Pilot Study of a Mobile Phone Chatbot for Medication Adherence and Toxicity Management Among Patients With GI Cancers on Capecitabine

PURPOSE

Capecitabine is an oral chemotherapy used to treat many gastrointestinal cancers. Its complex dosing and narrow therapeutic index make medication adherence and toxicity management crucial for quality care.

METHODS

We conducted a pilot study of PENNY-GI, a mobile phone text messaging-based chatbot that leverages algorithmic surveys and natural language processing to promote medication adherence and toxicity management among patients with gastrointestinal cancers on capecitabine. Eligibility initially included all capecitabine-containing regimens but was subsequently restricted to capecitabine monotherapy because of challenges in integrating PENNY-GI with radiation and intravenous chemotherapy schedules. We used design thinking principles and real-time data on safety, accuracy, and usefulness to make iterative refinements to PENNY-GI with the goal of minimizing the proportion of text messaging exchanges with incorrect medication or symptom management recommendations. All patients were invited to participate in structured exit interviews to provide feedback on PENNY-GI.

RESULTS

We enrolled 40 patients (median age 64.5 years, 52.5% male, 62.5% White, 55.0% with colorectal cancer, 50.0% on capecitabine monotherapy). We identified 284 of 3,895 (7.3%) medication-related and 13 of 527 (2.5%) symptom-related text messaging exchanges with incorrect recommendations. In exit interviews with 24 patients, participants reported finding the medication reminders reliable and user-friendly, but the symptom management tool was too simplistic to be helpful.

CONCLUSION

Although PENNY-GI provided accurate recommendations in >90% of text messaging exchanges, we identified multiple limitations with respect to the intervention's generalizability, usefulness, and scalability. Lessons from this pilot study should inform future efforts to develop and implement digital health interventions in oncology.

An augmented intelligence mobile phone chatbot for medication adherence and toxicity management among patients with gastrointestinal cancers on capecitabine

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Background: Capecitabine (cape), an oral chemotherapy, is the treatment backbone for many GI cancers. Its complex dosing and narrow therapeutic index make medication adherence and toxicity management crucial for quality patient care. Methods: We conducted a feasibility study of “Penny,” an augmented intelligence mobile phone chatbot that leverages algorithmic surveys and natural language processing (NLP) to engage with patients in conversational, bi-directional text messages. Penny provides patients with medication reminders tailored to their prescribed doses and schedules, sends weekly check-in messages, manages low-grade symptoms in real time, and escalates high-grade symptoms for resolution by the clinical team. Patients ≥18 years old receiving cape for the treatment of a GI cancer were accrued in sequential cohorts of 20 for participation over a three-month period. Feasibility was assessed during planned interim analyses and was predefined as the completion of a 20-patient cohort without a safety event, defined as the communication of incorrect medication or symptom management recommendations as ascertained by two independent clinician reviewers (Κ = 0.89). Secondary outcomes included patient-reported adherence and engagement with the chatbot’s weekly check-in messages. At study completion, all patients were invited to participate in structured interviews to provide feedback on the platform. Results: The first cohort of 20 patients was enrolled from 8/2021 to 4/2022; the median age was 57 years, and patients were primarily female (55%), white (65%), commercially insured (55%), and had colorectal cancer (55%). Chemotherapy regimens included cape with oxaliplatin (50%), concurrent RT (30%), temozolomide (5%), and monotherapy (15%). A total of 2,149 text messaging exchanges were reviewed with 150 (7%) medication-related and 9 (0.4%) symptom-related safety events identified. Most medication-related safety events were due to misalignment with prescribed chemotherapy schedules (55%) and doses (32%). Symptom-related safety events were primarily due to the misinterpretation of patient messages by Penny’s NLP functionality (89%). Average patient-reported adherence was 67% (SD 27%), and patients engaged with 27% (SD 24%) of the chatbot’s weekly check-in messages. In post-study interviews with 12 patients, participants reported that the medication reminders were reliable and user-friendly, whereas the symptom management tool was too simplistic to be helpful. Conclusions: Although Penny has not yet met its feasibility endpoint, the lessons learned from this first cohort have informed further refinements to the platform. Ongoing efforts aim to integrate Penny with the electronic health record and further train the chatbot’s NLP functionality to minimize medication- and symptom-related safety events, respectively. Clinical trial information: NCT05113264.

Bone infection: a clinical priority for clinicians, scientists and educators

Bone infection has received increasing attention in recent years as one of the main outstanding clinical problems in orthopaedic-trauma surgery that has not been successfully addressed. In fact, infection may develop across a spectrum of patient types regardless of the level of perioperative management, including antibiotic prophylaxis. Some of the main unknown factors that may be involved, and the main targets for future intervention, include more accurate and less invasive diagnostic options, more thorough and accurate debridement protocols, and more potent and targeted antimicrobials. The underlying biology dominates the clinical management of bone infections, with features such as biofilm formation, osteolysis and vascularisation being particularly influential. Based on the persistence of this problem, an improved understanding of the basic biology is deemed necessary to enable innovation in the field. Furthermore, from the clinical side, better evidence, documentation and outreach will be required to translate these innovations to the patient. This review presents the findings and progress of the AO Trauma Clinical Priority Program on the topic of bone infection.

Abstract P5-05-07: Expression of the cocaine- and amphetamine-regulated transcript (CART) recruits SWI/SNF chromatin remodelling complexes to the estrogen receptor

Introduction

Cocaine- and amphetamine-regulated transcript (CART) peptides are neuropeptides involved in regulating physiological processes, such as feeding and drug reward. Recent studies have associated high CART expression with worse overall survival in patients with small-bowel carcinoid tumours and estrogen receptor-positive (ER+), lymph node-negative breast cancer. CART was also shown to be associated with poor patient response to tamoxifen, suggesting CART may play a role in conferring tamoxifen resistance.

Materials and methods

We have previously demonstrated that CART can impact the transcriptional activity of ERα through the use of western blotting and qPCR for specific ERα gene targets. RNA sequencing was carried out using a stable CART-inducible cell line model to identify genes which are upregulated/downregulated in cells expressing CART. Further, using our stable CART-inducible cell line model, we preformed ERα-Immunoprecipitation followed by in-solution mass spectrometry to identify differentially recruited protein complexes +/- CART expression.

Results and discussion

RNA sequencing revealed 156 significantly downregulated, and 100 significantly upregulated, genes in cells expressing CART (p<0.05). Through mining of publicly available ERα ChIP-seq data sets, both upregulated and downregulated gene sets were found to contain genes which have previously been shown to contain ERα binding events within their promotor regions. Mass spectrometry analysis revealed that the majority of proteins recruited to ERα in the presence of CART were members of the SWI/SNF (BAF) chromatin remodelling complex. The identification of SMARCD1 within this complex was of particular interest to this study, as this protein has previously been reported to be a critical mediator of nuclear receptor function. Further in silico analysis demonstrated high expression of SMARCD1 correlates with poor overall survival (OS) (p<0.00001) and distant metastasis free survival (DMFS) (p=0.00708) in a cohort of ER+ breast cancer patients. Intriguingly, SMARCD1 expression did not correlate with poor OS or DMFS in a cohort of ER- breast cancer patients, suggesting that this negative impact on survival is dependent on ER status.

Conclusion

In conclusion, we suggest that CART expression results in the recruitment of chromatin remodelling complexes to ERα in order to facilitate the regulation of receptor function and this impacts on patient outcome.

Citation Format: O'Connor DP, Mooney B, Das S, Klinger R, Moran B, Ni Chonghaile T, Cagney G, Bracken A, Gallagher WM. Expression of the cocaine- and amphetamine-regulated transcript (CART) recruits SWI/SNF chromatin remodelling complexes to the estrogen receptor [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-05-07.

The challenge of contemporary nurse education programmes. Perceived stressors of nursing students: mental health and related lifestyle issues

This study aimed to identify the lifestyle behaviours of nursing students. The research tool was a 146-item questionnaire based upon the College Lifestyle and Attitudinal National survey. Most students considered their mental health as either good or very good. Those in the final year were more likely to rate their mental health poorly. Many experienced programme-related stressors including examinations and assignments and studies in general. More than one-third also reported stressors related to relationships with clinical staff and clinical assessment of competence. There is a concern that the added demands of modern nursing programmes place the student under considerably more pressure, because of competing demands. While many students talk to their peers or family, many do not and prefer rather to go it alone, with some choosing to escape through alcohol or drugs. The support and encouragement of healthy coping mechanisms among nursing students is paramount to ensure a healthy nursing workforce for the future. Nursing students support the mental and physical health of others, and therefore in many ways ought to a role model. Nurturing and supporting their mental health is crucial to the future of profession.

A retrospective look at long-term adolescent recovery: clinicians talk to researchers

The purpose of the present article is to identify factors associated with long-term recovery for adolescents. A group of 14 young adults were given semistructured in-depth (one to two hour) interviews. The subjects had been in recovery for two to 16 years. Length of stay in treatment, involvement with self-help groups, psychotropic medication, family support, peer support, spirituality, and other factors were identified as helpful for long-term recovery. A major limitation of this inquiry is that it does not meet minimum standards for research. It is hoped, however, that this inquiry can inform directions for further research.

The occurrence of hsp70 in the outer membrane of plant mitochondria

Hsp70 was localized to the mitochondrial outer membranes of bean and cauliflower mitochondria. Western blotting showed that the outer membrane hsp70 was antigenically distinct from the mitochondrial-matrix hsp70, but was similar to the cytosolic form. The protein was resistant to solubilization with 200 mM sodium carbonate which showed the hsp70 was tightly bound to the outer membrane. Proteinase K studies suggested that the hsp70 was partially exposed to the cytosol with approximately 17% of the protein protease-accessible. It is suggested that the position of the outer membrane hsp70 could relate to a precursor unfolding function during protein import into mitochondria.

Identification of a 42-kDa plant mitochondrial outer membrane protein, MOM42, involved in the import of precursor proteins into plant mitochondria

A 42-kDa plant outer mitochondrial membrane protein, MOM42, has been identified as an essential component of the plant mitochondrial precursor protein translocation apparatus. Immunological cross-reactivity has been detected between antibodies raised against both Neurospora and yeast mitochondrial outer membrane proteins and plant mitochondrial outer membrane proteins. Immunocompetition studies showed that import of precursors to Rieske FeS protein, ATPase su9-DHFR, and the adenine nucleotide transporter was inhibited in the presence of antibody to MOM42. The inhibition of Rieske Fes and su9-DHFR import was greater than that of the adenine nucleotide transporter. The competition studies suggest that the MOM42 is involved in the translocation of bound precursor proteins. The import data and the Western blots suggest that components of the mitochondrial import system are highly conserved.

Timing of strangulation in adult hernias

This retrospective study aimed to determine why the incidence of strangulated hernias in adults remains high. Seventy-nine patients presented with clinical evidence of hernia strangulation which required urgent surgery during the period 1979-87. Forty-six patients (58 per cent) had noted a hernia present for at least 1 month before strangulation: 18 (23 per cent) had not reported it to their family doctor, 19 (24 per cent) were known by family practitioners or non-surgical medical personnel to have a hernia but had not been referred for surgical opinion, and nine (11 per cent) had been previously assessed surgically with a view to elective repair. Of these nine, five were considered unfit, three were on waiting lists for operation and one had refused surgery. Thirty-two patients (40 per cent) presented primarily with strangulation within days of developing a hernia. The duration of hernia before strangulation in one patient was unknown. Although an unavoidable number of patients will continue to present with strangulation within days of developing a hernia, the overall incidence could be significantly reduced by greater public awareness of the risks of hernia strangulation and by a policy of immediate patient referral and prompt elective repair.

The effects of vasopressin on hepatic haemodynamics in the cirrhotic and non-cirrhotic rat

Liver blood flow (xenon-133 clearance method) and portal venous flow were measured in cirrhotic and non cirrhotic rats following the infusion of vasopressin at varying rates. At low rates of infusion, vasopressin had no significant effect on portal venous flow or liver blood flow in cirrhotic or non-cirrhotic rats. Infusion of vasopressin at a rate of 0.08 microU/g body wt/min in non-cirrhotic rats and 0.04 and 0.08 microU/g body wt/min in cirrhotic rats decreased portal venous flow and increased liver blood flow. At higher rates of infusion (0.2 microU/g body wt/min in non-cirrhotic rats and 0.16 microU/g body wt/min in cirrhotic rats) these effects were reversed. Furthermore, an infusion of 0.08 microU/g body wt/min vasopressin significantly reduced portal pressure in the cirrhotic rat. However, portal pressure was not significantly altered following an infusion of 0.16 microU/g body wt vasopressin. The implications of these findings in relation to the possible deleterious effects of high rates of vasopressin infusion in the management of portal hypertension and bleeding oesophageal varices is discussed.

The effect of vasopressin and hepatic artery ligation on the blood supply to normal and metastatic liver tissue

The effect of low (0.08 microU g-1 body wt min-1) and high (0.16 microU g-1 body wt min-1) rates of vasopressin infusion on blood flow to normal liver tissue and to liver metastases derived from azoxymethane induced colorectal carcinomas was studied in 36 male Wistar rats. Portal venous flow was measured by electromagnetic flowmetry and blood flow to normal and metastatic liver tissue by the clearance of xenon-133 injected directly into the liver parenchyma or metastasis. The low rate of vasopressin infusion decreased portal venous flow but increased blood flow to normal and metastatic liver tissue while at the higher rate of infusion these effects were reversed. Hepatic artery ligation (HAL) immediately following a low rate of vasopressin infusion abolished the observed increase in blood flow to both normal liver tissue and metastases. HAL immediately following the higher rate of vasopressin infusion further reduced blood flow to metastases but did not further alter blood flow to normal liver tissue. HAL prior to the infusion of the vasoactive drug significantly reduced blood flow to metastatic liver tissue, increased portal venous flow and was without effect on blood flow to normal liver tissue. Following HAL, blood flow to metastatic liver tissue was not further altered by either the low or high rates of vasopressin infusion. However, blood flow to normal liver tissue after HAL was reduced by a low rate of infusion of vasopressin and increased by the higher rate of infusion. The results of this study indicate that blood flow to normal or metastatic liver tissue can be increased or decreased by differential rates of infusion of vasopressin. These observations may have important implications in the treatment of liver metastases in man where different rates of vasopressin infusion may potentiate the effects of hepatic artery ligation or cytotoxic therapy.

The effect of vasopressin on hepatic artery flow in the rat

The effects of vasopressin infusion on hepatic artery flow was studied in rats. Hepatic artery ligation followed by the infusion of vasopressin (0.08 microU/g body weight per min) decreases portal venous flow and liver blood flow. Vasopressin infusion results in an increase in hepatic artery flow and liver blood flow both of which are abolished by subsequent hepatic artery ligation. The increase in hepatic artery flow and the decrease in portal venous flow following the infusion of vasopressin is discussed in relation to the management of patients presenting with bleeding oesophageal varices.

Decontamination of urinary bags for rehabilitation patients

Patients with neurologic injuries frequently have permanent indwelling or external catheters connected to disposable urinary bags. These patients routinely disconnect the bed bag during the day and apply a leg bag which can be concealed under their clothes. In our rehabilitation unit, both bags are discarded daily. This study investigated the possibility of safely reusing bed and leg bags. The procedure involved decontamination of the bags using 180 ml of a 1% solution of sodium hypochlorite. Initially, discarded bed and leg bags were decontaminated in the lab to ensure effectiveness of the procedure. Next, 22 patients reused their bed and leg bags with daily decontamination by the rehabilitation nursing staff. These bags were reused for two to eight days. Cultures of 137 bags were obtained to evaluate the technique. All cultures were negative. Baseline urine cultures for both time periods showed no significant difference in rates of bacteriuria. The potential savings for one year on our rehabilitation unit, with an average of 12 catheterized patients, would be approximately $39,000. Although this methodology conflicts with thoughts about not reusing disposable products, we have shown that the procedure can be done safely in rehabilitation patients and it is easy and inexpensive.

Effect of vasopressin on liver blood flow in the hypophysectomised rat

Liver blood flow (xenon-133 clearance method) and portal venous flow were measured in hypophysectomised rats following the infusion of vasopressin at a range of infusion varying from 0.0125 to 0.8 microU/g b.w./min over the range 0.0125-0.1 microU/g b.w./min, portal venous flow was reduced, the reduction being linearly related to the logarithm of the dose (r = -0.88). Following the infusion of 0.8 microU/g b.w. of vasopressin, portal venous flow significantly increased above pre-infusion levels (p less than 0.05). Liver blood flow was increased significantly (p less than 0.05) when vasopressin was infused over the range 0.0125-0.2 microU/g b.w. At higher rates of infusion, liver blood flow was progressively reduced, and at 0.8 microU/g b.w./min liver blood flow was less than pre-infusion levels (p less than 0.05). These data suggest that the effects of vasopressin on hepatic haemodynamics is related to the rate of infusion with a reversal of effects at higher rates of infusion. The implications of these findings in relation to the use of vasopressin in the management of portal hypertension and bleeding oesophageal varices is discussed.

Portal scanning for liver metastases in colorectal carcinoma

In a prospective study over 2 years, 14 patients suffering from colorectal cancer had radionuclide liver scans performed via the portal route. Technetium-99m-labelled macro-aggregates of human serum albumen were injected via the cannulated umbilical vein, distributed through the portal system of the liver and their presence recorded by a gamma camera. Of 11 patients with clinically normal livers and no metastases found at laparotomy, five had abnormal portal scans, two of these dying from multiple liver metastases during follow-up. None of the patients with normal portal scans died with liver metastases within the 2-year study period.

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Gastric and Duodenal Ulcer : A Review of One Thousand Seven Hundred X-Ray Examinations

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