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BackgroundInternational guidelines for the treatment of patients with pulmonary arterial hypertension (PAH) recommend the use of risk stratification to optimise therapy to achieve and maintain a low-risk profile. However, recommended methods require hospital-based investigations. We sought to develop a method for daily, remote risk evaluation.MethodsConsecutive patients (n=5820) with pulmonary hypertension (PH) were identified from the ASPIRE registry and stepwise Cox regression applied to identify parameters associated with survival. A physiological risk score was applied to all patients and survival assessed by the Kaplan-Meier method. Physical activity was measured in patients with PAH implanted with insertable cardiac monitors (ICM, n=80) to provide a remote measure of exercise capacity. In patients with PAH and implanted pulmonary artery pressure (PAP) monitor and ICM (n=28) we undertook a time-stratified bidirectional case–crossover study to determine the physiology of therapeutic escalation (TE) and clinical worsening and a remote physiological risk score applied to the data.ResultsAge, male sex, PH aetiology, WHO functional class (FC), incremental shuttle walk-distance (ISWD), heart rate reserve (HRR) and total pulmonary resistance (TPR) as independent predictors of survival. Mortality increased with each decile of baseline physiological risk (pConclusionRemote risk evaluation may facilitate personalised medicine and proactive management. The physiological risk score accurately stratifies patients with PH and may be applied to remote monitoring data for early evaluation of clinical efficacy and detection of clinical worsening.

Stepped-wedge cluster randomized trial (SW-CRT) designs are often used when there is a desire to provide an intervention to all enrolled clusters, because of a belief that it will be effective. However, given there should be equipoise at trial commencement, there has been discussion around whether a pre-trial decision to provide the intervention to all clusters is appropriate. In pharmaceutical drug development, a solution to a similar desire to provide more patients with an effective treatment is to use a response adaptive (RA) design.We introduce a way in which RA design could be incorporated in an SW-CRT, permitting modification of the intervention allocation during the trial. The proposed framework explicitly permits a balance to be sought between power and patient benefit considerations. A simulation study evaluates the methodology.In one scenario, for one particular RA design, the proportion of cluster-periods spent in the intervention condition was observed to increase from 32.2% to 67.9% as the intervention effect was increased. A cost of this was a 6.2% power drop compared to a design that maximized power by fixing the proportion of time in the intervention condition at 45.0%, regardless of the intervention effect.An RA approach may be most applicable to settings for which the intervention has substantial individual or societal benefit considerations, potentially in combination with notable safety concerns. In such a setting, the proposed methodology may routinely provide the desired adaptability of the roll-out speed, with only a small cost to the study's power.

Background To determine how much an augmented analysis approach could improve the efficiency of prostate-specific antigen (PSA) response analyses in clinical practice. PSA response rates are commonly used outcome measures in metastatic castration-resistant prostate cancer (mCRPC) trial reports. PSA response is evaluated by comparing continuous PSA data (e.g., change from baseline) to a threshold (e.g., 50% reduction). Consequently, information in the continuous data is discarded. Recent papers have proposed an augmented approach that retains the conventional response rate, but employs the continuous data to improve precision of estimation. Methods A literature review identified published prostate cancer trials that included a waterfall plot of continuous PSA data. This continuous data was extracted to enable the conventional and augmented approaches to be compared. Results Sixty-four articles, reporting results for 78 mCRPC treatment arms, were re-analysed. The median efficiency gain from using the augmented analysis, in terms of the implied increase to the sample size of the original study, was 103.2% (IQR [89.8,190.9%]). Conclusions Augmented PSA response analysis requires no additional data to be collected and can be performed easily using available software. It improves precision of estimation to a degree that is equivalent to a substantial sample size increase. The implication of this work is that prostate cancer trials using PSA response as a primary endpoint could be delivered with fewer participants and, therefore, more rapidly with reduced cost.

Mixed outcome endpoints that combine multiple continuous and discrete components to form co-primary, multiple primary or composite endpoints are often employed as primary outcome measures in clinical trials. There are many advantages to joint modelling the individual outcomes using a latent variable framework, however in order to make use of the model in practice we require techniques for sample size estimation. In this paper we show how the latent variable model can be applied to the three types of joint endpoints and propose appropriate hypotheses, power and sample size estimation methods for each. We illustrate the techniques using a numerical example based on the four dimensional endpoint in the MUSE trial and find that the sample size required for the co-primary endpoint is larger than that required for the individual endpoint with the smallest effect size. Conversely, the sample size required for the multiple primary endpoint is reduced from that required for the individual outcome with the largest effect size. We show that the analytical technique agrees with the empirical power from simulation studies. We further illustrate the reduction in required sample size that may be achieved in trials of mixed outcome composite endpoints through a simulation study and find that the sample size primarily depends on the components driving response and the correlation structure and much less so on the treatment effect structure in the individual endpoints., 36 pages, 8 figures, 7 tables

Adapting the final sample size of a trial to the evidence accruing during the trial is a natural way to address planning uncertainty. Designs with adaptive sample size need to account for their optional stopping to guarantee strict type-I error-rate control. A variety of different methods to maintain type-I error-rate control after unplanned changes of the initial sample size have been proposed in the literature. This makes interim analyses for the purpose of sample size recalculation feasible in a regulatory context. Since the sample size is usually determined via an argument based on the power of the trial, an interim analysis raises the question of how the final sample size should be determined conditional on the accrued information. Conditional power is a concept often put forward in this context. Since it depends on the unknown effect size, we take a strict estimation perspective and compare assumed conditional power, observed conditional power, and predictive power with respect to their properties as estimators of the unknown conditional power. We then demonstrate that pre-planning an interim analysis using methodology for unplanned interim analyses is ineffective and naturally leads to the concept of optimal two-stage designs. We conclude that unplanned design adaptations should only be conducted as reaction to trial-external new evidence, operational needs to violate the originally chosen design, or post hoc changes in the objective criterion. Finally, we show that commonly discussed sample size recalculation rules can lead to paradoxical outcomes and propose two alternative ways of reacting to newly emerging trial-external evidence.

Basket trials are increasingly used for the simultaneous evaluation of a new treatment in various patient subgroups under one overarching protocol. We propose a Bayesian approach to sample size determination in basket trials that permit borrowing of information between commensurate subsets. Specifically, we consider a randomised basket trial design where patients are randomly assigned to the new treatment or a control within each trial subset (`subtrial' for short). Closed-form sample size formulae are derived to ensure each subtrial has a specified chance of correctly deciding whether the new treatment is superior to or not better than the control by some clinically relevant difference. Given pre-specified levels of pairwise (in)commensurability, the subtrial sample sizes are solved simultaneously. The proposed Bayesian approach resembles the frequentist formulation of the problem in yielding comparable sample sizes for circumstances of no borrowing. When borrowing is enabled between commensurate subtrials, a considerably smaller trial sample size is required compared to the widely implemented approach of no borrowing. We illustrate the use of our sample size formulae with two examples based on real basket trials. A comprehensive simulation study further shows that the proposed methodology can maintain the true positive and false positive rates at desired levels., Comment: A submitted paper with 18 pages (inclusive of 3 figures and 1 table) and 9 pages of Supplementary Materials

Side effects of radiation therapy (RT) remain the most challenging issue for pancreatic cancer treatment. Cerium oxide nanoparticles (CONPs) are currently being tested in pre-clinical trials as an adjuvant to sensitize pancreatic cancer cells to RT and protect normal tissues from the harmful side effects. CONPs were not able to significantly affect RT-induced DNA damage in cancer cells, thereby ruling out sensitization through increased mitotic catastrophe. However, activation of c-Jun terminal kinase (JNK), a key driver of RT-induced apoptosis, was significantly enhanced by co-treatment with CONPs and RT in pancreatic cancer cells in vitro and human pancreatic tumors in nude mice in vivo compared to CONPs or RT treatment alone. Further, CONP-driven increase in RT-induced JNK activity was associated with a marked increase in Caspase 3/7 activation, indicative of apoptosis. We have previously shown that CONPs increase reactive oxygen species (ROS) production in cancer cells. ROS has been shown to drive the oxidation of thioredoxin 1 (TRX1) which results in the activation of apoptosis signaling kinase 1 (ASK1). The increase in ASK1 activation following the co-treatment with CONPs followed by RT suggests that the increased JNK activation is the result of increased TRX1 oxidation. The ability of CONPs to sensitize pancreatic cancer cells to RT was mitigated when the TRX1 oxidation was prevented by mutagenesis of a cysteine residue or when the JNK activation was blocked by an inhibitor. Taken together, these data demonstrate an important mechanism for CONPs in specifically killing cancer cells and provide novel insights into the utilization of CONPs as a radiosensitizer and therapeutic agent for pancreatic cancer.

The ability to accurately estimate the sample size required by a stepped‐wedge (SW) cluster randomized trial (CRT) routinely depends upon the specification of several nuisance parameters. If these parameters are misspecified, the trial could be overpowered, leading to increased cost, or underpowered, enhancing the likelihood of a false negative. We address this issue here for cross‐sectional SW‐CRTs, analyzed with a particular linear‐mixed model, by proposing methods for blinded and unblinded sample size reestimation (SSRE). First, blinded estimators for the variance parameters of a SW‐CRT analyzed using the Hussey and Hughes model are derived. Following this, procedures for blinded and unblinded SSRE after any time period in a SW‐CRT are detailed. The performance of these procedures is then examined and contrasted using two example trial design scenarios. We find that if the two key variance parameters were underspecified by 50%, the SSRE procedures were able to increase power over the conventional SW‐CRT design by up to 41%, resulting in an empirical power above the desired level. Thus, though there are practical issues to consider, the performance of the procedures means researchers should consider incorporating SSRE in to future SW‐CRTs.

Numerous publications have now addressed the principles of designing, analyzing, and reporting the results of stepped‐wedge cluster randomized trials. In contrast, there is little research available pertaining to the design and analysis of multiarm stepped‐wedge cluster randomized trials, utilized to evaluate the effectiveness of multiple experimental interventions. In this paper, we address this by explaining how the required sample size in these multiarm trials can be ascertained when data are to be analyzed using a linear mixed model. We then go on to describe how the design of such trials can be optimized to balance between minimizing the cost of the trial and minimizing some function of the covariance matrix of the treatment effect estimates. Using a recently commenced trial that will evaluate the effectiveness of sensor monitoring in an occupational therapy rehabilitation program for older persons after hip fracture as an example, we demonstrate that our designs could reduce the number of observations required for a fixed power level by up to 58%. Consequently, when logistical constraints permit the utilization of any one of a range of possible multiarm stepped‐wedge cluster randomized trial designs, researchers should consider employing our approach to optimize their trials efficiency.

Fluopyram, a broad spectrum fungicide, caused an increased incidence of thyroid follicular cell (TFC) adenomas in males at the highest dose evaluated (750 ppm equating to 105 mg/kg/day) in the mouse oncogenicity study. A series of short-term mechanistic studies were conducted in the male mouse to characterize the mode of action (MOA) for the thyroid tumor formation and to determine if No Observed Effect Levels (NOELs) exist for each key event identified. The proposed MOA consists of an initial effect on the liver by activating the constitutive androstane (Car) and pregnane X (Pxr) nuclear receptors causing increased elimination of thyroid hormones followed by an increased secretion of thyroid stimulating hormone (TSH). This change in TSH secretion results in an increase of TFC proliferation which leads to hyperplasia and eventually adenomas after chronic exposure. Car/Pxr nuclear receptors were shown to be activated as indicated by increased activity of specific Phase I enzymes (PROD and BROD, respectively). Furthermore, evidence of increased T4 metabolism was provided by the induction of phase II enzymes known to preferentially use T4 as a substrate. Additional support for the proposed MOA was provided by demonstrating increased Tsh β transcripts in the pituitary gland. Finally, increased TFC proliferation was observed after 28 days of treatment. In these dose–response studies, clear NOELs were established for phase 2 liver enzyme activities, TSH changes and TFC proliferation. Furthermore, compelling evidence for Car/Pxr activation being the molecular initiating event for these thyroid tumors was provided by the absence of the sequential key events responsible for the TCF tumors in Car/Pxr KO mice when exposed to fluopyram. In conclusion, fluopyram thyroid toxicity is mediated by activation of hepatic Car/Pxr receptors and shows a threshold dependent MOA.

The motuporamines isolated from the sea sponge Xestospongia exigua are of biological interest because of their unique antimigration and antiangiogenic properties. Key bioactive features were found to be a saturated 15-membered heterocycle and a norspermidine motif. This paper describes new analogues that modulate the cytotoxicity of this compound class and have enhanced antimigration properties. By movement of the polyamine chain outside the ring, new carbocycles were discovered that doubled the antimigration potency and reduced compound toxicity by 133-fold. Mice injected with metastatic human L3.6pl pancreatic cancer cells demonstrated significant reduction in liver metastases when treated with N(1)-(3-aminopropyl)-N(3)-(cyclopentadecylmethyl)propane-1,3-diamine compared with dihydromotuporamine C. Significant changes in specific ceramide populations (N16:0 and N22:1) were noted in L3.6pl cells treated with dihydromotuporamine C but not for the cyclopentadecylmethylnorspermidine derivative, which had lower toxicity. Both compounds gave increased levels of specific low molecular weight sphingomyelins, suggesting that they may act upon sphingomyelin processing enzymes.

Krüppel-like factor 8 (KLF8) is a transcriptional factor critical for metastatic progression of breast cancer. Epithelial stromal interaction 1 (EPSTI1), a recently identified stromal fibroblast-induced gene in non-invasive breast cancer cells is highly overexpressed in invasive breast carcinomas. The function and regulation of EPSTI1, however, remain largely unknown. In this paper, we report a novel KLF8 to EPSTI1 signaling pathway in breast cancer. Using various expression analyses, we revealed a high co-overexpression of KLF8 and EPSTI1 in invasive human breast cancer cells and patient tumors. Ectopic overexpression of KLF8 in the non-invasive, MCF-10A cells induced the EPSTI1 expression, whereas KLF8 knockdown from the invasive, MDA-MB-231 cells decreased the EPSTI1 expression. Promoter activation and binding analyses indicated that KLF8 promoted the EPSTI1 expression by directly acting on the EPSTI1 gene promoter. EPSTI1 knockdown dramatically reduced the KLF8-promoted MCF-10A cell invasion and ectopic expression of EPSTI1 in the non-invasive, MCF-7 cells is sufficient to induce the cell invasion. Experiments using nude mice demonstrated that the ectopic EPSTI1 granted the MCF-7 cells capability of both invasive growth in the breasts and metastasis to the lungs. Using co-immunoprecipitation coupled with mass spectrometry, we discovered that EPSTI1 interacts with the valosin containing protein (VCP), resulting in the degradation of IκBα and subsequent activation of NF-κB in the nucleus. These findings suggest a novel KLF8 to EPSTI1 to VCP to NF-κB signaling mechanism potentially critical for breast cancer invasion and metastasis.

Krüppel-like factor 8 (KLF8) regulates critical gene transcription associated with cancer. The underlying mechanisms, however, remain largely unidentified. We have recently demonstrated that KLF8 expression enhances the activity but not expression of matrix metalloproteinase-2 (MMP2), the target substrate of MMP14. Here, we report a novel KLF8 to MMP14 signaling that promotes human breast cancer invasion and metastasis. Using cell lines for inducible expression and knockdown of KLF8, we demonstrate that KLF8 promotes MMP14 expression at the transcriptional level. Knocking down KLF8 expression inhibited the breast cancer cell invasion both in vitro and in vivo as well as the lung metastasis in mice, which could be rescued by ectopic expression of MMP14. Promoter reporter assays and oligonucleotide and chromatin immunoprecipitations determined that KLF8 activates the human MMP14 gene promoter by both directly acting on the promoter and indirectly via promoting the nuclear translocation of β-catenin, the expression of T cell factor-1 (TCF1) and subsequent activation of the promoter by the β-catenin/TCF1 complex. Inhibition of focal adhesion kinase (FAK) using pharmacological inhibitor, RNA interference or knockout showed that the cell surface presentation of active MMP14 downstream of KLF8 depends upon FAK expression and activity. Taken together, this work identified novel signaling mechanisms by which KLF8 and FAK work together to promote the extracellular activity of MMP14 critical for breast cancer metastasis.

Side effect of radiation therapy (RT) remains the most challenging issue for pancreatic cancer treatment. In this report we determined whether and how cerium oxide nanoparticles (CONPs) sensitize pancreatic cancer cells to RT. CONP pretreatment enhanced radiation-induced reactive oxygen species (ROS) production preferentially in acidic cell-free solutions as well as acidic human pancreatic cancer cells. In acidic environments, CONPs favor the scavenging of superoxide radical over the hydroxyl peroxide resulting in accumulation of the latter whereas in neutral pH CONPs scavenge both. CONP treatment prior to RT markedly potentiated the cancer cell apoptosis both in culture and in tumors and the inhibition of the pancreatic tumor growth without harming the normal tissues or host mice. Taken together, these results identify CONPs as a potentially novel RT-sensitizer as well as protectant for improving pancreatic cancer treatment.Pancreatic tumors remain some of the most notoriously treatment-unresponsive malignancies. Cerium oxide nanoparticles may be capable of sensitizing such cells to radiotherapy, as demonstrated in this study.

This article reports the evaluation of cerium oxide (CeO 2 ) nanoparticles' ability to decrease xerostomia and radiation-induced dermatitis in mice after head and neck radiation. Mice were irradiated using an IC160 x-ray system. Two cohorts were included: (A) No-radiation and (B) 30 Gy/6 fractions, and were randomized into three groups: (1) saline, (2) 15 nM CeO 2 and (3) 15 μM CeO 2 . Stimulated salivary flow and radiation-induced dermatitis were evaluated post radiation. Stimulated sialometry demonstrated improved salivary production in all CeO 2 groups in comparison with controls (flow: 204 vs. 115 μL/10 minutes , P = 0.0002). One week post radiation, G-III dermatitis decreased in the 15 μM group in comparison with controls (10% versus 100% incidence, respectively). There was decreased skin hyperpigmentation at 12 weeks in the 15-μM group in comparison with 15-nM and non-CeO 2 groups (50%, 70%, and 90% G-II, respectively). This study suggests that CeO 2 may be radioprotective for salivary production and reduces G-III dermatitis and skin hyperpigmentation incidence. CeO 2 as radioprotectant may be a feasible concept during radiotherapy. From the Clinical Editor This study demonstrates in a mouse model that cerium oxide (CeO 2 ) nanoparticles may provide an important mechanism in preventing radiation induced xerostomia, a common complication of head and neck radiation treatments.

The aim of this study was to determine the effects of olestra and sorbitol consumption on three accepted objective measures of diarrhea (stool output >250 g/day, liquid/watery stools, bowel movement frequency >3/day), and how stool composition influences reports of common gastrointestinal symptoms. A double-blind, placebo-controlled study compared the effects of sorbitol (40 g/day in candy), a poorly absorbed sugar-alcohol with known osmotic effects, with those of olestra (20 or 40 g/day in potato chips), a nonabsorbed fat, on objective measures of stool composition and GI symptoms. Sixty-six subjects resided on a metabolic ward for 12 days: 2 days lead-in, 4 days baseline, 6 days treatment. Sorbitol 40 g/day resulted in loose/liquid stools within 1-3 h of consumption. In contrast, olestra resulted in a dose-responsive stool softening effect after 2-4 days of consumption. Subjects reported "diarrhea" when mean stool apparent viscosity (peak force (PF), g) decreased from a perceived "normal" (mean +/- SE, 1355 +/- 224 g PF; firm stool) to loose (260 +/- 68 g PF) stool. Mean apparent viscosity of stool during treatment: placebo, 1363 +/- 280 g (firm); olestra 20 g/day 743 +/- 65 g (soft); olestra 40 g/day, 563 +/- 105 g (soft); and sorbitol 40 g/day, 249 +/- 53 g (loose). Of the 1098 stool samples collected, 38% (419/1098) were rated by subjects as "diarrhea," yet only 2% of treatment days (all in the sorbitol treatment group) met commonly accepted criteria for a clinical diarrhea. Sorbitol, but not olestra, increased the severity of abdominal cramping, urgency and nausea compared to placebo. Olestra consumption, at levels far in excess of normal snacking conditions, resulted in a gradual stool softening effect after several days of consumption, did not meet any of the three objective measures of diarrhea, and did not increase GI symptoms. Sorbitol consumption, at only 80% of the dose requiring a "laxative effect" information label, resulted in rapid onset loose/liquid stools and a significant increase in abdominal cramping, urgency and nausea. Overall, subjects categorized stool as "diarrhea" when stool decreased from their perceived "normal," but the vast majority of these reports were not associated with clinically significant diarrhea.

Krüppel-like factor 8 (KLF8) regulates critical gene transcription and cellular events associated with cancer. However, the role of KLF8 in cancer remains largely unknown. Here, we report a surprisingly novel role for KLF8 in DNA repair in breast cancer cells. Comet, clonogenic, and WST-1 assays showed that KLF8 expression is required for protecting human breast cancer cells from doxorubicin-induced DNA damage and cell death. Western blotting indicated that overexpression of ectopic KLF8 attenuated the levels of the DNA damage marker γH2A.X in doxorubicin-treated PARP-1(+/+) but not PARP-1(-/-) mouse embryonic fibroblasts, whereas the PARP-1-binding-defective KLF8 mutant failed to do so. Interestingly, in response to the DNA damage, KLF8 was phosphorylated by the DNA-dependent protein kinase catalytic subunit and, subsequently, SUMOylated by SUMO E3 ligases protein inhibitors of activated STAT (PIASs), which depends upon the interaction of KLF8 with DNA-dependent protein kinase catalytic subunit, PIASs, and PARP-1 as well as their enzymatic activities. Lastly, we show evidence that KLF8 was recruited to the DNA damage site. These results suggest a novel role and mechanism for KLF8 in the regulation of DNA repair and therapeutic resistance in breast cancer cells.

This study sought to determine the appropriate starting dose of colchicine in children aged 2 to 4 years with familial Mediterranean fever (FMF) based on steady-state pharmacokinetics in pediatric patients with FMF from 2 to less than 16 years and adult patients with FMF from 16 to 65 years. Outpatients received colchicine for 90 days starting with a fixed dose for 14 days (blood sampling days 14 and 15). After starting doses of colchicine (0.6 mg/day [2 to less than 4 years], 0.9 mg/day [from 4 to less than 6 years], 0.9 mg/day [from 6 to less than 12 years], 1.2 mg/day [from 12 to less than 16 years], and 1.2 mg/day [from 16 to less than 65 years]), the observed steady-state pharmacokinetic parameters were comparable across age groups, despite the higher doses of colchicine on a mg/kg/day basis in the younger age groups. An exception occurred with once-daily colchicine, whereby mean Cmax for colchicine was higher in patients 4 to less than 6 years (9.4 ng/mL) compared with the younger and older age groups (6.1-6.7 ng/mL). Mean AUC0?24h values in children 2 to less than 4, 6 to less than 12, and 12 to less than 16 years were similar to those in adults. However, mean AUC0?24h values in children 4 to less than 6 years were 25 percent higher than those observed in adults. The results show that the recommended starting dose for children 2-4 years and 4-6 years should be 0.6 mg/day (half the US adult dose). Children aged 6 to less than 12 years should receive 0.9 mg/day (i.e. three-quarters of the US adult dose). The safety of colchicine in children 2 to less than 4 years was comparable to that in older children and adults.

To compare the clinical effects of a new oral synthetic conjugated estrogens, A (SCE), versus placebo in a clinically relevant population on the reduction in the mean number of moderate to severe vasomotor symptoms.A total of 120 healthy pre- and postmenopausal women (72 active, 48 placebo) were enrolled into a randomized, placebo-controlled, double-blind, multi-center clinical trial. Women of all races were enrolled, using minimal inclusion and exclusion criteria. Each subject received either orally administered SCE, in doses of 0.3 mg, 0.625 mg or 1.25 mg per day, or placebo. Analysis of variance was performed on the primary efficacy variable (change from baseline to weeks 4, 8, and 12 in the mean number of moderate to severe vasomotor symptoms).Changes in moderate to severe vasomotor symptoms in the intent to treat population showed statistically significant differences between the active and placebo treatments at week 4 (P.022), week 8 (P.010), and week 12 (P.010). By week 12, the mean percentage reduction in moderate to severe vasomotor symptoms was 81%, from an average baseline of 96.8, to 16.5 hot flashes per week for the active treatment group. The overall incidence of expected estrogen-related adverse effects was modest. Laboratory tests and vital sign measurements did not reveal clinically significant changes or abnormalities from screening to the final visit in either treatment group.The results of this study confirm the efficacy and safety of SCE in the treatment of moderate to severe vasomotor symptoms in menopausal women. In addition, the study also demonstrated that the use of more liberal entry criteria did not materially affect the efficacy outcome.

Krüppel-like factor 8 (KLF8) regulates critical gene transcription and invasion events associated with cancer, including epithelial to mesenchymal transition (EMT) and extracellular matrix degradation. Here, we report a novel KLF8-to- matrix metalloproteinase-14 (MMP14) signaling that promotes human breast cancer cell EMT, invasion and metastasis. Cell-surface protein biotinylation and streptavidin pull-down showed that overexpression of KLF8 induced cell-surface accumulation of MMP14 in MCF-10A cells in a FAK-dependent manner, which was correlated with increased MMP14 activity and the ectodomain shedding of E-cadherin. On the other hand, knockdown of KLF8 in MDA-MB-231 cells reduced expression and activity of MMP14 on the cell surface. Promoter reporter assays and chromatin and oligonucleotide precipitations determined that KLF8 activated the human MMP14 gene promoter both directly and indirectly via beta-catenin. Importantly, Matrigel invasion assays showed that MMP14 was required for the KLF8-induced MCF-10A cell invasion in vitro. Experiments using nude mice demonstrated that MMP-14 overexpression downstream of KLF8 in the MDA-MB-231 cells makes a significant contribution to the invasion and angiogenesis in the local primary tumors and lung metastasis. Taken together, this work identified a novel role and mechanisms for MMP14 downstream of KLF8 in the progression of breast cancer metastasis. Citation Format: Heng Lu, Liu Hu, Lin Yu, Xianhui Wang, Chao Shen, Tianshu Li, Debarati Mukherjee, Satadru Lahiri, Melissa Wason, Jihe Zhao. Krüppel-like factor 8 targets matrix metalloproteinase-14 to promote breast cancer invasion and metastasis . [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 2687. doi:10.1158/1538-7445.AM2013-2687

We present a case of a six-week-old infant who developed life-threatening complications after unintentional sodium bicarbonate intoxication. Baking soda was being used by the mother as a home remedy to "help the baby burp." A review of the literature regarding the use (or misuse) of baking soda follows. Our patient, along with the other noted case reports, emphasizes the need for warnings on baking soda products whose labels recommend its use as an antacid. Poisonings must be high in the differential diagnosis of any patient, regardless of age, who presents with altered mental status or status epilepticus.

Krüppel-like factor 8 (KLF8) regulates critical gene transcription and cellular events associated with cancer. Recently we have identified poly(ADP-ribose) polymerase-1(PARP-1) as a novel KLF8-interacting and regulating protein. However, whether KLF8 is involved in PARP-1 relulated DNA repair is unknown. Here, we report that KLF8 plays a role in the PARP-1-dependent DNA repair. Western blotting and immunofluorescence staining indicated that overexpression of KLF8 attenuated the αH2A.X levels in doxorubicin-treated PARP-1+/+ MEF cells but not in the PARP-1−/− MEF cells, whereas the PARP-1-interaction-defective KLF8 mutant did not affect the αH2A.X levels. Clonogenic assay and tetrazolium salt (WST-1) assay showed that KLF8 promoted cell survival in human breast cancer cells. Comet assay revealed that KLF8 expression could decrease DNA damage levels. Interestingly, we found that in response to DNA damage KLF8 was phosphorylated by DNA-PKcs and subsequently sumoylated, which depended on the interaction between KLF8 and PARP-1. These results suggest a novel role and mechanism for KLF8 in the regulation of DNA repair in cancer cells. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 2129. doi:1538-7445.AM2012-2129

Pancreatic cancer, one of the most lethal cancers, has a poor prognosis and a high mortality rate. Currently, the absence of effective therapies increases reliance on radiation therapy (RT) to treat pancreatic cancer. We have previously reported that Cerium Oxide Nanoparticles (CONPs) are selectively toxic to cancer cells and possess the ability to selectively sensitize pancreatic cancer cells to radiation-induced cell death. Radiation-induced H2O2 production was significantly increased in the presence of less than or equal to 10 µM of CONPs and radiation-induced ROS production was increased in human L3.6pl pancreatic cancer cells pre-treated with 10 µM CONPs, which correlated with a significant decrease in cell viability and clonogenicity as compared to radiation alone. Conversely, ROS production was decreased in normal hTERT-HPNE pancreatic cells without impacting cell viability. The volume of pancreatic tumors was reduced by 48% in mice treated with combination therapy compared to radiation alone. Immunohistochemical (IHC) analysis revealed that combination therapy resulted in a significant increase in tumor cell apoptosis. In the most recent study, we determined the mechanism responsible for the increase in apoptosis as a result of increased ROS levels. L3.6pl cells (radiation sensitive), PANC-1 (radiation resistant) and HPNE (normal pancreatic cells) were treated with 5 Gy radiation in the presence or absence of 10 µM CONPs. CONPs selectively increased RT-induced Thioredoxin (TRX) oxidation in the cancer cells (L3.6pl: 14.2%, p Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 1468. doi:1538-7445.AM2012-1468

PURPOSE: To evaluate the ability of cerium oxide nanoparticles (CeO2) to decrease xerostomia and skin reactions in athymic mice. METHODS: The head and neck (H&N) region of athymic nude mice was irradiated using a IC160 X-ray irradiation system (Kimtron Inc., Woodbury, Connecticut, USA). Animals were anesthetized and placed supine under the radiation focal spot. Irradiation was given with a single AP portal using a 160 kV X-ray unit. Three radiation cohorts were designed (N=30 per cohort); A) received no radiation exposure; B) received a single dose of 17.5 Gy; and C) received 30 Gy/6 fractions. In each cohort, animals were randomized into three groups (N=10 per group): 1) intraperitoneal (i.p.) injection of saline; 2) i.p. injection of 15 nM CeO2; and 3) i.p. injection of 15 µM CeO2. Two independent double-blinded researchers graded radiation-induced dermatitis and hyperpigmentation at 1, 4, and 12 weeks after radiation therapy according to CTC v. 3.0 criteria. Ninety days after radiation, all mice were anesthetized and stimulated salivary flow was measured after subcutaneous pilocarpine injection (2mg/kg of B.W.) RESULTS: Stimulated sialometry strongly demonstrated improved salivary production in all CeO2 groups compared to controls not receiving CeO2 (mean salivary flow 204 vs. 115 µL/10min p=.0002). Grade 3 dermatitis was more prevalent in the fractionated vs. the single fraction cohort. In the fractionated cohort, the incidence of grade 3 dermatitis 1 week after radiation was decreased in the 15 µM CeO2 group compared to the non-CeO2 controls (10% vs. 100% incidence of Grade 3 dermatitis, respectively). A similar effect in reduction of grade 3 dermatitis was seen in the 15 µM CeO2 group when compared to non-CeO2 controls in both radiation cohorts for all time points evaluated. This effect was not appreciated in the 15 nM CeO2 group. There was decrease in skin hyperpigmentation at 12 weeks in the 15 µM CeO2 group compared to the 15 nM CeO2 and non-CeO2 groups (50, 70, and 90% grade 2, respectively). There were four Grade V toxicities in the fractionated cohort; three in the 15 nM CeO2 group and one in the non-CeO2 group. No Grade V toxicities were noted in the 15 µM CeO2 group of mice. Additionally, there were no adverse effects noted in the groups of mice receiving CeO2 without radiation. CONCLUSIONS: This study suggests that cerium oxide nanoparticles may have a radiation protective effect on salivary production. Parallel observations indicate a reduction in Grade 3 radiation-induced dermatitis and skin hyperpigmentation. The use of cerium oxide nanoparticles as a radioprotectant may be a feasible concept, but should be tested in a larger cohort of mice using a 15 µM concentration of CeO2. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 101st Annual Meeting of the American Association for Cancer Research; 2010 Apr 17-21; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2010;70(8 Suppl):Abstract nr 1403.

Introduction Acute Otitis Media (AOM) is a common, painful disease often treated with topical analgesics, with or without systemic analgesics or antibiotics based on few published studies. Methods Consenting parents of assenting children (0.5 to 16 yrs) with painful AOM were randomized to topical treatment with either Auralgan (AU), Americaine (AM), or placebo (PBO). Parents or children (>4) rated pain on a 4 point categorical pain scale (no pain to a lot) at intervals prior and 48 hours after starting treatment. Compliance was assessed by diary entries and returned medications. Results 43 subjects were randomized and 41 were evaluable (11/10 PBO, 14/13 AU and 18/18 AM). Baseline pain scores were “medium” in 18 and “a lot” in 23. There were good pain relief with no statistically significant group differences. Results trended in the order AM>AU>PBO only for the first 4 hours in a) all children over age 4 regardless of baseline pain b) and all aged children with less than “a lot” of baseline pain. All children over 4 years of age reported some pain relief. Only one child, treated with PBO, had even a temporary increase in pain after use and compliance was good. Conclusion Further studies are needed with other pain assessment tools to determine whether topical analgesics, or their excipients alone, produce meaningful pain relief in children with AOM. Clinical Pharmacology & Therapeutics (2004) 75, P74–P74; doi: 10.1016/j.clpt.2003.11.280

Camphor is present in several over-the-counter compounds of questionable use and therefore may be ingested by small children. Because seizures may follow ingestion of certain amounts, appropriate treatment is needed, including the use of anticonvulsants.

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Alcohol intoxication (methyl, ethyl, isopropyl, and ethylene glycol) is treated frequently in emergency room and intensive care units. Although high morbidity and mortality rates exist, effective therapies for methyl alcohol and ethylene glycol (ethyl alcohol blocking and hemodialysis) and ethyl and isopropyl alcohol (hemodialysis) are available. Prompt and accurate clinical and laboratory differentiation is needed to optimize these therapies. This review presents clinical, pharmacologic, and management data, contrasts important aspects in differential diagnosis, and suggests an appropriate approach to management of isopropyl alcohol intoxication.

A previously well 2-year-old child presented with seizures and ventricular tachycardia shortly after playing with an aerosol can of a well-known proprietary deodorant. She required intensive care and survived without sequelae. The propellants used in this product were isobutane, n-butane, and propane. The propellants have been thought to be safer than the previously used Freons, which were known to be cardiotoxic and neurotoxic. Significant exposure was confirmed by the detection of n-butane and isobutane in the patient's serum. We conclude that unintentional exposure to non-Freon aerosol propellants in a nonconfined space can be hazardous to children. Aerosol cans should be considered to represent toxic hazards and should be kept out of reach of children.