pO2 and 2-[2-nitro-1H-imidazol-1-yl]-N-(2,2,3,3,3-pentafluoropropyl) acetamide (EF5) binding), and tumor bioenergetics and pH (31P NMR spectroscopy) was examined. Systemic measurements included hematocrit and blood glucose and lactate concentrations. The results of these studies suggest that these subcutaneously implanted RIF-1 tumors are both radiobiologically and metabolically hypoxic and that intravenous glucose infusion is not an effective method of modifying this metabolic state.

A review and assessment of tributyltin contamination in the North Sea, based on surveys of butyltin tissue burdens and imposex/intersex in four species of neogastropods

It is evident from measures of butyltin tissue burdens and imposex or intersex in neogastropods that tributyltin (TBT) contamination of coastal waters and open parts of the North Sea is now low. It has been declining for at least the past decade. This is probably due to two measures. First, regulations prohibiting the use of TBT-based paints on small boats and fish farms have reduced inputs of TBT from these sources so that they are now negligible (except possibly where the regulations are flaunted). Second, there is evidence from sites, where commercial vessels are the sole source of TBT, that the adoption of TBT SPC paints has been effective in reducing environmental levels of these contaminants. However, poor dockyard practices, allowing TBT-contaminated wastes, including paint flakes, to accumulate in sediments have left a legacy of hot-spots of contamination in some ports. The impact is localised so that TBT contamination is low in coastal areas immediately adjacent to ports.

MR-based statistical atlas of the Göttingen minipig brain

Thedomestic pig is increasingly being used as an experimental model for brain imaging studies with positron emission tomography (PET). The recording of radiotracer uptake by PET gives functional and physiological information, but with poor spatial resolution. To date, anatomical regions of interest in pig brain have been defined in MR images obtained for each individual animal, because of the lack of a standard stereotaxic coordinate system for the pig brain. In order to define a stereotaxic coordinate system, we coregistered T1-weighted MR images from 22 male Göttingen minipigs and obtained a statistically defined surface rendering of the average minipig brain in which stereotaxic zero is defined by the position of the pineal gland. The average brain is now used as a target for registration of dynamic PET data, so that time-activity curves can be extracted from standard volumes of interest. In order to define these volumes, MR images from each individual pig were manually segmented into a total of 34 brain structures, including cortical regions, white matter, caudate and putamen, ventricular system, and cerebellum. The mean volumes of these structures had variances in the range of 10-20%. The 34 brain volumes were transformed into the common coordinate system and then used to generate surface renderings with probabilistic threshold greater than 50%. This probabilistic threshold gave nearly quantitative recovery of the mean volumes in native space. The probabilistic volumes in stereotaxic space are now being used to extract time-radioactivity curves from dynamic PET recordings.

Hypoxia and VEGF mRNA expression in human tumors

High expression of circulating plasma vascular endothelial growth factor (VEGF) in patients with cancer is an indicator of poor treatment response. Similarly, hypoxia in tumors, as measured by oxygen needle electrodes, has been found to predict for tumor-treatment failure. These two predictors may be related because hypoxia is a potent stimulator of VEGF expression in vitro. However, the demonstration of a relationship between hypoxia and VEGF in human tumors has, to date, been indirect or even negative. The purpose of this study was to test whether this unexpected result was caused by factors unique to human tumors, or whether the prior results could have been influenced by the known complexities of VEGF regulation. Therefore, we undertook a direct assessment of VEGF induction in human tumors using in situ hybridization and compared its distribution with that of hypoxia, as measured by the distribution of adducts of the hypoxia marker EF5. The distribution of both markers was assessed in relationship to the distribution of blood vessels, as measured by antibodies to CD31. Our hypothesis was that VEGF mRNA and hypoxia would colocalize, assuming that detectability of the former was not limiting. Four squamous cell carcinomas, three sarcomas and one glioblastoma multiforme were studied. When VEGF mRNA signal was detectable, its maxima colocalized with regional maxima of EF5 binding. The strongest levels of both signals were sometimes adjacent to regions of tissue necrosis. However, we were unable to predict absolute levels of EF5 binding based on absolute levels of VEGF mRNA. Conversely, for all tumors studied, regions with relatively low levels of EF5 binding had relatively low or undetectable VEGF mRNA. We found moderate EF5 binding in some keratinized cells but VEGF mRNA was not expressed by these differentiated cells. The paradigm that hypoxia and VEGF expression are linked in human tumors is supported by the data presented herein. A better understanding of the biology behind VEGF expression, including its modulation by hypoxia, is important for optimizing its use as a prognostic indicator and/or modulating its presence with biologic therapies.

Effect of flupenthixol on subjective and cardiovascular responses to intravenous cocaine in humans

The effects of oral flupenthixol and intramuscular (i.m.) flupenthixol decanoate in combination with intravenous (i.v.) cocaine were evaluated in male cocaine abusers. Participants resided at an inpatient research unit for 27 days followed by an 11-day outpatient period. Oral flupenthixol (2.5 or 5.0 mg; p.o.) followed by flupenthixol decanoate (10 or 20 mg; i.m.) and placebo were investigated in individuals who were randomly assigned to one of three groups under double-blind conditions (placebo, low or high dose flupenthixol). During the inpatient period, participants had four fixed cocaine dosing sessions; each session they were administered four doses of i.v. cocaine (approx. 48 mg/70 kg), spaced 14 min apart. These sessions occurred once before medication (baseline phase), once following oral medication (oral phase), and twice following intramuscular medication (IM phase). Out of 23 participants, 18 completed the study; 4 of the 5 non-completers were in the high dose flupenthixol group. Overall, there were few subjective, cardiovascular, or cocaine pharmacokinetic differences between the placebo group and the low dose flupenthixol group, indicating that the low dose of flupenthixol was well tolerated, but ineffective. In the high dose flupenthixol group, two out of seven individuals (29%) experienced a dystonic reaction following oral flupenthixol and were medically discharged. Taken together, these findings indicate that flupenthixol is not a good candidate for treating cocaine abusers.

Interactive roles of superoxide and inducible nitric oxide synthase in rat intestinal injury provoked by non-steroidal anti-inflammatory drugs

The role of nitric oxide (NO) formed by inducible NO synthase (iNOS), superoxide and the lipopolysaccharide from luminal bacteria in non-steroidal anti-inflammatory drug-induced intestinal injury was investigated in the rat. Administration (s.c. or p.o.) of indomethacin (10 mg kg(-1)), flurbiprofen (40 mg kg(-1)) or diclofenac (40 mg kg(-1)) increased the vascular leakage of radiolabelled albumin in the jejunum, determined after 24 h, associated with the induction of iNOS, assessed by the conversion of radiolabelled L-arginine. Pre-treatment with ampicillin (200 mg kg(-1) day(-1), p.o.), metronidazole (200 mg kg(-1) day(-1), p.o.), or polymixin B (15 mg kg(-1) day(-1), s.c.), inhibited indomethacin-induced lesion formation, reduced microvascular leakage and prevented the expression of iNOS activity. Administration of the highly selective iNOS inhibitor, GW273629 ((R)-2-amino-4,4-dioxo-6(1-iminioethylamino)-4-thiahexanoic acid; 5 mg kg(-1), s.c.), 18 h after indomethacin, likewise prevented the intestinal lesions and attenuated the microvascular leakage. Superoxide dismutase conjugated with polyethylene glycol (3000 U kg(-1), i.v.), inhibited the indomethacin-induced lesions and microvascular leakage, but not the expression of iNOS activity. These findings suggest that non-steroidal anti-inflammatory drugs compromise mucosal integrity, leading to luminal bacterial translocation. This provokes iNOS induction, leading to microvascular injury involving both NO and superoxide.

Hypoxic heterogeneity in human tumors: EF5 binding, vasculature, necrosis, and proliferation

We evaluated the levels and distribution of hypoxia in 31 human tumors using fluorescent immunohistochemical detection of binding by the 2-nitroimidazole, EF5. Hypoxia was found to be a heterogeneous property of human tumors. Necrosis was usually found adjacent to the highest level of binding in an individual patient's tumor. However, hypoxia often occurred without necrosis. In the group of tumors studied, the most common relationship between blood vessels (PECAM/CD31) and EF5 staining was consistent with diffusion-limited hypoxia; acute hypoxia occurred infrequently. Within a given patient's tumor, there was an inverse correlation between regions of proliferation (Ki-67) and regions of hypoxia. Again, however, when these parameters were examined in a group of patients, the absence of proliferation did not predict the presence of hypoxia. The relationships between hypoxia and other biologic endpoints are complex, but, within a given tumor's spatial relationships, they are in accord with known physiologic principles. Thus, our data emphasize that the relationships between hypoxia and other biologic parameters vary between patients. Necrosis, proliferation, and blood vessel distribution cannot predict the level or presence of hypoxia in an individual patient's tumor.

Pharmacokinetics of EF5 [2-(2-nitro-1-H-imidazol-1-yl)-N-(2,2,3,3,3-pentafluoropropyl) acetamide] in human patients: implications for hypoxia measurements in vivo by 2-nitroimidazoles

OBJECTIVES

Pharmacokinetic studies were performed on the first 28 patients enrolled in a phase I trial to determine the ability of EF5 [2-(2-nitro-1-H-imidazolI-yl)-N-(2,2,3,3,3-pentafluoropropyl) acetamide] to detect hypoxia in human tumors in the absence of patient toxicity.

METHODS

EF5 was made in purified form and formulated for intravenous injection by the National Cancer Institute. After obtaining consent from the patients, EF5 was administered and blood samples were drawn at various times over approximately 48 h. For most patients it was possible to collect total urine at approximately 8-h intervals. EF5 in plasma and urine was analyzed by high-performance liquid chromatography.

RESULTS

EF5's plasma concentration followed a simple exponential decay following infusion. The plasma half-life was 11.7 +/- 2.6 h (+/- SD) and was not affected by drug dose (9 to 28 mg/kg), fractional urine recovery, patient weight or gender. Absolute plasma values suggested even biodistribution of the drug throughout the soft tissue with a volume of distribution equal to 0.56 l/ kg. Despite the relatively high lipid partition coefficient (logP = 0.6), EF5 was excreted primarily (up to 70%) via kidney clearance. No drug metabolites (e.g. retaining the 2-nitroimidazole chromophore) were detected in either plasma or urine. No toxicity was found at drug doses adequate to detect tumor hypoxia.

CONCLUSIONS

Currently held paradigms of 2-nitroimidazole metabolism (e.g. clearance rate and toxicity as affected by octanol/ water partition coefficient) are discussed. The results reported herein suggest that EF5 is biologically stable with predictable pharmacokinetics. EF5's consistent half-life and clearance properties will allow quantitative analysis of EF5 binding relative to tissue oxygen levels.

Long-term comparative experience with tolcapone and entacapone in advanced Parkinson's disease

The objective of this study was to compare the long-term tolerability and efficacy of tolcapone and entacapone in patients with fluctuating Parkinson's disease (PD). Tolcapone and entacapone are two currently available catechol- O -methyltransferase inhibitors that have demonstrated efficacy in the treatment of advanced PD. There are little published data on long-term experience and no direct comparisons. We compared the results of two separate, simultaneous, long-term open label extensions, one for tolcapone and the other for entacapone. The inclusion/exclusion criteria were similar. Data were collected prospectively at 6, 12, 24, and 36 months. Efficacy measures included the Unified Parkinson's Disease Rating Scale (UPDRS) total score, subscores, items 32 (duration of dyskinesia) and 39 (duration of "off" time), and levodopa dose. The two groups were compared using a Mann-Whitney U test for change from baseline and analysis of variance. Tolerability was defined as the ability of patients to maintain therapy and was compared using a Kaplan-Meier analysis. Eleven patients enrolled in the entacapone study and 14 in the tolcapone study. The tolcapone group had more severe disease with significantly higher UPDRS motor score, duration of "off," and levodopa dose requirement. Tolcapone was more effective in lowering UPDRS motor and complication subscores, duration of "off" time, and levodopa doses. UPDRS motor scores and change in levodopa dose in the tolcapone group remained below baseline level for 36 months; however, they were above baseline in the entacapone group from 6 months on. Tolerability was the same for both treatments. Tolcapone appears to have greater and longer efficacy with regard to motor symptoms, "off" time, and change in levodopa requirements than entacapone. These findings indicate that tolcapone continues to have a place in the treatment of advanced PD. However, the risks associated with this drug, particularly hepatic injury, and the requirement for rigorous blood monitoring, need to be considered when choosing an appropriate treatment for patients with advanced PD.

Development of a high throughput in vitro toxicity screen predictive of high acute in vivo toxic potential

At an early stage of drug discovery high throughput screens are an invaluable tool to de-select compounds with undesirable properties. A high throughout in vitro toxicity screen has been developed and validated to identify compounds that have a high potential to be acutely toxic in vivo. This screen is based on treating Chinese hamster ovary (CHO) cells with test compounds for 24 h and then determining the degree of cytotoxicity by the reduction of Resazurin. Twenty-six structurally unrelated compounds were chosen that spanned a range of acute LD(50) values and mechanisms of toxicity. The acute LD(50) values (intraperitoneal and intravenous routes) from rat and mouse were taken from the RTECS database. Experimentally derived in vitro IC(35) results were compared to the 'most toxic' (lowest) LD(50) values for each compound. The resulting correlation was statistically significant (r=0.8475). However, due to the scatter of the data points, it was considered not appropriate to rank compounds according to their degree of in vivo toxicity on the basis of the in vitro result. However, by defining cut-off concentrations for both the in vivo (LD(50)) and the in vitro (IC(35)) values it was possible, using the in vitro result (IC(35) <10 microM), to identify compounds that had a high potential to be acutely toxic in vivo ('most toxic' LD(50) <25 micromol/kg). Further development led to a high throughput screen capable of giving a 'Yes', 'No' or 'Borderline' classification as to whether a compound has a high acute in vivo toxic potential. This screen is highly specific (no false positive classifications) and has a sensitivity of approximately 80%. This is deemed acceptable for a first tier toxicity screen at an early stage in the drug discovery process. Transfer of this screen from GlaxoSmithKline UK to sites in Italy, Spain and the USA resulted in very similar findings indicating the inter-laboratory robustness of this screen and therefore the ability to compare results across the GlaxoSmithKline sites.

Volunteers assess marine biodiversity

Much less is known about marine biodiversity than that of terrestrial and freshwater environments. There is surprisingly little information about even the most common of organisms that live on the seashore. Science has limited resources to study them and volunteers can therefore make significant contributions. This article considers the value of a project in which volunteers are mapping the distribution and abundance of littoral animals and plants of the Northumberland coast.

Plasma endothelin levels and outcome in patients undergoing repair of ruptured infrarenal abdominal aortic aneurysm

BACKGROUND

Endothelin-1 (ET-1) is the most potent known vasoconstrictor. Elevated plasma levels have been demonstrated in patients with myocardial infarction, cardiogenic and septic shock, and respiratory, heart, and kidney failure, as well as in those undergoing elective abdominal aortic aneurysm (AAA) repair. However, endothelin levels have not previously been examined in patients undergoing repair of ruptured AAA. We hypothesized that hemorrhagic shock, lower torso ischemia, and reperfusion associated with ruptured AAA repair lead to increased synthesis and secretion of ET-1, which, in turn, predispose to organ failure, one of the principal causes of death in this condition.

METHODS

Fourteen patients were studied. Plasma levels of big ET-1 and ET-1 were measured immediately before operation and immediately before, 5 minutes, and 6 hours after aortic clamp release.

RESULTS

All patients survived for at least 24 hours after operation. Big ET-1 levels were above the normal range at one or more sample points in all patients, and the ET-1 levels were above the normal range in all survivors and four of five nonsurvivors. Five patients who died of organ failure had significantly lower big ET-1 levels at all sample points and significantly lower ET-1 levels after 5 minutes of reperfusion when compared with survivors. Preoperative ET-1 levels were significantly lower in eight patients who subsequently developed kidney failure than in six patients who did not.

CONCLUSION

Contrary to our original hypothesis, these novel data demonstrate that patients with ruptured AAA in whom fatal postoperative organ failure develops have significantly lower perioperative endothelin levels than survivors.

Location preference related to smoked heroin self-administration by rhesus monkeys

RATIONALE

Although common in humans, little is known about the reinforcing efficacy of smoked heroin in laboratory animals.

OBJECTIVES

To evaluate the reinforcing efficacy of smoked heroin in non-opioid dependent, non-human primates.

METHODS

Self-administration and location-preference measures were obtained by having monkeys live in two chambers with heroin self-administration (0, 0.3, 0.6 mg/kg; eight dosings available per day) specific to one chamber and no commodity available in the other chamber. Operant responding reinforced by smoked heroin provided a self-administration measure of reinforcement, and the length of time monkeys spent in the heroin-associated chamber provided a location preference estimate of reinforcing efficacy.

RESULTS

Four of six monkeys acquired heroin self-administration: these monkeys completed six to eight smoking trials each day when either of the active heroin doses was available. Urine toxicology confirmed that monkeys were absorbing the smoked heroin. The number of completed smoking trials rapidly decreased under extinction conditions, indicating that smoked heroin was an efficacious reinforcer using the self-administration measure. Monkeys developed a location preference for the chamber where heroin was self-administered, indicating that smoked heroin was an efficacious reinforcer using the location-preference measure.

CONCLUSIONS

Smoked heroin is an efficacious reinforcer in non-opioid dependent rhesus monkeys as measured using a self-administration procedure and estimated using a location-preference procedure.

Low pO2 and beta-estradiol induce VEGF in MCF-7 and MCF-7-5C cells: relationship to in vivo hypoxia

Previous work from this laboratory demonstrated that MCF-7 breast carcinoma cells grown in nude mice contained minimal hypoxia but that tamoxifen treatment of these tumors resulted in increased hypoxia (Evans S. et al., Cancer Research, 1997). These findings led to studies exploring the link between estrogen signaling and tumor oxygenation and determining the role of VEGF in this process. The stimulation of estrogen-dependent MCF-7 breast carcinoma cells in vitro with beta-estradiol resulted in a two-fold induction of VEGF mRNA and 1.3-2-fold increase in protein, similar to what was observed when these cells were exposed to 0. 1% oxygen. Furthermore, the two stimuli given together had an additive effect on (increasing) VEGF expression, suggesting that the combination of hypoxia and estrogen may be important in upregulating VEGF in some breast cancers. Estrogen-independent MCF-7-5C cells, developed by growing MCF-7 cells in long-term culture in estrogen-free media, were also studied. Using EF5, a fluorinated 2-nitroimidazole which localizes to hypoxic cells, MCF-7-5C tumors grown in nude mice were found to contain lower pO2 levels and more hypoxic regions than similarly grown MCF-7 tumors. We tested the hypothesis that this might be the result of defective expression of VEGF in MCF-7-5C cells in response to beta-estradiol and/or hypoxia. However, MCF-7-5C and MCF-7 cells showed a similar induction of VEGF in vitro in response to either beta-estradiol or hypoxia. Therefore, although these two cell lines grown as tumors have substantial differences in the presence and patterns of hypoxia, this could not be explained by a difference in VEGF induction.

The effects of D-amphetamine on responding for candy and fruit drink using a fixed ratio and a progressive ratio schedule of reinforcer delivery

The first purpose of this study was to compare the effects of D-amphetamine (AMPH) on operant responding reinforced under fixed ratio (FR) or progressive ratio (PR) schedules of reinforcement, testing the hypothesis that responding reinforced under a PR operant schedule would be disrupted by lower doses of AMPH than responding reinforced under a FR operant schedule. The second purpose of this study was to test the generalizability of the first hypothesis by comparing the effects of AMPH on responding reinforced by two different reinforcers under both FR and PR operant schedules. Rhesus monkeys had five to six candy and five to six fruit drink sessions per day, and could receive two reinforcers per session. Responding was initially reinforced under a PR procedure, such that the ratio size increased with each subsequent session. The parameters of the PR schedule were individually selected so that monkeys consumed a similar number of candy and fruit-drink reinforcers each day. The effects of oral AMPH (0.5, 0.75, 1.0 mg/kg) on responding were assessed. Responding was then stabilized using a FR schedule with parameters individually selected so that monkeys consumed a similar number of candy and fruit-drink reinforcers each day, and the effects of oral AMPH were again assessed. The PR breakpoint was significantly greater for candy than fruit-drink. AMPH produced dose-related decreases in both candy and fruit-drink intake, but each AMPH dose decreased the number of fruit-drink deliveries to a greater extent than the number of candy deliveries. The results failed to support the hypothesis that responding under PR schedules of reinforcement would be disrupted by lower doses of AMPH.

Doppler ultrasound imaging detects changes in tumor perfusion during antivascular therapy associated with vascular anatomic alterations

Noninvasive monitoring of antiangiogenic therapy was performed by serial power Doppler ultrasound imaging of murine tumors treated with recombinant interleukin 12, the results of which were correlated with assessments of tumor vascularity by microscopy. Growth of established K1735 tumors, but not of IFN-gamma-unresponsive K1735.N23 variants, was suppressed by treatment. Serial Doppler imaging of K1735 tumor vascularity during treatment revealed a progressive change from a diffuse perfusion pattern to a more punctate distribution. Quantitative analysis of the images revealed that color-weighted fractional average, representing overall tumor perfusion, consistently decreased in these tumors, primarily because of a decrease in fractional tumor cross-sectional area carrying blood flow. In contrast, these parameters increased in nonresponsive tumors during treatment. Confocal microscopy of thick tumor sections revealed a reduction in the density and arborization of vessels labeled in vivo by fluorochrome-conjugated lectin with effective treatment. Immunohistological examination of thin tumor sections confirmed the preferential loss of small vessels with successful therapy. Similar changes in tumor vascular anatomy and perfusion were also observed during recombinant interleukin 12 treatment of two other responsive murine tumor types. These results indicate that power Doppler ultrasound is a sensitive, noninvasive method for reporting functional consequences of therapy-induced vascular anatomical changes that can be used to serially monitor tumor perfusion and efficacy of antivascular therapy in clinical trials.

The farnesyltransferase inhibitor L744,832 reduces hypoxia in tumors expressing activated H-ras

Many tumors contain extensive regions of hypoxia. Because hypoxic cells are markedly more resistant to killing by radiation, repeated attempts have been made to improve the oxygenation of tumors to enhance radiotherapy. We have studied the oxygenation of tumor xenografts in nude mice after treatment with the farnesyltransferase inhibitor L744,832. Hypoxia was assessed by measuring the binding of the hypoxic cell marker pentafluorinated 2-nitroimidazole. We show that xenografts from two tumor cell lines with mutations in H-ras had markedly improved oxygenation after farnesyltransferase treatment. In contrast, xenografts from two tumors without ras mutations had equivalent hypoxia regardless of treatment. The effect on tumor oxygenation could be detected at 3 days and remained after 7 days of treatment. These results indicate that treatment with farnesyltransferase inhibitors can alter the oxygenation of certain tumors and suggest that such treatment might be useful in the radiosensitization of these tumors.