A population-based study of pulmonary monitoring and toxicity for patients with testicular cancer treated with bleomycin.

Background: Bleomycin is commonly used to treat advanced testicular cancer and can be associated with severe pulmonary toxicity. The primary objective of the present study was to describe the use of pulmonary function tests (pfts) and chest imaging before, during, and after treatment with bleomycin. Methods: To identify all incident cases of testicular cancer treated with bleomycin-based chemotherapy in the Canadian province of Ontario during 2005-2010, the Ontario Cancer Registry was linked with chemotherapy treatment records. Health administrative databases were used to describe use of pfts, chest imaging, and physician visits for respiratory complaints. Results: Of 394 patients treated with orchiectomy and chemotherapy who received at least 1 dose of bleomycin, 93% had complete chemotherapy records available. In the 4 weeks before, during, and within 2 years after finishing bleomycin-based chemotherapy, pfts were performed in 17%, 17%, and 29% of patients respectively. Chest imaging was performed in 68%, 62%, and 98% of patients in the same time periods. In the 2 years after bleomycin-based chemotherapy, 23% of treated patients had a physician visit for respiratory symptoms. That rate was substantially higher for men with greater exposure to bleomycin: 40% (24 of 60) for 10-12 doses bleomycin compared with 21% (53 of 250) for 7-9 doses and with 14% (8 of 58) for 1-6 doses (p = 0.002). Conclusions: Quality improvement initiatives are needed to increase baseline rates of chest imaging within 4 weeks of starting chemotherapy for testicular cancer; to understand why such a high proportion of men have chest imaging during bleomycin-based chemotherapy; and to mitigate the excess pulmonary toxicity seen with increasing exposure to bleomycin.

Venous Thromboembolism During Chemotherapy for Testicular Cancer: A Population-Based Study.

AIMS: Venous thromboembolism (VTE) is a potential complication among germ cell tumour patients. We evaluated the incidence rate, timing and factors associated with VTE among patients with germ cell cancer in routine practice. MATERIALS AND METHODS: The Ontario Cancer Registry was linked to electronic records of treatment to identify all cases of testicular cancer treated in Ontario during 2000-2010. Administrative databases were used to identify VTE in the 3 months before and 5 years after orchiectomy. We explored patient-, disease- and treatment-related factors associated with VTE among all patients as well as those with detailed chemotherapy records available. RESULTS: During 2000-2010, 2650 patients underwent orchiectomy for testicular cancer; among this cohort, 920 (33%) received chemotherapy. The VTE rate was 8% (69/920) among patients treated with chemotherapy and 0.6% (11/1730) among those without chemotherapy. Among the patients treated with chemotherapy who had VTE, 13% (9/69) occurred in the month before starting chemotherapy, 62% (42/69) in the first 3 months after starting and 25% thereafter. For patients who received three and four cycles, VTE rates were 8% (21/258) and 16% (19/121), respectively. In adjusted analyses, the only factor independently associated with VTE was increasing number of cycles (odds ratio 3.91 for four cycles, odds ratio 1.63 for three cycles (P = 0.022) compared with one to two cycles). CONCLUSION: This population-based study confirms findings from institutional case series regarding the high rate of VTE among patients with germ cell tumours treated with chemotherapy. Future studies should evaluate the extent to which VTE prophylactic strategies might mitigate this risk.

Neurotoxicity Among Survivors of Testicular Cancer: A Population-based Study.

AIMS: Neurotoxicity may affect the quality of life of survivors of testicular cancer. Understanding the burden of neurotoxicity is important to guide survivorship care. A population-based study was undertaken to describe the proportion of patients in the 'real world' with neurotoxicity. MATERIALS AND METHODS: A population-based, retrospective, cohort study of patients with advanced testicular cancer treated in the province of Ontario. The Ontario Cancer Registry was linked to electronic treatment records to identify all incident cases of testicular cancer during 2000-2010. Administrative databases were used to describe health system visits for symptoms potentially related to neurotoxicity. Health system visit rates were explored by number of chemotherapy cycles among patients treated during 2005-2010 for whom complete chemotherapy details were available. RESULTS: During 2000-2010, 2650 patients underwent an orchiectomy for testicular cancer; 920 (33%) also received chemotherapy. The proportion of patients with health system visits for neurotoxicity in the 2 years before surgery compared with the 2 years after surgery remained stable among patients treated with orchiectomy alone (18% [303/1730] versus 18% [316/1730], P = 0.523); however, there was a substantial increase among patients treated with chemotherapy (16% [151/920] versus 25% [231/920], P < 0.001). Among patients treated with chemotherapy in 2005-2010 for whom complete details were available regarding number of treatment cycles there was a dose-response effect. The increase in health system visits for neurotoxicity from 2 years before compared with 2 years after orchiectomy was greater among patients treated with four cycles of chemotherapy (17% [21/121] versus 37% [45/121]) and three cycles of chemotherapy (17% [45/258] versus 28% [72/258]) compared with those treated with one to two cycles of chemotherapy (<13% [<6/45] versus 20% [9/45], P = 0.013). CONCLUSIONS: This population-based study suggests that symptoms of neurotoxicity are common among survivors of testicular cancer and that this seems to be driven by increasing exposure to chemotherapy. Clinicians should carefully evaluate patients for neurotoxicity during the survivorship phase of treatment.

Extending standard testing period in honeybees to predict lifespan impacts of pesticides and heavy metals using dynamic energy budget modelling.

Concern over reported honeybee (Apis mellifera spp.) losses has highlighted chemical exposure as a risk. Current laboratory oral toxicity tests in A. mellifera spp. use short-term, maximum 96 hour, exposures which may not necessarily account for chronic and cumulative toxicity. Here, we use extended 240 hour (10 day) exposures to examine seven agrochemicals and trace environmental pollutant toxicities for adult honeybees. Data were used to parameterise a dynamic energy budget model (DEBtox) to further examine potential survival effects up to 30 day and 90 day summer and winter worker lifespans. Honeybees were most sensitive to insecticides (clothianidin > dimethoate ≫ tau-fluvalinate), then trace metals/metalloids (cadmium, arsenic), followed by the fungicide propiconazole and herbicide 2,4-dichlorophenoxyacetic acid (2,4-D). LC50s calculated from DEBtox parameters indicated a 27 fold change comparing exposure from 48 to 720 hours (summer worker lifespan) for cadmium, as the most time-dependent chemical as driven by slow toxicokinetics. Clothianidin and dimethoate exhibited more rapid toxicokinetics with 48 to 720 hour LC50s changes of <4 fold. As effects from long-term exposure may exceed those measured in short-term tests, future regulatory tests should extend to 96 hours as standard, with extension to 240 hour exposures further improving realism.

Causes of death and subsequent treatment after initial radical or palliative therapy of stage III non-small-cell lung cancer.

INTRODUCTION: Stage iii lung cancer is the most advanced stage of lung cancer for which radical (potentially curative) treatment is often discussed. Understanding the reasons for mortality and subsequent treatments in patients with stage iii non-small-cell lung cancer (nsclc) is important. METHODS: This retrospective cohort study extracted demographic, clinical, treatment, and outcomes data for patients with newly diagnosed stage iii nsclc diagnosed between 1 January 2008 and 31 December 2012 at a single institution. RESULTS: The study included 237 patients with stage iii nsclc, 130 of whom were not treated with radical or curative intent (55%). Median survival in the entire cohort was 14 months from diagnosis. For patients treated with radical-intent therapy, causes of death varied with the time period. The hazard rate for death was approximately 2.8 per 100 person-months of follow-up over the entire disease course and was highest between 6 months and 24 months. Over the entire time period, local causes accounted for 29% of deaths; systemic non-central nervous system metastases, for 25%; and brain metastases, for 14%. For patients treated with palliative intent, the overwhelming cause of death was local disease complications or progression (56% of deaths). Only 12% of patients in the palliative treatment group who progressed received subsequent chemotherapy; 23% of patients in the radical group who progressed received palliative chemotherapy. The most frequent subsequent treatment in both groups was radiation therapy. CONCLUSIONS: The eventual life-ending event in stage iii nsclc varied for the patients who qualified for, and were treated with, radical or curative intent and for the patients who received palliative-intent therapy. Utilization of systemic chemotherapy in patients not fit for radical therapy is low.

Reasons for palliative treatments in stage III non-small-cell lung cancer: what contribution is made by time-dependent changes in tumour or patient status?

INTRODUCTION: Stage iii lung cancer is the most advanced stage of lung cancer for which the potential of curative treatment is often discussed. However, a large proportion of patients are treated with palliative intent. An understanding of the time-dependent and -independent factors contributing to the choice of palliative-intent treatment is needed to help optimize patient outcomes. METHODS: This retrospective cohort study of patients with stage iii non-small-cell lung cancer (nsclc) newly diagnosed between 1 January 2008 and 31 December 2012 at the Cancer Centre of Southeastern Ontario collected data including patient demographics, clinical characteristics, tumour characteristics, treatment, and outcomes. RESULTS: Of 237 patients with stage iii nsclc included in the study, 130 were not treated with radical or curative intent (55%). Major time-independent variables cited for palliative-intent treatment included extreme age (5%), comorbidity (27%), patient choice (5%), and poor lung function (5%). Time-dependent variables included tumour progression on imaging (15%), weight loss (33%), performance status (32%), and the occurrence of a major complication such as hemoptysis, lung collapse, or pulmonary embolism (7%). A significant number of patients (20%) experienced a decline in performance status-to 2, 3, or 4 from 0 or 1-over the course of the diagnostic journey, and 12% experienced a transition from no weight loss to more than 10% weight loss. CONCLUSIONS: A significant proportion of patients receive palliative therapy for stage iii nsclc because of changes that occur during the diagnostic journey. Shortening or altering that pathway to avoid tumour growth or patient deterioration during care could allow for more patients to be treated with curative intent.

Genetic influences on social attention in free-ranging rhesus macaques.

An ethological approach to attention predicts that organisms orient preferentially to valuable sources of information in the environment. For many gregarious species, orienting to other individuals provides valuable social information but competes with food acquisition, water consumption and predator avoidance. Individual variation in vigilance behaviour in humans spans a continuum from inattentive to pathological levels of interest in others. To assess the comparative biology of this behavioural variation, we probed vigilance rates in free-ranging macaques during water drinking, a behaviour incompatible with the gaze and postural demands of vigilance. Males were significantly more vigilant than females. Moreover, vigilance showed a clear genetic component, with an estimated heritability of 12%. Monkeys carrying a relatively infrequent 'long' allele of TPH2, a regulatory gene that influences serotonin production in the brain, were significantly less vigilant compared to monkeys that did not carry the allele. These findings resonate with the hypothesis that the serotonin pathway regulates vigilance in primates and by extension provoke the idea that individual variation in vigilance and its underlying biology may be adaptive rather than pathological.

Valve surgery in octogenarians.

OBJECTIVE: To review the outcomes of octogenarians undergoing valve operations. PATIENTS AND METHODS: One hundred and twenty-five consecutive patients aged 80 years and over received valve operations between 1990 and 1996 at the Toronto General Hospital, Toronto, Ontario. All hospital survivors were prospectively followed for a mean of 36.6 months (range 0.1 to 89.9). RESULTS: One hundred and two patients received aortic valve operations, 18 patients received mitral procedures and five patients underwent double valve operations. Significant aortic stenosis was present in 95 of 102 patients (93%) receiving isolated aortic valve surgery, and mitral regurgitation was present in 16 of 18 patients (89%) undergoing mitral valve operations. Overall in-hospital mortality was 6.4% (n=8) and the perioperative infarction rate was 1.6% (n=2). In-hospital mortality was higher for mitral valve patients at 17% (n=3) than for aortic valve patients at 4% (n=4) (P=0.06). For the group overall, the six-year actuarial survival rate was 71.6+/-6%. The actuarial freedom from valve-related death was 97.1+/-2% at three years. Concomitant coronary artery disease was not significantly associated with perioperative mortality. Survivors had significantly improved New York Heart Association functional class status. CONCLUSION: In carefully selected patients aged 80 years and over, aortic valve surgery carries a low perioperative mortality with good intermediate term survival and benefits. Octogenarians undergoing mitral valve procedures experience higher perioperative mortality. Although the number of participants was small for this study, it does appear that coexistent coronary artery disease should not be the sole reason for denial of surgery because it has less of an impact on short and intermediate term survival than other factors.

The central oxytocin pulse generator: a pacemaker for the ovarian cycle.

During luteolysis in sheep, episodic pulses of oxytocin (OT), contributed by the neurohypophysis and the corpus luteum (CL), stimulate uterine luteolytic pulses of prostaglandin (PG) F2 alpha via endometrial OT receptors. To distinguish relative contributions of neurohypophysial and luteal OT, ovariectomized sheep were given estradiol-17 beta (E) and progesterone (P) to stimulate levels during the cycle. In intact sheep, luteectomy was performed to exclude the CL as a source of OT and to initiate P withdrawal. In ovariectomized sheep, E (1 microgram/h) for 12 to 36 h) superimposed on basal E(0.05 microgram/h), caused a series of 4 to 6 episodes of high frequency pulses of OT, each episode lasting 1 to 2 h at intervals of 3 h, and commencing at 24 h. Withdrawal of P (500 micrograms/h), superimposed on basal E in ovariectomized sheep, or luteectomy in intact sheep, evoked similar episodes of high frequency pulses of OT beginning at 24 h. We conclude that (1) an increase in E levels, or the return of E action following P withdrawal, causes intermittent increases in the frequency of the central OT pulse generator. (2) high frequency pulses of OT initiate subluteolytic levels of uterine PGF2 alpha which trigger a supplemental release of luteal OT; (3) luteal OT amplifies the secretion of uterine PGF2 alpha which initiates luteolysis and causes more luteal OT to be secreted; and (4) in addition to the established hypothalamic-anterior pituitary-gonadal axis for initiating the ovarian cycle (via the gonadotrophins), there is now evidence for a hypothalamic-posterior pituitary-gonadal axis for terminating the ovarian cycle (via OT).

The central oxytocin pulse generator: a pacemaker for luteolysis.

Oxytocin (OT) is released from the neurohypophysis into the jugular vein of sheep in small 1-2 min pulses (ca. 10 pg/ml) in both cyclic and ovariectomized sheep. In intact cycling sheep, additional hour long bursts of OT (up to 200 pg/ml) occur in peripheral blood during luteolysis at intervals of 6 to 9 hrs which appear to regulate large luteolytic pulses of uterine prostaglandin F2a (PGF2a). Since the ovine corpus luteum (CL) also synthesizes OT, experiments were performed to distinguish between the relative contributions of the neurohypophysis and the CL to the large bursts of OT secreted during luteolysis. Two models were used. First, ovariectomized sheep were given exogenous E and/or P by constant infusion to simulate levels during the estrous cycle. Second, in tact cycling sheep, the CL was surgically excised during the luteal phase to exclude the CL as a source of OT and, at the same time, subject the animals to the withdrawal of P. Pulses of OT in jugular vein plasma were determined by RIA or biometry of the uterus. The findings are summarized as follows: In ovariectomized sheep, maintained on low E (0.05 g/hr) to preserve the OT pulse generator, infusion of E (1 microgram, 2 micrograms or 4 micrograms/hr) for 12 to 36 hr, caused a series (4 to 6) of rapid increases in OT pulse frequency each lasting 1 to 2 hrs at intervals of 3 hrs. The time of onset of high frequency pulses was dose-dependent. Withdrawal of 10 day infusions of P (500 micrograms/hr) superimposed on low E (0.05 microgram/hr) also evoked a series of high frequency episodes of OT pulses beginning 24 hrs after P withdrawal. In intact sheep, surgical removal of the CL resulted in a series of high frequency pulses similar in duration and frequency to those following the withdrawal of P in the ovariectomized animal. We conclude that: (1) an increase in E or returning E action causes the OT pulse generator to alter its frequency intermittently thus producing a series of 4 to 6 episodes of high frequency pulses of OT. (2) Similar changes can be evoked by withdrawal of P either by terminating an infusion of P in the presence of E in the ovariectomized sheep or by surgically removing the CL from the ovary in the intact sheep. (3) At the end of the reproductive cycle, the central OT pulse generator appears to act as a pacemaker which, acting on the endometrial OT receptors, triggers a series of pulses of PGF2a from the uterus and hence causes regression of the CL. In the sheep and other ruminants, an intermittent supplemental secretion of OT from the CL, triggered via the central OT pulse generator, may also be required to amplify the luteolytic pulses of PGF2a from the uterus. (4) In addition to the well established interaction of ovarian steroid hormones, and the hypothalamic pituitary system for the initiation of the reproductive cycle via the gonadotrophins, there is now good evidence for an interaction of ovarian steroids and the posterior pituitary for terminating the reproductive cycle.

Control of posterior pituitary vasopressin content: implications for the regulation of the vasopressin gene.

Axon terminals in the posterior pituitary store large quantities of the hormone vasopressin (AVP), buffering the synthesizing neurons in the hypothalamus against acute changes in physiological demand for hormone release. The dynamics of pituitary AVP content reflect the competing processes of release and synthesis. This report demonstrates substantial increases in pituitary AVP content in the maturing rat. Between 7-10 weeks of age, the total pituitary AVP content in the rat increases from 957 +/- 72 to 1667 +/- 160 ng. Cross-sectional data indicate a parallel relationship between body weight and pituitary AVP content. Nevertheless, weight maintenance does not affect age-related increases in AVP content. Decreasing demand for hormone release and synthesis by inducing hyponatremia blocks subsequent pituitary accumulation. After withdrawing the hyponatremic experimental conditions, animals resume accumulation of pituitary AVP, but do not catch up to age-matched controls. This indicates that increases in pituitary AVP content do not result from a feedback signal from the neural lobe, but rather, pituitary AVP levels passively reflect changes in hormone release and compensatory synthesis.

The diagnosis and management of diabetes insipidus during medical emergencies.

The abrupt presentation of hypertonic polyuria, polydipsia and hypernatremia, reflects vasopressin deficiency owing to multiple potential etiologies. Diabetes insipidus becomes an emergency and leads to severe hyperosmolality and dehydration when fluid intake does not match obligate losses. Decreased mental alertness may impair the ability to sense thirst or to obtain access to fluids, thus placing patients postoperatively or posttrauma at particular risk of complicated diabetes insipidus. Intravenously administered DDAVP and hydration with hypotonic fluids is the preferred therapy in the acute setting. As diabetes insipidus may be of unpredictable duration, the need for ongoing medical therapy must be frequently reassessed.

c-fos expression in vasopressin and oxytocin neurons reveals functional heterogeneity within magnocellular neurons.

The c-fos protein is rapidly induced in hypothalamic magnocellular nuclei following hemorrhage. We used specific antibodies directed against c-fos and either vasopressin (AVP) or oxytocin (OT) neurophysin to investigate c-fos activation in individual AVP and OT neurons. AVP and OT neurons expressed c-fos in response to hypovolemic stimuli. Following a protocol of incremental hemorrhage, AVP and OT neurons expressed c-fos with a graded response that correlated with stimulus intensity. As the volume of hemorrhage increased, there was an increase in the number of cells expressing c-fos as well as in the amount of c-fos immunoreactivity per cell. These increases correlated with the amount of hormone released into the peripheral blood. In addition, a differential pattern of activation for AVP neurons occurred in response to hemorrhagic stimuli. AVP neurons in the supraoptic nucleus (SON) had a lower threshold for response than those in the paraventricular nucleus (PVN). For OT, activation required a greater blood loss than AVP and c-fos expression encompassed both SON and PVN neurons. We conclude that c-fos expression is proportional to stimulus intensity and reveals functional heterogeneity among magnocellular neurons.

Transient hyponatremia after damage to the neurohypophyseal tracts.

Section of the neurohypophyseal stalk classically produces a triphasic response: diabetes insipidus (1st phase), hyponatremia or normonatremia (2nd phase), and diabetes insipidus (3rd phase). Transient hyponatremia without diabetes insipidus has been reported after transsphenoidal pituitary surgery. We report two additional cases of transient hyponatremia which occurred 6-8 days after pituitary surgery. We hypothesize that this outcome may be due to partial section or damage of the hypothalamiconeurohypophyseal tracts. The remaining intact vasopressin neurons function normally to protect against the diabetes insipidus of the first and third phase, but leak of vasopressin from the damaged tracts and posterior pituitary is sufficient to cause what can be described as an isolated second phase. To study this hypothesis in rats, partial damage to the hypothalamicneurohypophyseal tracts was produced by radiofrequency lesions. The lesions did not affect anterior pituitary function. A variety of responses in posterior pituitary function occurred, including classic triphasic response in 2 rats and transient hyponatremia in 20 of 35 lesioned animals. The mean sodium nadir was 128.7 +/- 1.5 mEq/l in comparison to the sham-operated value of 140.0 +/- 0.4 mEq/l. Of the 20 rats exhibiting transient hyponatremia, 12 went on to develop diabetes insipidus, and 8 recovered. In the recovered group, the transient hyponatremia occurred 1-3 days after lesioning and returned to normal by day 7 which corresponds to the timing of the second phase of the triphasic response in rats. Hyponatremia was accompanied by vasopressin levels inappropriate for the plasma sodium level, inappropriately concentrated urine, water retention, and natriuresis.(ABSTRACT TRUNCATED AT 250 WORDS)

Models of neurohypophyseal homeostasis.

Rats subject to prolonged (3-6 days) hypernatremia show significantly decreased pituitary vasopressin content as well as increased levels of hypothalamic vasopressin mRNA; these values return to baseline levels after the stimulus is removed. In this paper, we tested whether a single cellular mechanism for regulation of synthesis could account for the experimental observations of both pituitary hormone depletion-repletion and hypothalamic mRNA content. We developed several "minimal" models of vasopressin synthesis in which control of hormone synthesis was regulated exclusively by transcription, translation, or mRNA decay and tested each model to see which best emulated the dynamics of neuro-hypophyseal vasopressin content and hypothalamic vasopressin mRNA. Experimental data provided parameters for pituitary content, baseline and stimulated release rates, mRNA decay, transcription, and translation. Models based exclusively on translation and mRNA decay failed to produce predictions similar to experimental observations. Of the models tested, the transcription model provided predictions most consistent with laboratory data, although some quantitative differences remain. The results of the computer modeling strongly suggest that transcription represents the predominant means by which magnocellular neurons regulate vasopressin synthesis.

Vasopressin transport regulation is coupled to the synthesis rate.

Vasopressin is synthesized in the perikarya of magnocellular neurons and is transported down long axons to the storage terminals of the posterior pituitary. To maintain stable pituitary stores following vasopressin secretion, the hypothalamus must synthesize and transport an amount of new vasopressin, equivalent to the amount released. Vasopressin release and synthesis rate can be chronically upregulated or suppressed relative to basal levels, depending on the demand for vasopressin. We studied whether vasopressin transport was similarly regulated during situations of varying demand. During chronic hyponatremia, when synthesis of vasopressin was reduced to undetectable levels, transport of vasopressin was also markedly decreased, as evidenced by continued presence of vasopressin in the transport system. Upregulation of transport was demonstrated by measuring pituitary accumulation of vasopressin in rats whose pituitary stores were initially depleted by hypernatremia and in whom subsequent release was suppressed by hyponatremia. In hypernatremic rats, transport of vasopressin was increased fivefold over baseline as determined by pituitary accumulation, and this elevated rate persisted for 7 days in the absence of release. This study demonstrates that axonal transport of vasopressin is a regulated process and is linked to synthesis rate rather than release.