Dasatinib Plus Capecitabine for Advanced Breast Cancer: Safety and Efficacy Data from Phase 1 Study CA180-004

Background: SRC is a potential therapeutic target in breast cancer and has a central role in hormone therapy resistance and in osteoclast activity. Dasatinib is a potent SRC inhibitor that inhibits breast cancer cell proliferation and migration in vitro, including synergy with 5FU in some cell lines, and inhibits osteoclast activity in clinical trials. CA180-004 is a phase 1 study designed to identify dose-limiting toxicities (DLT) and recommended phase 2 doses of dasatinib plus capecitabine in women with advanced breast cancer (ABC). Safety and efficacy data are now reported with additional follow-up.Methods: Cohorts of pts with ABC were treated at four dose levels (DL) with capecitabine (mg/m2 twice daily [BID] on D1-14 of 21-day cycles) and dasatinib (mg daily): DL1: capecitabine 825 + dasatinib 50 BID; DL2: capecitabine 825 + dasatinib 70 BID; DL3: capecitabine 1000 + dasatinib 70 BID; DL3a: capecitabine 1000 + dasatinib 100 once daily (QD). All pts had performance status 0-1, prior taxane and/or anthracycline and ≤2 prior chemotherapy-containing regimens for advanced disease. Disease assessments were performed every 6 weeks. DL3a was expanded for further safety and efficacy estimate using best objective response and progression-free survival (PFS) rates.Results: To date, 47 pts with ABC have been treated, 31 in escalation phase plus 16 in expansion (5 too early). Median age was 52 years (range 35-77). Tumor subtypes: 14% were Her2-amplified, 57% ER+ or PR+, 29% triple-negative. Safety was previously reported (ASCO 2009) for escalation phase; no MTD was defined based on DLTs. Of 20 evaluable pts in DL3a, 2 DLTs have been observed: 1 pneumonia, pain and pleural effusion plus 1 diarrhea, neutropenia, vomiting, mucositis and anemia. The most common drug-related adverse events (AEs, any grade) were headache, fatigue/asthenia, nausea/vomiting, diarrhea, hand-foot syndrome (HFS) and pleural effusion. The most common grade 3/4 AEs were fatigue/asthenia, HFS, vomiting and diarrhea. To date, 19 have remained on treatment ≥4 months, including 3 for >1 year. Median duration of treatment (n=42) was 13 weeks; 23 pts have discontinued for progression and 7 for toxicity. Of 38 pts with on-study assessment, 6 had confirmed partial response (treatment durations 17+, 23, 25, 36+, 71, 73 wks), 6 had unconfirmed partial or clinical response (5, 11, 13, 18, 23+, 24 wks), and 9 had prolonged stable disease (16+, 17, 23+, 24+, 25+, 29, 39+, 48+, 63+ wks). Updated efficacy data, including PFS by hormone receptor status, will be presented.Conclusions: Dasatinib and capecitabine combination treatment was well tolerated and encouraging efficacy was observed. Further assessment of this combination is warranted.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 3092.

Dasatinib plus capecitabine (Cap) for progressive advanced breast cancer (ABC): Phase I study CA180004

1012

Background: SRC family kinases (SFK) mediate numerous signal-transduction pathways relevant to breast cancer as well as osteoclast function. Dasatinib, a potent oral inhibitor of SFK and other kinases has preclinical activity in breast models and in vitro synergy with Cap in some breast cancer cell lines (KPL-4 and HCC-70). A phase I trial of dasatinib plus Cap was conducted to define dose-limiting toxicities (DLT), maximum tolerated (MTD), and recommended phase II (RP2D) doses. Methods: Sequential cohorts of pts with ABC were treated with Cap twice daily (BID) on days 1–14 and dasatinib daily in 21-day cycles using dose levels (DL) for Cap (mg/m2) and dasatinib (mg): DL1: Cap 825 + dasatinib 50 BID; DL2: Cap 825 + dasatinib 70 BID; DL3: Cap 1000 + dasatinib 70 BID; DL3a: Cap 1000 + dasatinib 100 once daily (QD). All pts had ECOG performance status 0–1, had prior anthracycline and/or taxane, and received ≤2 regimens in advanced setting. MTD was based on DLT in first cycle and RP2D also based on tolerability of additional cycles. Results: 31 pts with ABC, median age 53 years (range 36–78) were treated. Number of pts treated/evaluable for DLT/reported DLT (event) were DL1: 7/6/1 (headache, grade 3); DL2: 9/7/0; DL3: 6/6/1 (diarrhea, grade 3), and DL3a: 9/9/1 (pneumonia, grade 3). Most frequent AEs related to either drug and occurring at any time on study (n pts) were nausea (12), vomiting (7), diarrhea (6), abdominal pain (2), fatigue (8), headache (7), musculoskeletal pain (1), and pleural effusion (4); hand-foot syndrome (5) was as expected for Cap alone. 11 patients experienced a Grade 3–4 non-hematologic AE at some point during the study. Laboratory abnormalities were uncommon. To date, 20 pts have continued treatment for ≥6 weeks and 9 pts for ≥12 weeks. Number of pts who (at any time) reduced dasatinib/reduced Cap/discontinued for toxicity were DL1: 2/2/1; DL2 2/2/3; DL3: 2/1/2; DL3a: 0/1/1. Updated safety and efficacy data will be presented. Conclusions: Dasatinib + Cap was tolerated without unexpected combined-treatment toxicity; few pts required dose reduction in later cycles. The recommended phase II dose, Cap 1000 plus dasatinib 100 QD, is well tolerated and will be studied for efficacy in an expanded patient cohort.

[Table: see text]

A single U/C nucleotide substitution changing alanine to valine in the beet necrotic yellow vein virus P25 protein promotes increased virus accumulation in roots of mechanically inoculated, partially resistant sugar beet seedlings

Beet necrotic yellow vein virus (BNYVV) A type isolates E12 and S8, originating from areas where resistance-breaking had or had not been observed, respectively, served as starting material for studying the influence of sequence variations in BNYVV RNA 3 on virus accumulation in partially resistant sugar beet varieties. Sub-isolates containing only RNAs 1 and 2 were obtained by serial local lesion passages; biologically active cDNA clones were prepared for RNAs 3 which differed in their coding sequences for P25 aa 67, 68 and 129. Sugar beet seedlings were mechanically inoculated with RNA 1+2/RNA 3 pseudorecombinants. The origin of RNAs 1+2 had little influence on virus accumulation in rootlets. E12 RNA 3 coding for V(67)C(68)Y(129) P25, however, enabled a much higher virus accumulation than S8 RNA 3 coding for A(67)H(68)H(129) P25. Mutants revealed that this was due only to the V(67) 'GUU' codon as opposed to the A(67) 'GCU' codon.

DCE-MRI and dynamic FDG PET to monitor breast cancer response to neoadjuvant sunitinib in patients with locally-advanced breast cancer

Abstract #6006

Background: We are enrolling patients with locally-advanced (LABC) or inflammatory breast cancer on a phase II trial of neoadjuvant sunitinib and metronomic chemotherapy. The addition of sunitinib is hypothesized to increase rate of pathologic complete response (pCR) via its effect on tumor vasculature. Measurement of FDG PET and MRI parameters of metabolism and blood flow (BF) after a one week run-in of sunitinib alone provides an opportunity to evaluate in vivo pharmacodynamics of sunitinib which may be predictive of response and provide insight into mechanism of sunitinib activity. Materials and Methods: Patients with HER2 negative LABC participated in an imaging trial with pre-therapy [18F]-FDG PET and DCE-MRI (T0) followed by a one-week run-in of sunitinib 37.5 mg orally daily with a second PET and MRI on day 7 (T1). FDG metabolic rate (MRFDG), transport (FDG K1) and MR indices of tumor perfusion (peak enhancement (PE), signal enhancement ratio (SER), and washout volume(WV)) were assessed. Results: Metabolism and perfusion parameters are available for the first 3 patients treated on this trial. All patients presented with grade 3, HER2 negative LABC. DCI-MRI (left) and PET images (right) pre-therapy (T0, top) and after one week sunitinib (T1, bottom) are illustrated in Figure 1. DCE-MRI studies show gray-scale images with color-coded regional perfusion (SER) superimposed; red indicates high levels of perfusion and blue lower levels. Three different responses were observed and expressed as percent change T0 to T1: patient 1 had no significant change in metabolism (MRFDG) or perfusion (K1,SER, PE); patient 2 showed a decline in perfusion with decreases in K1 (-55%), SER (-19%), PE (-10%), and WV (-56%), but minimal change in MRFDG (+ 5.9%); while patient 3 had marked declines in perfusion K1 (-41%), SER (-25%), WV (-78%) and MRFDG (-59%). Discussion: These early data demonstrate the ability to measure changes in tumor metabolism and blood flow by PET and MRI and illustrate heterogeneity in tumor response to sunitinib. As patients complete neoadjuvant chemotherapy (NC), metabolism and perfusion parameters from mid-therapy (T2) and end-therapy (T3) imaging will be evaluated in the context of pCR versus other with the goal of exploiting functional imaging parameters to predict response to NC and elucidate mechanism of response to sunitinib and metronomic chemotherapy. Supported by grant from NCCN, SI11.
 


Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 6006.

Metabolism-perfusion mismatch as assessed by PET varies with breast cancer phenotype and predicts response to neoadjuvant chemotherapy

Abstract #6005

Background: Kinetic analysis of FDG and water PET can identify patterns of breast cancer metabolism and perfusion in patients receiving neoadjuvant chemotherapy (NC). Previously, we found that high pre-therapy glucose tumor metabolism relative to perfusion was associated with poor tumor pathologic response, early relapse, and death in patients with locally advanced breast cancer (LABC) treated with NC. This analysis examines tumor metabolism and perfusion as a function of tumor phenotype. Material and Methods: Tumor phenotype, defined by immunohistochemistry (IHC), was determined in 51 patients undergoing NC between 1995 and 2005. Luminal tumors were defined as those expressing either estrogen receptor (ER) or progesterone receptor (PR). The triple-negative (TN) phenotype was defined as ER and PR negative without HER2 overexpression by IHC or amplification by FISH. HER2 phenotype showed HER2 overexpression or amplification but were ER/PR negative. Women with LABC underwent dynamic [18F]-FDG and [15O]-water PET scans prior to NC. The FDG metabolic rate (MRFDG) and transport (FDG K1) parameters were calculated; blood flow (BF) was estimated from the water PET scan. Response to NC was determined from surgical specimens with pathologic complete response (pCR) defined as eradication of invasive tumor in the breast vs. other. Results: Of the tumors studied, 16 (31%) were TN, 30 (59%) were luminal, and 5 (10%) were HER2. pCR was observed in 4/16 (25%) TN tumors (95% CI: 0.10-0.50) compared to only 4/30 (13%) of luminal tumors (95% CI: 0.05-0.30) and 3/5 HER2 tumors. Linear regression of the association between PET parameters and phenotype (TN vs. luminal) found that TN was associated with higher MRFDG (p=0.007) and MRFDG/BF ratio (p=0.02), but not with BF (p=0.27). Only patients with low pre-therapy MRFDG/BF ratio (<35 umol/mL) achieved a pCR. Using this value as an ad-hoc cutoff, 4/7 (57%) of TN patients with low ratios had a pCR, while 0/9 with higher ratios had pCR. In contrast, only 4/21 (19%) of the luminal patients with low ratios had a pCR (one-sided mid-p=0.04 for TN vs. luminal pCR rate for patients with MRFDG/BF < 35 umol/mL). Discussion: These results demonstrate heterogeneity in breast tumor metabolism and perfusion as assessed by PET, and suggest a clinically relevant association between PET parameters and tumor phenotypes. The high MRFDG/BF ratio that predicts poor response to NC is more common in TN tumors; whereas in luminal or HER2 tumors, high MRFDG is generally matched with higher BF. Measurement of tumor metabolism and perfusion may identify a subset of tumors which are unlikely to respond to NC. Identification of such tumors may direct therapy toward those biologic targets most likely to overcome resistance.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 6005.

Use of changes in blood flow PET measurements to predict post-therapy lymph node status among locally advanced breast cancer patients

575

Background: Response to neoadjuvant therapy in the primary tumor and nodal metastasis predicts benefit to patients as shown in several large clinical trials. We have previously shown that changes in tumor blood flow (BF) measured by [15O]-water PET predict pathologic primary tumor response. We now test whether primary tumor blood flow changes also predict axillary nodal metastases response and post-therapy lymph node status among women with locally advanced breast cancer (LABC) receiving neoadjuvant chemotherapy. Methds: Fifty-five women with a primary diagnosis of LABC underwent dynamic [15O]-water PET scans prior to and at midpoint of neoadjuvant chemotherapy. We evaluated associations between tumor BF changes and pathologic primary tumor response: categorized as complete (CR), partial (PR) or no response (NR). We also assessed the relationship between primary tumor BF changes and post-therapy axillary lymph node status, categorizing the high risk (HR) group as 4+ nodes with extracapsular extension (ECE, n=12) versus the lower risk (LR) group with either fewer than 4+ nodes or without ECE (n=43). Results: The median changes in BF versus tumor response were: CR = -77%, PR = -40%, and, NR = +20% (P = <0.001). For axillary node response, the median BF change among HR patients was +20% versus - 49% among LR patients (P = 0.004). Eight of 17 patients with an increase in tumor blood flow were HR whereas 4/38 patients with decreased tumor blood flow were HR (P = 0.002). Conclusions: Change in primary tumor blood flow over the course of neoadjuvant chemotherapy predicts pathologic response to treatment with a substantial decrease observed among CRs. An increase in primary tumor BF with treatment portends significant residual primary tumor and a nearly 50% chance of very high-risk nodal disease post-therapy.

No significant financial relationships to disclose.

Tumor metabolism, blood flow changes, and prognosis by positron emission tomography: A prospective cohort of locally advanced breast cancer patients

506

Background: Breast cancer patients with locally advanced tumors receive preoperative chemotherapy to provide early systemic treatment and assess in-vivo tumor response. Positron emission tomography (PET) has been used to follow tumor response to therapy, as pathologic response is predictive of patient outcome. We evaluated the prognostic utility of serial quantitative PET tumor blood flow (BF) and metabolism measurements. Methods: Fifty-five women with a primary diagnosis of locally advanced breast carcinoma (LABC) underwent dynamic [18F]-FDG and [15O]-water PET scans prior to and at midpoint of neoadjuvant chemotherapy. The FDG metabolic rate (MRFDG), transport (K1), and flux (Ki) parameters were calculated, and tumor blood flow was estimated from the [15O]-water study. Associations between tumor BF and MRFDG measurements and disease-free survival (DFS) and overall survival (OS) were evaluated using the Cox proportional hazards model. Results: Patients that had an increase in BF and K1, from baseline to mid-therapy measurements, had elevated recurrence and mortality risks compared to patients that had reductions in BF and MRFDG values. In multivariate analysis, changes in BF and K1 remained independent prognostic indicators of DFS and OS survival. Conclusions: PET measurements of tumor response prior to completion of neoadjuvant chemotherapy were predictive of patient outcome. Patients that failed to have a decline in BF and K1 experienced higher risks of recurrence and mortality that was largely independent of clinical tumor characteristics assessed in this study. These results suggest that tumor perfusion, measured directly by [15O]-water or indirectly by dynamic FDG PET, is highly predictive of outcome in neoadjuvantly treated breast cancer.

No significant financial relationships to disclose.

Early experience with 'new federalism' in health insurance regulation

The authors monitored the implementation of the Health Insurance Portability and Accountability Act (HIPAA) from 1997 to 1999. Regulators in all states and relevant federal agencies were interviewed and applicable laws and regulations studied. The authors found that HIPAA changed legal protections for consumers' health coverage in several ways. They examine how the process of regulating such coverage was affected at the state and federal levels and under an emerging partnership of the two. Despite some early implementation challenges, HIPAA's successes have been significant, although limited by the law's incremental nature.

[Structure and quality of German-language gastroscopy information forms from the patients' viewpoint]

Information about procedure and risks is prerequisite for obtaining informed consent for endoscopy. This prospective and randomized investigation evaluated (i) the extent of patients' information needs and (ii) the formal quality (language, ease of understanding, length, figures etc.) of three information forms concerning upper CI-endoscopy issued in 1995 by DIOmed (1), perimed compliance (2), and PERIMED-spitta (3) as judged by the patients. (iii) Outcome quality was investigated as the influence of these forms on understanding why and how endoscopy was performed as well as the influence on feeling threatened. Furthermore patients' anxiety was assessed by using Spielberger's state-trait anxiety inventory (STAI). 218 patients completed the investigation (n = 73; 70; 75, respectively). 60% claimed the need for a detailed explanation of the planned endoscopy and 48% said they wanted exhaustive informations about potential complications and risks. The three forms (length 819, 771, 1,245 words) were entirely read by 87%, 89% and 82% of the patients. Positive language, adequate length (69%, 69%, 71%) and adequate layout were evenly attributed to the three forms. A high impact of the figures for understanding was found more frequently (48%, 46%, 35%) with (1) and (2) and language war regarded easy by 57%, 54% and 44%, respectively. Flesh's reading ease score, however, proved a sophisticated niveau of language with all three forms. The indication for endoscopy (37%, 49%, 56%) and explanation of performance (43%, 43%, 63%) was superior with (3). This form also reduced anxiety as judged by STAI-means, overall STAI-changes, and relevant changes (> or = 5 points). Form (2) increased patients' anxiety.

CONCLUSION

While the formal quality of all information forms is appreciated by patients both their reading ease score and figures should be improved. A significant reduction of anxiety can be achieved by appropriate selection of the information material.

Dendritic cells retrovirally transduced with a model antigen gene are therapeutically effective against established pulmonary metastases

Dendritic cells (DCs) are bone marrow-derived leukocytes that function as potent antigen presenting cells capable of initiating T cell-dependent responses from quiescent lymphocytes. DC pulsed with tumor-associated antigen (TAA) peptide or protein have recently been demonstrated to elicit antigen-specific protective antitumor immunity in a number of murine models. Transduction of DCs with TAA genes may allow stable, prolonged antigen expression as well as the potential for presentation of multiple, or unidentified, epitopes in association with major histocompatibility complex class I and/or class II molecules. To evaluate the potential efficacy of retrovirally transduced DCs, bone marrow cells harvested from BALB/c mice were transduced with either a model antigen gene encoding beta-galactosidase (beta-gal) or a control gene encoding rat HER-2/neu (Neu) by coculture with irradiated ecotropic retroviral producer lines. Bone marrow cells were differentiated into DC in vitro using granulocyte/macrophage colony-stimulating factor and interleukin-4. After 7 d in culture, cells were 45-78% double positive for DC phenotypic cell surface markers by FACS(R) analysis, and DC transduced with beta-gal were 41-72% positive for beta-gal expression by X-gal staining. In addition, coculture of beta-gal transduced DC with a beta-gal-specific T cell line (CTLx) resulted in the production of large amounts of interferon-gamma, demonstrating that transduced DCs could process and present endogenously expressed beta-gal. DC transduced with beta-gal and control rat HER-2/neu were then used to treat 3-d lung metastases in mice bearing an experimental murine tumor CT26.CL25, expressing the model antigen, beta-gal. Treatment with beta-gal-transduced DC significantly reduced the number of pulmonary metastatic nodules compared with treatment with Hank's balanced salt solution or DCs transduced with rat HER-2/neu. In addition, immunization with beta-gal-transduced DCs resulted in the generation of antigen-specific cytotoxic T lymphocytes (CTLs), which were significantly more reactive against relevant tumor targets than CTLs generated from mice immunized with DCs pulsed with the Ld-restricted beta-gal peptide. The results observed in this rapidly lethal tumor model suggest that DCs transduced with TAA may be a useful treatment modality in tumor immunotherapy.

Caregiving: concept analysis and outcomes

More than ever before, caregiving has become a salient public policy issue. A number of recent and anticipated demographic, economic and social changes have occurred that make it imperative for researchers to critically examine the impact of caregiving on family caregivers' health, behavior, emotions, and social status. Researchers at the University of Iowa College of Nursing are working to classify standardized nursing-sensitive patient outcomes for use in language development, practice, research, and education to evaluate the effectiveness of nursing interventions and clinical nursing services. This article focuses on family caregiving and the analysis of caregiver role performance in both direct and indirect care, linking outcomes and indicators, to enable nurses to promote the health of caregivers.

Genome duplication in soybean (Glycine subgenus soja)

Restriction fragment length polymorphism mapping data from nine populations (Glycine max x G. soja and G. max x G. max) of the Glycine subgenus soja genome led to the identification of many duplicated segments of the genome. Linkage groups contained up to 33 markers that were duplicated on other linkage groups. The size of homoeologous regions ranged from 1.5 to 106.4 cM, with an average size of 45.3 cM. We observed segments in the soybean genome that were present in as many as six copies with an average of 2.55 duplications per segment. The presence of nested duplications suggests that at least one of the original genomes may have undergone an additional round of tetraploidization. Tetraploidization, along with large internal duplications, accounts for the highly duplicated nature of the genome of the subgenus. Quantitative trait loci for seed protein and oil showed correspondence across homoeologous regions, suggesting that the genes or gene families contributing to seed composition have retained similar functions throughout the evolution of the chromosomes.

The cost of treating pressure ulcers following implementation of a research-based skin care protocol in a long-term care facility

Although concern for the costs associated with pressure ulcer treatments persists, studies that precisely quantify costs are limited. A retrospective research design was used to describe the costs incurred by an 830-bed, long-term care facility to treat 81 pressure ulcers over a one-year period following implementation of a research-based, skin care protocol. The total cost for the study period was $30,079 with 73% of these expenditures attributable to nursing care. Mean cost of treatment was $3.74/pressure ulcer/day, which was a reduction from the $5.35/pressure ulcer/day cost prior to implementation of the skin care protocol. These findings suggest that implementing a research-based, skin care protocol can promote a reduction in treatment costs.

Alzheimer's special care units

An overview of Alzheimer's special care units is provided, including the several models that have been used to guide their development. Philosophy and programming, physical and social environments, staff selection and training, admission and discharge criteria, family programming, and quality and cost features are described. Evaluation and research of special units and interventions for residents with Alzheimer's, their family members and staff caregivers are discussed.

Disseminated neoplastic cells in Mytilus trossulus: verification of host species origin by (16S-like) rRNA sequence comparison

Disseminated neoplasia is a leukemia-like disease that occurs in many species of bivalve molluscs worldwide, including the bay mussel (Mytilus trossulus). The etiology of the disease is undetermined, but an early report proposed that the anomalous bivalve cells were actually an invasive parasite rather than cancerous cells of host origin. Comparison of partial sequences of small subunit rRNA from normal and putative cancer cells was performed to resolve this issue. These studies showed a close phylogenetic relationship of the different forms of cancer cells to each other (similarity coefficient, 0.982), to the normal hemocytes (similarity coefficient, 0.990, 0.992), and to the oyster, Crassostrea virginica (similarity coefficient, 0.895-0.927). A large phylogenetic distance separates all 3 mussel hemocyte types from several representative protists (similarity coefficient, 0.702-0.761). These results indicate that the disseminated neoplastic cells in mussels are indeed proliferative host cells and not unicellular parasites.

Adoption of research-based practice for treatment of pressure ulcers in long-term care

Implementation of a clinical trial to evaluate the effectiveness of electrotherapy on pressure ulcer healing provided the stimulus for adoption of research-based innovations for pressure ulcer treatment in one long-term care facility. A five-year retrospective study conducted prior to introduction of the clinical trial revealed that 72 different treatments were applied to pressure ulcers. Forty-two percent of the pressure ulcers were left open to the air or covered with a dry gauze dressing and 64% were treated with some type of antiseptic solution. Since implementation of the clinical trial and the accompanying access to wound healing research knowledge it provided in this setting, the prevailing treatment for pressure ulcers has become moist physiologic dressings.

The cost of treating pressure ulcers in a long-term care facility

Although there is rising concern with the cost of pressure ulcer treatment, actual expenditures have not been quantified in many settings. A retrospective research design was used to describe the costs incurred by an 830-bed long-term care facility to treat 240 pressure ulcers over a five-year period. The total cost was $116,416 for the study period. The mean cost of treatment was $5.35/pressure ulcer/day. These costs are substantially lower than the costs of pressure ulcer treatment in acute care. Further study to compare treatment costs with prevention costs would provide useful information on the cost benefits of prevention.

Adjunct executive appointment for faculty. An innovation in nursing collaboration

The need for collaboration has never been greater. The healthcare delivery system faces unprecedented challenges arising from prospective payment, competition in the marketplace, higher patient acuity levels, and a shortage of professional nursing staff. The authors discuss a service-education collaboration model based on adjunct executive appointments of faculty members to healthcare organizations. The authors describe the model, a conceptual framework to guide its development, case studies of its implementation, and a summary of the benefits and risks associated with the initial implementation of the model.

The implementation of nursing diagnoses. The Iowa Veterans Home experience

This article has reviewed the process of implementing nursing diagnoses in one long-term care agency. Nursing diagnoses improved nursing process skills, made problem identification more accurate, and aided the identification of nursing interventions and desired outcomes. Nursing diagnoses have become the organizing framework for quality assurance, staff development, specialization and consultation, and computer applications. The presence of a professional model of nursing practice facilitated the use of nursing diagnoses. Prior to implementing nursing diagnoses, IVH nurses had defined the scope of nursing practice and formed a committee structure for decision-making by all RNs. The structure included mechanisms for collective and individual accountability. All nurses participated in the decision to use nursing diagnoses in their practice. Each nurse had the opportunity to influence the process of change. The process of implementing nursing diagnoses at IVH continues. Nurses recognize the need to establish the validity of each diagnostic statement. Skill with the diagnostic process is expected to improve. Nurses also recognize the need to test interventions for specific diagnoses. The standard nomenclature will continue to be used for the improvement of nursing practice and for nursing department programming. The use of nursing diagnoses is the basis of the continued development of a professional model of nursing practice.