Support group webcasting: a feasibility assessment

Stress from chronic illness can be ameliorated by participation in support groups (SGs). Attending "gold standard" in-person, moderated SGs can be challenging. Taking care to address confidentiality concerns, we developed a web-based method for remote participants to "attend" in-person SGs. Authorized participants gain a realtime, audiovisual connection to the SG; on-site attendees discuss textual comments sent by remote participants to, and selected for discussion by, the group moderator. Feasibility studies with three SGs are encouraging.

DeTMan: a decision tree management tool for the Web and PDA environments

Illness management protocols, often represented as decision trees, are used in many areas of medicine. Some clinical departments maintain numerous, often quite complex protocols. Protocol access in acute care situations can be challenging, especially when available only in hardcopy format. Access via the web and especially via personal digital assistants would be more helpful. In the absence of the prior availability of a general purpose web/PDA decision tree editor/navigator, we are developing such a tool.

Leveraging of open EMR architecture for clinical trial accrual

Accrual to clinical trials is a major bottleneck in scientific progress in clinical medicine. Many methods for identifying potential subjects and improving accrual have been pursued; few have succeeded, and none have proven generally reproducible or scalable. We leveraged the open architecture of the core clinical data repository of our electronic medical record system to prototype a solution for this problem in a manner consistent with contemporary regulations and research ethics. We piloted the solution with a local investigator-initiated trial for which candidate identification was expected to be difficult. Key results in the eleven months of experience to date include automated screening of 7,296,708 lab results from 69,288 patients, detection of 1,768 screening tests of interest, identification of 70 potential candidates who met all further automated criteria, and accrual of three candidates to the trial. Hypotheses for this disappointing impact on accrual, and directions for future research, are discussed.

Web services-based access to local clinical trial databases: a standards initiative of the Association of American Cancer Institutes

Electronic discovery of the clinical trials being performed at a specific research center is a challenging task, which presently requires manual review of the center's locally maintained databases or web pages of protocol listings. Near real-time automated discovery of available trials would increase the efficiency and effectiveness of clinical trial searching, and would facilitate the development of new services for information providers and consumers. Automated discovery efforts to date have been hindered by issues such as disparate database schemas, vocabularies, and insufficient standards for easy intersystem exchange of high-level data, but adequate infrastructure now exists that make possible the development of applications for near real-time automated discovery of trials. This paper describes the current state (design and implementation) of the Web Services Specification for Publication and Discovery of Clinical Trials as developed by the Technology Task Force of the Association of American Cancer Institutes. The paper then briefly discusses a prototype web service-based application that implements the specification. Directions for evolution of this specification are also discussed.

Fentanyl-associated syndrome of inappropriate antidiuretic hormone secretion

A 43-year-old woman with advanced pulmonary blastoma was admitted for worsening back pain. Her drug regimen included hydromorphone and benazepril. On admission, hydromorphone patient-controlled analgesia (PCA) was started for acute pain control and dexamethasone for possible cord compression. Baseline laboratory tests were unremarkable, but magnetic resonance imaging revealed T3 and L3 lesions. Irradiation was started with improvement in her pain. In anticipation of discharge, a fentanyl transdermal patch was given, and PCA was tapered. Two days later, the patient became progressively confused and fell. Neurologic examination and computed brain tomography were normal. Her serum sodium was 119 mEq/L (normal 136-144 mEq/L) and was confirmed on repeat testing, urine sodium was 194 mEq/L, and urine and serum osmolalities were 554 mOsm/kg (normal 300-900 mOsm/kg) and 245 mOsm/kg (normal 280-300 mOsm/kg), respectively, consistent with the syndrome of inappropriate antidiuretic hormone secretion (SIADH). Fluids were restricted, hydromorphone PCA was started again, and fentanyl was discontinued. After 36 hours, her serum sodium increased to 136 mEq/L. Because we were unsure whether the fentanyl or her cancer was causative and were unable to find any published reports of fentanyl-associated SIADH, we readministered the fentanyl patch 2 days later. Within 48 hours, serum sodium dropped to 123 mEq/L. Fentanyl was discontinued, fluids were restricted, and 3% saline was started. Her serum sodium increased to 132 mEq/L in 48 hours. The patient was prescribed oral hydromorphone and benazepril and was discharged. The repeated temporal relationship between the administration of fentanyl and the onset of SIADH strongly implicates fentanyl as the causative agent in this case. To our knowledge, this is the first report of fentanyl-associated SIADH.

Medical therapy of prostate cancer: 1999

Prostate cancer is the most commonly diagnosed male malignancy and the second most common cause of male cancer death in the U.S. The principles of management of newly diagnosed metastatic prostate cancer have changed little in the last 50 years. Medical therapy continues to have no standard role in the management of localized disease. The various hormonal monotherapy approaches targeting androgen deprivation yield comparable results in the treatment of advanced disease. Supplementing an LHRH agonist (but not orchiectomy) with an antiandrogen may improve survival in men with minimal disease, but the economic cost and the risk for significant impairment of quality of life are quite high. The benefit of combined androgen blockade for patients with more extensive disease remains unclear, with support for this approach waning in recent years. New chemotherapeutic agents and combinations of such, as well as agents with entirely new mechanisms of action, recently have shown encouraging results in the treatment of HRPC. Much additional research is needed to improve our armamentarium against this epidemic disease.

Electronic clinical trial protocol distribution via the World-Wide Web: a prototype for reducing costs and errors, improving accrual, and saving trees

Clinical trials today typically are inefficient, paper-based operations. Poor community physician awareness of available trials and difficult referral mechanisms also contribute to poor accrual. The Physicians Research Network (PRN) web was developed for more efficient trial protocol distribution and eligibility inquiries. The Medical University of South Carolina's Hollings Cancer Center trials program and two community oncology practices served as a testbed. In 581 man-hours over 18 months, 147 protocols were loaded into PRN. The trials program eliminated all protocol hardcopies except the masters, reduced photocopier use 59%, and saved 1.0 full-time equivalents (FTE), but 1.0 FTE was needed to manage PRN. There were no known security breaches, downtime, or content-related problems. Therefore, PRN is a paperless, user-preferred, reliable, secure method for distributing protocols and reducing distribution errors and delays because only a single copy of each protocol is maintained. Furthermore, PRN is being extended to serve other aspects of trial operations.

Expression of oligohistidine-tagged ricin B chain in Spodoptera frugiperda

DNA encoding ADPGH6G was fused to the 5'-end of RTB DNA and subcloned as a BamHI-EcoRI DNA cassette into the baculovirus transfer vector, pAcGP67A. Spodoptera frugiperda Sf9 cells were cotransfected with pAcGP67A-ADPGH6G-RTB DNA and BaculoGold AcNPV DNA, and recombinant baculovirus was isolated by two cycles of limiting dilution assay followed by dot blot analysis with 32P-dCTP random primer labeled RTB DNA. Recombinant virus was purified and amplified to obtain stocks at titers of 10(7) infectious particles/mL. Sf9 cells grown in serum-free medium were then infected at an moi of 3 in the presence of 25 mM alpha-lactose. After 5 days, supernatants and cell pellets were harvested and assayed by an asialofetuin ELISA for recombinant RTB protein. Fusion RTB protein was produced in the supernatant at 5 mg/L and in the cell pellet at 1 mg/L. Recombinant protein was purified to > 80% homogeneity using either a monoclonal antibody affinity matrix with alkaline elution or a Ni(2+)-NTA matrix with imidazole elution. The purified protein bound asialofetuin similarly to plant RTB. N-terminal sequencing confirmed the oligohistidine tag. SDS-PAGE confirmed the 1,000 Da increase in mass relative to "wild-type" recombinant RTB produced in Sf9 cells. Immunoblots confirmed reactivity with polyclonal and monoclonal antibodies to plant RTB. The fusion protein reassociated with plant RTA similarly to plant RTB.(ABSTRACT TRUNCATED AT 250 WORDS)

Medical therapy of prostate cancer

Prostate cancer is now the most commonly diagnosed male malignancy and the second most common cause of male cancer death in the U.S. There is no standard role for medical therapy in the treatment of localized disease, although ongoing trials are investigating possible adjuvant and neoadjuvant roles. Subtotal androgen ablation by surgical or medical means is standard therapy for advanced disease, but such therapy does not exterminate the androgen-independent clone which is hypothesized to develop very early in the course of the disease. The current favored medical therapy for subtotal androgen ablation is the use of a depot formulation of an LHRH agonist accompanied initially by an antiandrogen. Once first-line hormonal therapy has failed, there is little to be gained by any other hormonal therapy, although withdrawal of the hormone(s) might itself be a therapeutic maneuver. Cytotoxic agents presently have no standard role in the management of prostate cancer. Future effective therapies for prostate cancer are being presaged by advances in prostate tumor biology.

The effect of physician personality on laboratory test ordering for hypertensive patients

Laboratory tests are responsible for a large percentage of health care expenses in the United States. In a retrospective study of the outpatient test ordering by residents for hypertensive patients between the years 1980 and 1986 at the Department of Family Medicine at the Medical University of South Carolina, we found great variability in laboratory test ordering as well as an association between personality as measured by the Myers-Briggs Type Indicator (MBTI) and test ordering. Introverts ordered more than extroverts, and intuitives ordered more than sensors. This association was confirmed by a multiple regression analysis controlling for potential confounders of test ordering, such as severity of disease, the presence of coexisting diabetes mellitus, the demographic characteristics of the patient population, and the number of initial evaluations for hypertension. Elucidation of a relationship between resident personality and laboratory test ordering has important implications for planning intervention strategies to reduce excessive laboratory test ordering in ambulatory care.