Pilot Study of Recurrent Ewing's Sarcoma Management with Vigil/Temozolomide/Irinotecan and Assessment of Circulating Tumor (ct) DNA

PURPOSE

Treatment options for recurrent or refractory Ewing's sarcoma (ES) are limited. Vigil is a novel autologous tumor cell therapy expressing bi-shRNA furin/GMCSF plasmid, which previously demonstrated monotherapy activity in advanced ES. Herein we report safety and evidence of benefit to Vigil for ES as potential treatment.

PATIENTS AND METHODS

In this pilot trial, eligible patients with recurrent or refractory ES who failed initial standard-of-care therapy received treatment with temozolomide (TEM) 100 mg/m2/day oral and irinotecan (IRI) 50 mg/m2/day oral, Days 1 to 5, in combination with Vigil (1 × 106-107 cells/mL/day intradermal, Day 15), every 21 days (Vigil/TEM/IRI). Objective response rate (ORR) by RECIST v1.1, progression-free survival (PFS), and overall survival (OS) were assessed. Circulating tumor (ct) DNA analysis was done by patient-specific droplet digital PCR on baseline and serially collected on-treatment samples.

RESULTS

Eight of 10 enrolled patients were evaluable for safety and efficacy (mean age 24.6; 12.6-46.1 years old); 2 did not receive Vigil. Seven of 8 patients previously received TEM/IRI. No Vigil-related adverse events were reported. Common ≥Grade 3 chemotherapy-related toxicity included neutropenia (50%) and thrombocytopenia (38%). We observed two partial response patients by RECIST; both showed histologic complete response without additional cancer therapy. Median PFS was 8.2 months (95% confidence interval, 4.3-NA). Five patients showed stable disease or better for ≥6 months. Patient-specific EWS/FLI1 ctDNA was detectable in all 8 evaluable patients at baseline. Changes in ctDNA levels corresponded to changes in disease burden.

CONCLUSIONS

Results demonstrated safety of combination Vigil/TEM/IRI.

Corrigendum to "Long-term follow-up of Phase 2A trial results involving advanced ovarian cancer patients treated with Vigil® in frontline maintenance" [Gynecol. Oncol. Rep. 34 (2020) 100648]

[This corrects the article DOI: 10.1016/j.gore.2020.100648.].

A phase I combination study of vigil and atezolizumab in recurrent/refractory advanced-stage ovarian cancer: Efficacy assessment in BRCA1/2-wt patients

3002

Background: Recent studies have shown poor clinical outcomes and limited survival advantage to checkpoint inhibitors (CIs) in advanced stage ovarian cancer (OvC). Vigil is a personalized precision vaccine constructed from autologous tumor tissue transfected with a DNA plasmid encoding GM-CSF and bi-shRNA-furin thereby creating TGFβ expression control and enhancing immune activation. Phase 1 and 2 trials in OvC demonstrate safety, functional immune activation and clinical response benefit. Combining Vigil with CIs may broaden responsiveness of immunotherapy in OvC. Methods: This is a randomized, 3-part safety Phase 1 study of Vigil in combination with Atezolizumab in recurrent OvC patients. Part 2 is a randomized, intra-patient crossover study of Vigil first (VF) or Atezolizumab first (AF) for two cycles followed by sequence of the combination of the two agents. Vigil (1 x 106 or 1 x 107 cells/ml) or Atezolizumab (1200mg) were administered 1x every 21 days each cycle until progression or untoward adverse event. We now report the preliminary results of part 2 of the study. Results: Twenty-one patients were randomized (1:1) to VF (n = 11) or AF (n = 10), groups were similar in demographics. Grade 3/4 toxic events occurred in 17% of AF patients compared to 3% in VF patients. Median OS of VF patients (n = 11) was not reached vs. AF (n = 10) 10.8 months suggested modest advantage to VF (HR 0.33, one-sided p 0.097). However, the subset analysis of BRCA1/2 wild type (wt) demonstrated more significant overall survival benefit in VF (n = 7) median OS not reached vs. AF (n = 7) 5.2 months (HR 0.12, one-sided p 0.015). Conclusions: The combination of Vigil immunotherapy and checkpoint inhibitor atezolizumab in recurrent OvC demonstrated safety and suggest a lower toxicity profile and a significant OS advantage in recurrent BRCA1/2-wt OvC patients treated with Vigil first followed by the combination of Vigil and Atezolizumab. Clinical trial information: NCT03073525 . [Table: see text]

Pulmonary function testing as a diagnostic tool to assess respiratory health in bottlenose dolphins Tursiops truncatus

Pulmonary function testing was performed in 3 bottlenose dolphins Tursiops truncatus (1 female and 2 males) under managed care during a 2 yr period to assess whether these data provide diagnostic information about respiratory health. Pulmonary radiographs and standard clinical testing were used to evaluate the pulmonary health of each dolphin. The female dolphin (F1) had evidence of chronic pulmonary fibrosis, and 1 male (M2) developed pneumonia during the study. Pulmonary function data were collected from maximal respiratory efforts in water and from spontaneous breaths while beached. From these data, the flow-volume relationship, the flow measured between 25 and 75% of the expired vital capacity (mid forced expiratory flow, FEF25%-75%), and the percent of the vital capacity (VC) at the peak expiratory flow (%VCPEF), were evaluated and compared with the diagnostic assessment. For maximal respiratory manoeuvres in water, there were no differences in FEF25%-75% or %VCPEF, and the flow-volume relationship showed a consistent pattern for F1. Additionally, FEF25%-75% and %VCPEF decreased by 27 and 52%, respectively, and the flow-volume relationship showed clear flow limitations with emerging disease in M2. While spontaneously breathing on land, M2 also showed a 49% decrease in %VCPEF and changes in the flow-volume relationship, indicating flow limitations following the development of pneumonia. Based on these preliminary results, we suggest that pulmonary function testing should be given more attention as a non-invasive and possibly adjunctive diagnostic tool to evaluate lung health of dolphins under managed care and in the wild.

Quantifying the radiant exposure and effective dose in patients treated for actinic keratoses with topical photodynamic therapy using daylight and LED white light

Daylight photodynamic therapy (dl-PDT) is as effective as conventional PDT (c-PDT) for treating actinic keratoses but has the advantage of reducing patient discomfort significantly. Topical dl-PDT and white light-PDT (wl-PDT) differ from c-PDT by way of light sources and methodology. We measured the variables associated with light dose delivery to skin surface and influence of geometry using a radiometer, a spectral radiometer and an illuminance meter. The associated errors of the measurement methods were assessed. The spectral and spatial distribution of the radiant energy from the LED white light source was evaluated in order to define the maximum treatment area, setup and treatment protocol for wl-PDT. We compared the data with two red LED light sources we use for c-PDT. The calculated effective light dose is the product of the normalised absorption spectrum of the photosensitizer, protoporphyrin IX (PpIX), the irradiance spectrum and the treatment time. The effective light dose from daylight ranged from 3  ±  0.4 to 44  ±  6 J cm^-2due to varying weather conditions. The effective light dose for wl-PDT was reproducible for treatments but it varied across the treatment area between 4  ±  0.1 J cm^-2 at the edge and 9  ±  0.1 J cm^-2 centrally. The effective light dose for the red waveband (615-645 nm) was 0.42  ±  0.05 J cm^-2 on a clear day, 0.05  ±  0.01 J cm^-2 on an overcast day and 0.9  ±  0.01 J cm^-2 using the white light. This compares with 0.95  ±  0.01 and 0.84  ±  0.01 J cm^-2 for c-PDT devices. Estimated errors associated with indirect determination of daylight effective light dose were very significant, particularly for effective light doses less than 5 J cm^-2 (up to 83% for irradiance calculations). The primary source of error is in establishment of the relationship between irradiance or illuminance and effective dose. Use of the O'Mahoney model is recommended using a calibrated logging illuminance meter with the detector in the plane of the treatment area.

Meat quality characteristics of springbok (Antidorcas marsupialis). 3: Fatty acid composition as influenced by age, gender and production region

The effects of age, gender and production region on the fatty acid composition of springbok Musculus longissimus dorsi (LD) were investigated. The major fatty acid of the LD muscle was stearic acid (C18:0), which contributed 23.92-27.02%. Oleic acid (C18:1) represented the largest component (16.33-20.45%) of the mono-unsaturated fatty acids (MUFA). The major n-6 polyunsaturated fatty acid (PUFA) was C18:2n-6, which formed 18.77-21.62%, whereas C18:3n-3 (3.33-4.00%) was the most abundant n-3 PUFA. The n-6:n-3 ratio of the meat varied from 3.02 to 3.35, with an average ratio of 3.2. Polyunsaturated to saturated (P:S) ratios varied between 0.96 and 1.18 and averaged at 1.06. Total MUFA was found to be higher (P<0.05) in males (20.99%) than females (16.67%). The cholesterol content of the meat varied from 54.45 to 59.34mg/100g muscle. Linear correlations between the fatty acid and the intramuscular fat (IMF) content indicated a significant increase in certain saturated and mono-unsaturated fatty acids with increasing IMF content of the meat.

Meat quality characteristics of springbok (Antidorcas marsupialis). 2: Chemical composition of springbok meat as influenced by age, gender and production region

The effects of age, gender and production region on the chemical, mineral and amino acid composition of the M. longissimus dorsi (LD) muscle of springbok were investigated. There was a significant gender(∗)region interaction for protein content - for the four production regions it varied between 18.80 and 21.16g/100g. The intramuscular fat (IMF) content of the LD muscle varied between 1.32 and 3.46g/100g. Females (3.13±0.28g/100g) had a higher (P<0.05) fat content than males (1.35±0.08g/100g). The IMF content of the adult (2.45±0.26g/100g) and sub-adult (2.50±0.28g/100g) categories was higher (P<0.05) in comparison to that of the lambs (1.32±0.11g/100g). An inverse correlation was noted between the IMF and moisture content (r=-0.49, P<0.001) of the meat. The two main amino acids were glutamic and aspartic acid, which contributed 2.47-2.74 and 2.31-2.54g/100g of dry matter, respectively. Phosphorous was the predominant mineral in the LD muscle (122.92-159.78mg/100g of dry matter), followed by potassium (119.44-131.25mg/100g of dry matter) and calcium (6.57-145.18mg/100g of dry matter). Production region had a significant effect on the mineral and amino acid composition of the meat, while the effects of age and gender were found to be insignificant.

A comparative study on the antimutagenic properties of aqueous extracts of Aspalathus linearis (rooibos), different Cyclopia spp. (honeybush) and Camellia sinensis teas

Antimutagenic activity of aqueous extracts of the South African herbal teas, Aspalathus linearis (rooibos) and Cyclopia spp. (honeybush) was compared with that of Camellia sinensis (black, oolong and green) teas in the Salmonella mutagenicity assay using aflatoxin B(1) (AFB(1)) and 2-acetylaminofluorene (2-AAF) as mutagens. The present study presents the first investigation on antimutagenic properties of C. subternata, C. genistoides and C. sessiliflora. The herbal teas demonstrated protection against both mutagens in the presence of metabolic activation, with the exception of "unfermented" (green/unoxidised) C. genistoides against 2-AAF, which either protected or enhanced mutagenesis depending on the concentration. Antimutagenic activity of "fermented" (oxidised) rooibos was significantly (P<0.05) less than that of Camellia sinensis teas against AFB(1), while for 2-AAF it was less (P<0.05) than that of black tea and similar (P>0.05) to that of oolong and green teas. Antimutagenic activity of unfermented C. intermedia and C. subternata exhibited a similar protection as fermented rooibos against AFB(1). Against 2-AAF, fermented rooibos exhibited similar protective properties than unfermented C. intermedia and C. sessiliflora. Unfermented rooibos was less effective than the C. sinensis teas and fermented rooibos, but had similar (P>0.05) antimutagenicity to that of fermented C. sessiliflora against AFB(1) and fermented C. subternata against 2-AAF. Fermented C. intermedia and C. genistoides exhibited the lowest protective effect against 2-AAF, while fermented C. intermedia exhibited the lowest protection when utilising AFB(1) as mutagen. Aspalathin and mangiferin, major polyphenols in rooibos and Cyclopia spp., respectively, exhibited weak to moderate protective effects when compared to the major green tea catechin, (-)epigallocatechin gallate (EGCG). Antimutagenic activity of selected herbal tea phenolic compounds indicated that they contribute towards (i) observed antimutagenic activity of the aqueous extracts against both mutagens and (ii) enhancement of the mutagenicity of 2-AAF by unfermented C. genistoides. Antimutagenic activity of the South African herbal teas was mutagen-specific, affected by fermentation and plant material, presumably due to changes and variation in phenolic composition.

The Programme for Global Paediatric Research

Millions of children die every year from malaria, tuberculosis, diarrhoea, neonatal disorders, and many other diseases found primarily in low and mid income countries. Many devoted clinicians and scientists have contributed significantly to the understanding and care of these diseases, however research remains disproportionately aimed at diseases affecting those in high income countries.

Quality control ofHarpagophytum procumbensand its related phytopharmaceutical products by means of NIR-FT-Raman spectroscopy

NIR-FT-Raman spectroscopy was used for identification and quantification of harpagoside in secondary roots of Harpagophytum procumbens as well as in related phytopharmaceutical products, e.g., ethanolic extracts and tablets. Applied Raman mappings reveal the spatial distribution of this valuable iridoid glycoside within the different samples. The same technique can be used for quality control purposes beginning from the plant to its final products. Based on the obtained spectral data and reference HPLC values of harpagoside, a reliable multivariate calibration model was developed.

Effect of training on adoption of cancer prevention nutrition-related activities by primary care practices: results of a randomized, controlled study

OBJECTIVE

The National Cancer Institute (NCI) developed a manual to guide primary care practices in structuring their office environment and routine visits so as to enhance nutrition screening, advice/referral, and follow-up for cancer prevention. The adoption of the manual's recommendations by primary care practices was evaluated by examining two strategies: physician training on how to implement the manual's recommendations versus simple mailing of the manual. This article reports on the results of a randomized controlled trial to evaluate the effectiveness of these two strategies.

DESIGN

A three-arm, randomized, controlled study.

SETTING

Free-standing primary care physician practices in Pennsylvania and New Jersey.

INTERVENTION

Each study practice was randomly assigned to one of three groups. The training group practices were invited to send one member from their practice of their choosing to a 3-hour "train-a-trainer" workshop, the manual-only-group practices were mailed the nutrition manual, and the control group practices received no intervention. For training group practices, training was provided in the four major components of the nutrition manual: how to organize the office environment to support cancer prevention nutrition-related activities; how to screen patient adherence to the NCI dietary guidelines; how to provide dietary advice/referral; and how to implement a patient follow-up system to support patients in making changes in their nutrition-related behaviors.

MEASUREMENTS

The primary outcomes of the study were derived from two evaluation instruments. The observation instrument documented the tools and procedures recommended by the nutrition manual and adopted in patient charts and the office environment. The in-person structured interview evaluated the physician and staff's self-reported nutrition-related activities reflecting the nutrition manual's recommendations. Data from these two instruments were used to construct four adherence scores corresponding to the areas: office organization, nutrition screening, nutrition advice/referral, and patient follow-up.

MAIN RESULTS

The adoption of the manual's recommendations was highest among the practices in the training group as reflected by their higher adherence scores. They organized their office ( P =.005) and screened their patients regarding their eating habits ( P =.046) significantly more closely to the recommendations of the nutrition manual than practices in the manual-only group. However, despite being the highest in compliance, the training group practices were only 54.9% adherent to the manual's recommendations regarding nutrition advice/referral, and 28.5% adherent to its recommendations on office organization, 23.5% adherent to its recommendations on nutrition screening, and 14.6% adherent to its patient follow-up recommendations.

CONCLUSIONS

Primary care practices exposed to the nutrition manual in a training session adopted more of the manual's recommendations. Specifically, practices invited to training were more likely to perform nutrition screening and to structure their office environment to be conducive to providing nutrition-related services for cancer prevention. The impact of the training was moderate and not statistically significant for nutrition advice/referral or patient follow-up, which are important in achieving long-term dietary changes in patients. The overall low adherence scores to nutrition-related activities demonstrates that there is plenty of room for improvement among the practices in the training group.

The American Stop Smoking Intervention Study. Conceptual framework and evaluation design

Reducing tobacco use, especially cigarette smoking, is a public health priority. The American Stop Smoking Intervention Study (ASSIST) was initiated in 1991 to prevent and reduce tobacco use primarily through policy-based approaches to alter the social-political environment. This article describes the conceptual design, research framework, evaluation components, and analytic strategies that are guiding the evaluation of this demonstration research endeavor. The ASSIST evaluation is a unique analysis of the complex relationships between the social context, public health activity at the state level, tobacco use, and individual behavior. The measures of tobacco control activity developed for this evaluation may be useful in ongoing national cancer control surveillance efforts, and the lessons learned will enhance the development of tobacco control programs.

International medical students' career choice, attitudes toward psychiatry, and emigration to the United States : examples from India and zimbabwe

The selection residents who are international medical graduates can be facilitated by knowledge of the context of their training and experience in psychiatry; the career opportunities in the country from which they come; and their attitudes toward psychiatry, medicine, and the United States. This study examines some of these variables as well as the emigration plans of 209 Indian and 46 Zimbabwe medical students in their next to last year of medical school. Both groups tended to hold positive attitudes toward psychiatry and had good experiences with the field. Fifty-six percent of the Indian students indicated that they had at least thought about emigrating to the United States for postgraduate training, and 22% had definite plans. Only 25% of the Zimbabwe students had thought about U.S. emigration, and a mere 2% had plans. Indian, as well as other IMGs, will continue to be a presence in U.S. residency programs, and those who have a preresidency stay in the United States may come to know and appreciate psychiatry more as they become more familiar with the field and with American culture.

The American Stop Smoking Intervention Study for cancer prevention: an overview

The American Stop Smoking Intervention Study (ASSIST) is a programme to implement proven interventions in 17 states across the United States. ASSIST applies all that we have learned in 10 years of research on tobacco use prevention and control. The goal of this seven-year project is to reduce the prevalence of smoking and cigarette consumption in the ASSIST states. The scientific basis for ASSIST is described, followed by a general description of the project and its current status in the 17 targeted states.

Use of the nicotine skin patch by smokers in 20 communities in the United States, 1992-1993

OBJECTIVE

To measure the characteristics of smokers associated with the use of the nicotine skin patch in the general population and to evaluate whether use of the patch is associated with successful smoking cessation.

DESIGN

Data from two surveys conducted in 20 communities in the United States as part of the National Cancer Institute's Community Intervention Trial for Smoking Cessation (COMMIT) study. Nicotine patch prevalence was estimated using data from a 1993 cross-sectional survey of 13691 current and former smokers. The effectiveness of the nicotine skin patch as a smoking cessation aid was evaluated adjusting for other covariants using data from a cohort tracking study of 9809 smokers who were followed between 1988 and 1993. As the nicotine patch was not available to consumers until January 1992, analyses were restricted to respondents who reported themselves to be current smokers in 1993 or former smokers who reported quitting after January 1992.

OUTCOME MEASURES

Current and former smokers who reported having made a serious effort to stop smoking in the past five years were asked to indicate whether they had used the nicotine skin patch to help them stop smoking. Those answering "Yes", were classified as nicotine patch users. Smoking cessation was based on self-report. A "quitter" was defined as someone who had been a smoker as of January 1992 who reported in 1993 not smoking any cigarettes for the preceding six months or longer.

RESULTS

The prevalence of nicotine patch use by smokers averaged across the 20 study communities was 12.8%, making the patch one of the most popular cessation methods used by smokers. Compared with non-users, patch users were more likely to be female, white, have higher annual household incomes, be more motivated to stop smoking, and to smoke more heavily. Among low-income smokers (annual household income below US$10000), nicotine patch use was significantly higher among those who lived in a state where the public insurance programme (Medicaid or Medi-Cal) included the patch as a benefit (12.1% vs 7.7%). Among those who made an attempt to quit smoking, the likelihood of successful quitting was more than twice as high among patch users compared with non-users. Among patch users, the highest quit rates were observed among those who used the patch for between one and three months.

CONCLUSIONS

The nicotine skin patch is a popular and effective means of smoking cessation. Use of the nicotine patch, especially by low-income smokers, could be increased by reducing the out-of-pocket expenditure required for smokers to get the product.

Fetal cells in maternal blood: recovery by charge flow separation

Fetal blood cells can be recovered from the maternal circulation by charge flow separation (CFS), a method that obviates the risks associated with amniocentesis and chorionic villus sampling. By CFS, we processed blood samples from 13 women carrying male fetuses, 2 carrying fetuses with trisomy 21, and 1 who had delivered a stillborn infant with trisomy 18. On average more than 2000 fetal nucleated red blood cells were recovered per 20-ml sample of maternal blood. Recovery of fetal cells was confirmed by fluorescence in situ hybridization with probes for chromosomes Y, 18 and 21. After culturing of CFS-processed cells, amplification by the polymerase chain reaction revealed Y-chromosomal DNA in clones from four of six women bearing male fetuses, but not in clones from three women bearing female fetuses.

A molecular-based magnet test for malaria

The molecular-based magnet test for malaria is shown to be more sensitive than the thin blood film test. The globally used thin blood film test is less sensitive because it uses preparation steps that result in the reduction of the absolute number of diagnostically pertinent erythrocytes. Several reports of diagnostic error with the thin film test and the thick film test have appeared in the literature. In marked contrast to the commonly accepted tests, the magnet test concurrently partitions and concentrates the infected erythrocytes present in the initial sample. The magnetic test permits a brief and sensitive microscopic-based enumeration of the malaria-infected erythrocytes in the enriched sample. Diagnostically pertinent hemozoin is simply identified through two of its specific molecular properties: paramagnetism and birefringence. The former property mediates the capture and enrichment of malaria-infected erythrocytes within the magnetic flux and the latter property manifests the characteristic birefringence demonstrated by polarized light.

Smoking cessation methods: recommendations for health professionals. Advisory Group of the European School of Oncology

Smoking is the leading preventable cause of death. Approximately 40% of Europeans now smoke. Many smokers want to stop but do not make the attempt, and of those who try, most are unsuccessful. Primary care health providers can help their patients to stop by using brief behavioural and pharmacological interventions. Specialised smoking cessation clinics can support selected patients referred by primary care providers. This report reviews intervention techniques for health care providers, which, in combination with effective legislative and educational interventions, can significantly reduce the prevalence of smoking.

The COMMIT dental model: tobacco control practices and attitudes

The National Cancer Institute's program to help dentists reduce tobacco use among their patients is part of the Community Intervention Trial for Smoking Cessation, a 22-community, randomly controlled trial of an intervention program for smoking cessation. Results of COMMIT baseline surveys of dentists in the 11 intervention communities are presented.

Study of neuropathologic changes in the striatum following 4, 8 and 12 months of treatment with fluphenazine in rats

Persistent tardive dyskinesia is a serious side effect of long-term treatment with neuroleptics. Although striatal pathologic changes are believed to underlie this potentially irreversible iatrogenic syndrome, the nature of the neuroleptic-induced neuropathology is unclear. In the present study, we treated rats with either vehicle or fluphenazine decanoate (5 mg/kg, IM) every 2 weeks for 4, 8 or 12 months. Four to nine weeks after the last injection, the animals were sacrificed and the density of cells in the central part of the striatum was measured with a computerized image-analysis system. The control and experimental animals did not differ in body weight with 4 and 8 months of treatment, but the rats treated with fluphenazine for 12 months had significantly lower body weights than comparable controls. Four months of neuroleptic use produced no significant neuropathologic changes. The animals treated with fluphenazine for 8 months had a significantly lower density of the large neurons. In the 12-month-treated group, there was no significant difference between the control and experimental animals, probably because of a 'floor effect': the density of the large neurons was significantly lower in the 12-month-treated compared to the 8-month-treated control rats.

An improved device for continuous intraventricular infusions prevents the introduction of pump-derived toxins and increases the effectiveness of NGF treatments

The recent demonstrations of the ability of nerve growth factor (NGF) to protect and promote the welfare of certain cholinergic neurons in the adult CNS have increased the need for safe, accurate, and reliable procedures for intracerebral administration of protein and other experimental agents. Osmotic minipumps have been used to infuse NGF into the lateral ventricle of adult rats, but a sustained and harmless performance of such infusions has not been fully evaluated. The study reported here has led to (i) the recognition that cytotoxic substances, released from some minipumps into the infusion fluid, may be responsible for various degrees of periventricular tissue damage, and (ii) the redesigning of an infusion device which, among other modifications, uses the osmotic pump to propel infusion fluid into the ventricle but prevents pump-derived materials from entering the infusate itself. Besides several other advantages, the modified infusion device has permitted the demonstration that NGF can fully protect experimentally axotomized medial septum cholinergic neurons and can do so with less variability than previously observed and without creating tissue damage.

Assessment of compliance in hemodialysis adaptation

Research in hemodialysis adaptation has been facilitated by the use of reliable outcome measures such as BUN, K, and interdialysis weight gain. Their use, however, has at times been impressionistic, without reference to the actual range and distribution of those markers in a large population of dialysis patients over a long period of time. This study is a retrospective review to determine that range and distribution at one center. We found the interdialysis weight gains for most patients to be much higher than the levels used in the literature as cut-off points in determining 'non-compliance'. High levels on non-compliance in previous reports may be inflated. Significant correlations among the three biological markers and between each marker and staff assessment of compliance validate the use of inter-dialysis weight gain. Suggestions are made for interpreting such data in the future.

The liaison psychiatrist and the outpatient hemodialysis unit. Part I: Reliability and validity of staff assessments of patient compliance on a hemodialysis unit

The use of staff ratings as an outcome measure in adaptation to hemodialysis studies is discussed, and the absence of reliability or validity of such ratings is emphasized. Staff ratings for global impressions of patient compliance are collected in an outpatient hemodialysis unit, inter-rater reliability is calculated, and the rating averages are correlated with three biological markers. A high degree of exact inter-rater agreement is found and correlation of ratings with inter-dialysis weight gain, mean BUN, and mean K are determined.

The liaison psychiatrist and the outpatient hemodialysis unit. Part II: Clinical psychiatric-liaison issues

A brief review of the literature is presented followed by a discussion of three main groups of liaison problems on a dialysis service: patient non-compliance, inter-staff disputes, and patient-staff emotional involvements. Clinical vignettes are used to illustrate the discussion and suggested guidelines for intervention are offered . Basic principles underlying a "liaison stance" are outlined.