Feasibility of Large-Scale Implementation of an Electronic Patient-Reported Outcome Remote Monitoring System for Patients on Active Treatment at a Community Cancer Center

PURPOSE

The use of digital symptom monitoring with patient-reported outcomes (PROs) has been shown to improve patient outcomes. The evidence of benefit has been largely derived from research studies. The feasibility of adopting this technology in the real-world setting is unknown.

METHODS

We report on the clinical implementation of a proprietary electronic patient-reported outcome (ePRO)-based digital symptom monitoring platform at the Highlands Oncology Group practice, a large community oncology practice. We present here our experience with patient enrollment, engagement, and retention; reasons for discontinued use; proportion of reports generating alerts and containing severe symptoms; and the responses to alerts including nursing telephone consultations and urgent office visits.

RESULTS

Over an approximately 17-month period, 923 patients were successfully enrolled. Patients enrolled from June 20, 2020, through November 30, 2021, with follow-up through February 28, 2022. Retention rates at 3, 6, 9, and 12 months were 94%, 88%, 73%, and 67%, respectively, with greater retention at 12 months in patients age 65 years or older. Few patients discontinued use for reasons related to the platform (n = 47; 5%). Of the 25,311 ePRO reports submitted, 49% (n = 12,334) exceeded the predefined alert thresholds and 8% (n = 1,920) included severe symptoms. The nursing team responded within 24 hours by telephone to 31.2% (n = 3,910) of all reports with alerts. Of reports with severe symptoms, 72.7% (n = 1,395) received a call. Only 6.4% (n = 249) of phone calls required an office evaluation within 72 hours of the report.

CONCLUSION

This single-center experience indicates that an ePRO-based digital symptom monitoring platform can be effectively implemented at a large scale with a high level of long-term patient engagement. Most reports could be effectively resolved by nurses, and physician intervention was infrequently required.

Quality Measurement in Cancer Care: A Review and Endorsement of High-Impact Measures and Concepts

Although oncology care has evolved, outcome assessment remains a key challenge. Outcome measurement requires identification and adoption of a succinct list of metrics indicative of high-quality cancer care for use within and across healthcare systems. NCCN established an advisory committee, the NCCN Quality and Outcomes Committee, consisting of provider experts from NCCN Member Institutions and other stakeholders, including payers and patient advocacy, community oncology, and health information technology representatives, to review the existing quality landscape and identify contemporary, relevant cancer quality and outcomes measures by reevaluating validated measures for endorsement and proposing new measure concepts to fill crucial gaps. This manuscript reports on 22 measures and concepts; 15 that align with existing measures and 7 that are new.

Fully percutaneous fetoscopic repair of myelomeningocele: 30-month follow-up data

OBJECTIVE

This observational study reports on the postnatal mortality and 30-month outcome of children who underwent fully percutaneous fetoscopic repair of myelomeningocele (MMC) at a single center in Giessen, Germany.

METHODS

Between October 2010 and August 2014, a total of 72 patients underwent fully percutaneous fetoscopic MMC closure at 21 + 0 to 29 + 1 (mean, 23 + 5) weeks' gestation. Of these, 52 (72%) participated in this study; however, 30-month mortality data are available for all 72 children. Children were examined at four timepoints: shortly after birth and at 3 months, 12 months and 30 months of corrected age. The patients underwent age-specific standardized neurological examinations and assessment of leg movements and ambulation at all timepoints. Cognitive and motor development were assessed using the Bayley Scales of Infant Development, second edition (BSID-II), at 30 months.

RESULTS

All 72 children survived the intrauterine procedure, however, four (5.6%) infants died postnatally (including two of the 52 comprising the study cohort). Of the 52 patients included in the study, 11.5% were delivered before the 30^th week of gestation (mean, 33 + 1 weeks) and, of the survivors, 48.1% had ventriculoperitoneal shunt placement. Of the 50 infants that were alive at 30 months, independent ambulation, without orthosis, was feasible for 46%. At 30 months of follow-up, 46% of children presented with a functional level that was at least two segments better than the anatomical level of the lesion. At 30 months, 70% of the children presented with BSID-II psychomotor development index score of ≥ 70 and 80% with BSID-II mental development index score of ≥ 70.

CONCLUSION

Intrauterine repair of MMC by percutaneous fetoscopy shows largely similar outcomes to those reported for open repair, with respect to mortality, prematurity, shunt-placement rates, motor and mental development and free ambulation. © 2020 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

BRAND – Search for BSM physics at TeV scale by exploring transverse polarization of electrons emitted in neutron decay

Neutron and nuclear beta decay correlation coefficients are linearly sensitive to the exotic scalar and tensor interactions that are not included in the Standard Model (SM). The proposed experiment will measure simultaneously 11 neutron correlation coefficients (a, a, B, D, H, L, N, R, S, U, V) where 7 of them (H, L, N, R, S, U, V) depend on the transverse electron polarization – a quantity that vanishes for the SM weak interaction. The neutron decay correlation coefficients H, L, S, U, V were never attempted experimentally before. The expected ultimate sensitivity of the proposed experiment that currently takes off on the cold neutron beamline PF1B at the Institut Laue-Langevin, Grenoble, France, is comparable to that of the planned electron spectrum shape measurements in neutron and nuclear β decays but offers completely different systematics and additional sensitivity to imaginary parts of the scalar and tensor couplings.

P14.07 Complete response under treatment with proton therapy followed by chemotherapy together with Tumor Treating Fields in a biopsied IDH wildtype glioblastoma patient

BACKGROUND

Proton therapy is able to apply high radiation doses to the tumor while sparing healthy tissues by reducing integral dose. Tumor Treating Fields (TTFields) are low intensity (1–3 V/cm) and intermediate frequency (100–300 kHz) alternating electric fields that demonstrated significantly increased survival rates in combination with adjuvant temozolomide (TMZ) in patients with newly diagnosed glioblastoma (ndGBM). Especially in ndGBM IDH wildtype with unmethylated MGMT promotor therapeutic options are restricted. Here, we report on a patient with biopsied ndGBM IDH wildtype with complete radiological response.

MATERIAL AND METHODS

Brain MRI demonstrated an occlusive hydrocephalus and a ring enhancing lesion in the right posterior thalamus in a 42 year old male. Endoscopic third ventriculostomy and stereotactic biopsy of the lesion were performed. Histopathological examination resulted in the diagnosis of a glioblastoma (WHO grade IV), IDH 1 wildtype (R132), IDH 2 wildtype (R172), HIST1H3B/C wildtype, TERT wildtype (C228 and C250), BRAF wildtype, and unmethylated MGMT promotor. In view of the tumor site, resection was not feasible. Consequently, the patient received definitive chemoradiation with TMZ to a total dose of 60Gy incl. proton boost of 5x2 GyRBE. TTFields therapy in combination with TMZ was initiated 4 weeks after completion of chemoradiation, TMZ maintenance was completed per protocol after 6 cycles. TTFields therapy was continued for more than 13 month and to-date the patient is still on therapy.

RESULTS

Current follow up time is 20 months after initial diagnosis with the patient showing a radiological complete response. The first MRI following chemoradiation with TMZ and protons (showed pseudoprogression. After 3 months, the MRI again showed slightly increasing contrast enhancement. However, no clinical symptoms of tumor progression were present. The TTFields usage (compliance) rate, i.e. the rate per time the patient is applying the therapy, of the patient was 86 %. This was well above the independent prognostic threshold of 75 % and supports the feasibility of this approach. A further MRI after 8 weeks showed a stable disease. In a MRI 4 months later, partial response with decreased contrast enhancement plus perfusion restriction in the tumor area was observed. Another MRI after 3 months showed a complete response without perfusion signal in the tumor area. In the clinical examination the patient had no neurological deficits and to-date the patient is still stable

CONCLUSION

Complete response was observed following combination treatment of chemoradiation with TMZ including proton boost, TMZ maintenance and TTFields in a patient with pathologically confirmed GBM IDH wildtype. To our knowledge, this is the first report on a ndGBM patient receiving proton therapy followed by TTFields therapy.

[Radiological dose and metadata management]

This article describes the features of management systems currently available in Germany for extraction, registration and evaluation of metadata from radiological examinations, particularly in the digital imaging and communications in medicine (DICOM) environment. In addition, the probable relevant developments in this area concerning radiation protection legislation, terminology, standardization and information technology are presented.

Getting Past No in Cancer Care

This article examines the potential impact of several proposals for controlling the rapidly increasing costs of cancer care.

Biomolecular characterization of adrenal gland tumors by means of SR-FTIR

The adrenal glands are small endocrine organs located on the bottom pole of each kidney. Anatomically they are composed of cortical and medullar parts. Due to dysfunctional processes they can transform into the pathological lesions (in both cortex and medulla). The incidentally detected adrenal lesions have become an arising clinical problem nowadays. The crucial issue for an accurate treatment strategy is relevant diagnosis. Distinguishing between benign and malignant lesions is often difficult during the standard histological examination. Hence the alternative methods of differentiation are investigated. One of them is Fourier transform infrared spectroscopy which allows the analysis of the biomolecular composition of the studied tissue. In this paper we present the very preliminary FTIR studies for defining the biomolecular pattern of three types of adrenal lesions: adenoma (AA) and adrenal cortical hyperplasia (ACH) - both derived from adrenal cortex as well as pheochromocytoma (PCC) - from the medullar part of the gland. All studied cases were classified as benign lesions. The general observations show that cortically derived tissues are rich in lipids and they are rather protein depleted while for medullar pheochromocytoma there is the opposite relationship. Furthermore, the unequivocal differences were noticed within the "fingerprinting" range. In addition subtle shifts in absorption band positions were observed between studied cases.

Roscovitine has anti-proliferative and pro-apoptotic effects on glioblastoma cell lines: A pilot study

Purine analogue roscovitine, a cyclin-dependent kinase (CDK) inhibitor, has shown strong anti-proliferative and pro-apoptotic effects in solid and hematologic cancers such as non small-cell lung cancer and lymphomas. It targets CDK2, 7 and 9 preferentially, which are also overexpressed in glioblastoma. Τherefore, the biological effects of roscovitine in glioblastoma cell lines were investigated. Glioblastoma A172 and G28 cell lines were incubated with serial concentrations of roscovitine for 24-120 h. Proliferation was measured using the xCELLigence Real-Time Cell Analyzer, an impedance‑based cell viability system. Cell cycle distribution was assessed by flow cytometry and gene expression was quantified by quantitative RT-PCR and western blot analysis. Roscovitine exhibited a clear dose-dependent anti‑proliferative and pro‑apoptotic effect in the A172 cell line, while G28 cells showed a anti-proliferative effect only at 100 µM. The results of the flow cytometric (FACS) analysis revealed a dose-dependent increase of the G2/M and sub-G1 fractions in A172 cells, while G28 cells responded with an elevated sub-G1 fraction only at the highest concentration. Roscovitine led to a dose‑dependent decrease of transcripts of p53, CDK 7 and cyclins A and E and an increase of >4-fold of p21 in A172 cells. In G28 cells, a dose‑dependent induction of CDK2, p21 and cyclin D was observed between 10 and 50 µM roscovitine after 72 h, however, at the highest concentration of 100 µM, all investigated genes were downregulated. Roscovitine exerted clear dose-dependent anti-proliferative and pro-apoptotic effects in A172 cells and less distinct effects on G28 cells. In A172 cells, roscovitine led to G2/M arrest and induced apoptosis, an effect accompanied by induced p21 and a reduced expression of CDK2, 7 and 9 and cyclins A and E. These effects requre further studies on a larger scale to confirm whether roscovitine can be used as a therapeutic agent against glioblastoma.

IVEU: IT-based collection and reporting of radiological examination parameters

In Germany, each site using ionising radiation in human medicine is assigned to a competent medical authority (CMA) for quality assurance. Duties of these CMAs are, e.g. the inspection of medical aspects of the use of X-rays and nuclear medicine at the sites as well as technical quality assurance of X-ray devices. The CMAs themselves have to report the collected exposure values to the ministries and the Federal Office for Radiation Protection. The IVEU (IT-gestütztes Verfahren zur Erfassung von Untersuchungsparametern) Software Framework assists CMAs and radiological departments in collecting and analysing data provided in DICOM headers.

The Affordable Care Act: where are we now? An NCCN roundtable

The Affordable Care Act (ACA) is a transformational event for health care in the United States, with multiple impacts on health care, the economy, and society. Oncologists and other health care providers are already experiencing many changes-direct and indirect, anticipated and unanticipated. A distinguished and diverse panel assembled at the NCCN 19th Annual Conference to discuss the early phase of implementation of the ACA. The roundtable touched on early successes and stumbling blocks; the impact of the ACA on contemporary oncology practice and the new risk pool facing providers, payers, and patients; and some of the current and future challenges that lie ahead for all.

Real-Time PCR Identification of Unique Bacillus anthracis Sequences

Bacillus anthracis is a spore-forming, Gram-positive microorganism. It is a causative agent of anthrax, a highly infectious disease. It belongs to the "Bacillus cereus group", which contains other closely related species, including Bacillus cereus, Bacillus thuringiensis, Bacillus mycoides, Bacillus weihenstephanensis, and Bacillus pseudomycoides. B. anthracis naturally occurs in soil environments. The BA5345 genetic marker was used for highly specific detection of B. anthracis with TaqMan probes. The detection limit of a real-time PCR assay was estimated at the level of 16.9 copies (CI95% - 37.4 to 37.86, SD = 0.2; SE = 0.118). Oligonucleotides designed for the targeted sequences (within the tested locus) revealed 100 % homology to B. anthracis strain reference sequences deposited in the database (NCBI) and high specificity to all tested B. anthracis strains. Additional in silico analysis of plasmid markers pag and cap genes with B. anthracis strains included in the database was carried out. Our study clearly indicates that the BA5345 marker can be used with success as a chromosomal marker in routine identification of B. anthracis; moreover, detection of plasmid markers indicates virulence of the examined strains.

Management of biochemically recurrent prostate cancer following local therapy

Localized therapy for prostate cancer is often curative; however, 20% to 30% of patients experience a recurrence. Men with biochemical recurrence (BCR) are typically identified following routine monitoring of prostatespecific antigen after treatment for localized disease. These patients exhibit no signs of prostate cancer. Initial evaluation attempts to determine whether the BCR is due to local recurrence or systemic disease. Depending on the type of initial local therapy, treatment options for local recurrence include salvage radiation therapy or salvage prostatectomy. If systemic recurrence is suspected, other options must balance the onset of metastatic disease with avoidance of overtreatment. The most common treatment is androgen deprivation therapy (ADT) via gonadotropinreleasing hormone agonists or antagonists. Because there are challenges associated with standard ADT, other treatment options are being investigated, including a number of natural products.

Private Payers and Cancer Care: Land of Opportunity

The authors conclude that future changes in payment for oncology services mandated by CMS can be sustained within the infrastructures being built today through payer-provider collaborations.

Benchmarks for value in cancer care: an analysis of a large commercial population

PURPOSE

Cancer costs are increasing at an unprecedented rate. Key cost drivers include chemotherapy, hospital admissions/emergency room visits, and aggressive end-of-life care. We sought to evaluate these costs in a commercial payer population in collaboration with consultants from Milliman.

PATIENTS AND METHODS

We used a retrospective analysis of Medstat 2007 to evaluate chemotherapy costs and use. Included patients had a cancer diagnosis; received chemotherapy during the evaluation period; had at least 1 day of coverage between January 1 and December 31, 2007 (medical and prescription coverage); was younger than age 70, and had active employment or was the spouse of an active employee. Costs are allowed amounts and are trended until 2009. Admission rates and emergency room visits are reported. Hospice use and chemotherapy during the last 14 and 30 days of life were also evaluated.

RESULTS

In this commercial population of 14 million patients, 0.68% had claims for a cancer diagnosis; approximately 22% of those received chemotherapy during the study time period. Patients with cancer receiving chemotherapy averaged $111,000 per year in total medical and pharmacy costs. The average hospitalization rate for any reason was 1 admission/yr. Approximately 40% (or 0.4 admits/year) were identified as being chemotherapy related. Of the 3.5% of patients who died in the hospital, 51% received chemotherapy within 30 days of death.

CONCLUSION

Understanding the costs of cancer care offers opportunities to formulate a strategic plan to control cancer costs and maintain quality care. Comprehensive cancer solutions to address the full spectrum of care will facilitate improved quality and patient outcomes.

Pathways, outcomes, and costs in colon cancer: retrospective evaluations in two distinct databases

PURPOSE

The goal of this study was to use two separate databases to evaluate the clinical outcomes and the economic impact of adherence to Level I Pathways, an evidence-based oncology treatment program in the treatment of colon cancer.

PATIENTS AND METHODS

The first study used clinical records from an electronic health record (EHR) database to evaluate survival according to pathway status in patients with colon cancer. Disease-free survival in patients receiving adjuvant treatment and overall survival in patients receiving first-line therapy for metastatic disease was calculated. The second study used claims data from a national administrative claims database to examine direct medical costs and use, including the cost of chemotherapy and of chemotherapy-related hospitalizations according to pathway status.

RESULTS

Overall costs from the national claims database-including total cost per case and chemotherapy costs-were lower for patients treated according to Level I Pathways (on-Pathway) compared with patients not treated according to Level I Pathways. Use of pathways was also associated with a shorter duration of therapy and lower rate of chemotherapy-related hospital admissions. Survival for patients on-Pathway in the EHR database was comparable with those in the published literature.

CONCLUSION

Results from two distinct databases suggest that treatment of patients with colon cancer on-Pathway costs less; use of these pathways demonstrates clinical outcomes consistent with published evidence.

Creating a process to standardize regimen order sets within an electronic health record

PURPOSE

US Oncology uses regimen order sets in clinical practice to treat patients. However, the process to assure accuracy and upkeep of these order sets has not been described. The purpose of this project was to evaluate the regimens housed in the electronic health record, iKnowMed, to determine their appropriateness and accuracy.

MATERIALS AND METHODS

US Oncology conducted an audit of its standardized regimen library. A utilization review compared chemotherapy regimens in the library and consolidated order sets on the basis of past utilization. Next, internal and external clinical pharmacists were contracted to verify the accuracy, dose, duration, and cycle length of regimens. References cited in the regimen library were evaluated. New or updated references or clinical practice standards were added or modified when necessary. US Oncology corporate pharmacists reviewed the recommendations and discussed findings with an oversight committee. Final proposals were voted on before being incorporated into iKnowMed. An internal database tracking system tool for all reviewed recommendations was created to track and communicate needed changes to the electronic health record.

RESULTS

Out of 511 regimen order sets, 51 were recommended for removal or consolidation. Of the remaining 460 regimen order sets, all had some administrative changes. Specifically, 75% had title changes, 14% had cycle-related changes, 31% had reference updates, and 13% had dosing updates.

CONCLUSION

Electronic health records systems, such as iKnowMed, can provide standardized order sets for a large oncology network. However, the regimens need to be evaluated routinely using standardized procedures to ensure they are accurate and current.

Pathways, outcomes, and costs in colon cancer: retrospective evaluations in 2 distinct databases

OBJECTIVE

The goal of this study was to use 2 separate databases to evaluate the clinical outcomes and the economic impact of adherence to Level I Pathways, an evidence-based oncology treatment program in the treatment of colon cancer.

PATIENTS AND METHODS

The first study used clinical records from an electronic health record (EHR) database to evaluate survival according to pathway status in patients with colon cancer. Disease-free survival in patients receiving adjuvant treatment and overall survival in patients receiving first-line therapy for metastatic disease was calculated. The second study used claims data from a national administrative claims database to examine direct medical costs and use, including the cost of chemotherapy and of chemotherapy-related hospitalizations according to pathway status.

RESULTS

Overall costs from the national claims database-including total cost per case and chemotherapy costs-were lower for patients treated according to Level I Pathways (on- Pathway) compared with patients not treated according to Level I Pathways. Use of pathways was also associated with a shorter duration of therapy and lower rate of chemotherapy-related hospital admissions. Survival for patients on- Pathways in the EHR database was comparable with that in the published literature.

CONCLUSION

Results from 2 distinct databases suggest that treatment of patients with colon cancer on-Pathways costs less; use of these pathways demonstrates clinical outcomes consistent with published evidence.

Cost effectiveness of evidence-based treatment guidelines for the treatment of non-small-cell lung cancer in the community setting

PURPOSE

The goal of this study was to evaluate the cost-effectiveness of Level I Pathways, a program designed to ensure the delivery of evidence-based care, among patients with non-small-cell lung cancer (NSCLC) treated in the outpatient community setting.

PATIENTS AND METHODS

We included patients with NSCLC initiating a chemotherapy regimen between July 1, 2006, and December 31, 2007, at eight practices in the US Oncology network. Patients were characterized with respect to age, sex, stage, performance status, and line of therapy and were classified by whether they were treated according to Level I Pathways guidelines. Twelve-month cost of care and overall survival were compared between patients treated on Pathway and off Pathway. A net monetary benefit approach and corresponding cost-effectiveness acceptability curves were used to evaluate the cost-effectiveness of Level I Pathways.

RESULTS

Overall, outpatient costs were 35% lower for on-Pathway versus off-Pathway patients (average 12-month cost, $18,042 v $27,737, respectively). Costs remained significantly less for patients treated on Pathway versus off Pathway in the adjuvant and first-line settings, whereas no difference in overall cost was observed in patients in the second-line setting. No difference in overall survival was observed overall or by line of therapy. In the net monetary benefit analysis, after adjusting for potential confounders, we found that treating patients on Pathway was cost effective across a plausible range of willingness-to-pay thresholds.

CONCLUSIONS

Results of this study suggest that treating patients according to evidence-based guidelines is a cost-effective strategy for delivering care to those with NSCLC.

Phase I/II trial of docetaxel and concurrent radiation therapy in localized high risk prostate cancer (AGUSG 03-10)

PURPOSE

A Phase I/II trial was conducted to assess the radiosensitizer docetaxel administered weekly (20 mg/m(2)) with concurrent intensity modulated radiation therapy (72 Gy at 1.8 Gy/fraction) in high risk prostate cancer.

PATIENTS AND METHODS

Patients with high risk prostate cancer (clinical stage > or = T3; Gleason score 8, 9, or 10; Gleason score 7 and PSA > 10) received IMRT (Clinac 600 CD with 6 MV photons and sliding window technique) and concurrent weekly docetaxel (20 mg/m(2)) as a continuous 30 minute infusion for 8 weeks. Patients desirous of concurrent androgen suppression were not excluded.

RESULTS

Twenty men (median age: 64 years; range, 50-78 years) were enrolled in the chemoradiation protocol. Three patients experienced treatment interruptions: dehydration requiring inpatient hydration (n = 2); NSAID induced GI bleed (n = 1). An additional patient required outpatient hydration (<24 hours) with no treatment interruption. Overall, the most frequently observed toxicities were grade 2 diarrhea (40%), grade 2 fatigue (40%), grade 2 urinary frequency (35%), taste aversion (20%), grade 2 constipation (20%), and rectal bleeding (15%). No significant hematologic toxicity (grades 2-4) was encountered among the 20 patients. Although the follow-up interval was relatively short, no significant subacute gastrointestinal toxicities have been observed. At a median follow-up duration of 11.7 months, 17 patients were free of biochemical disease recurrence, and all patients are alive.

CONCLUSION

The radiosensitizer docetaxel administered weekly (20 mg/m(2)) with concurrent IMRT is well tolerated with acceptable toxicity. Early oncologic outcomes in this challenging patient cohort are encouraging.

Phase II trial of docetaxel/capecitabine in hormone-refractory prostate cancer

BACKGROUND

Docetaxel is the most active single agent in the treatment of hormone-refractory prostate cancer (HRPC). Because of the preclinical and clinical evidence of synergy of capecitabine and docetaxel, it was hypothesized that this combination would be active and tolerable in HRPC.

PATIENTS AND METHODS

Patients received docetaxel 60 mg/m2 intravenously over 60 minutes on day 1 of each 21-day cycle and capecitabine 1000 mg/m2 administered orally twice daily on days 1-14 of each cycle for a maximum of 8 cycles or until disease progression or intolerable toxicity. Seventy-seven patients were enrolled at 43 US Oncology sites. The median age was 69.3 years (range, 48-86 years); 86% were white, and the Eastern Cooperative Oncology Group performance status scores of 0 and 1 were 49% and 51% respectively. Sixty-nine (90%) patients were evaluated for prostate-specific antigen response.

RESULTS

Overall, 41% of patients had a decreased prostate specific antigen level > or = 50%. There were 4 complete responses (6%), 24 partial responses (35%), 29 incidences of stable disease (43%), and 11 incidences of progressive disease (16%). Nine patients has stable disease > or = 6 months and the clinical benefit rate was 54%. The median time to response was 1.5 months (range, 1-16.9 months). The estimated survival at 12 and 24 months (range, < 1-27 months). There were no treatment-related deaths. Grade 3/4 toxicities included neutropenia (50%), leukopenia (22%), hand-foot syndrome (17%), fatigue (11%), and nausea (11%).

CONCLUSION

Docetaxel/capcitabine is an active and tolerable combination in HRPC. Toxicity was acceptable and anticipated. Response rate and survival are comparable with other docetaxel combinations.

Argon plasma coagulation (APC) in brain tumor surgery: experimental study and clinical experiences

OBJECTIVE

The present study aims to provide preliminary results of the thermal effects on rat brain tissue after argon plasma coagulation (APC). It also presents and discusses the clinical experiences in the treatment of brain tumor using APC.

MATERIALS AND METHODS

A controlled study of APC in the rat brain was conducted. Twelve rats were randomly divided into 2 experimental groups. In the first group (n = 6), histopathological evaluation was performed 2 days following the coagulation. In the second group (n = 6), the evaluation was performed 12 days post operation. In a prospective study of APC-treated tumor tissue in 3 patients, the depth of plasma penetration and histological alteration were evaluated.

RESULTS

In the animal experiment, extent of tissue defect became significantly smaller after 12 days (p = 0.010). The maximum depth of tissue alteration after APC application was limited to 2.15 mm (range: 1.5-2.15 mm) at day 2. The histological alteration of tissue after the thermal injury can be divided into 3 zones. In addition, the depth of tissue alteration in the APC-treated human brain tumor was measured in vertical and horizontal planes under light microscope. Similar to the animal experiment result, penetration of the plasma energy in human brain tumors was limited to a maximum of 2.13 mm (range: 1.6-2.13 mm).

CONCLUSION

The limited depth of energy penetration may confirm APC as a safe and beneficial tool for coagulation of human brain tissue. However, further clinical studies are required to evaluate the suitability and indications of this method in brain tumor treatment.

Expression of liver carnitine palmitoyltransferase I and II genes during development in the rat

The enzyme activity and the expression (protein and mRNA concentrations) of genes encoding for hepatic carnitine palmitoyl-transferases (CPT) I and II were studied during neonatal development, in response to nutritional state at weaning and during the fed-starved transition in adult rats. The activity, the protein concentration and the level of mRNA encoding CPT I are low in foetal-rat liver and increase 5-fold during the first day of extra-uterine life. The activity and gene expression of CPT I are high during the entire suckling period, in the liver of 30-day-old rats weaned at 20 days on to a high-fat diet and in the liver of 48 h-starved adult rats. The activity and CPT I gene expression are markedly decreased in the liver of rats weaned on to a high-carbohydrate diet. By contrast, the activity, the protein concentration and the level of mRNA encoding CPT II are already high in the liver of term foetuses and remain at this level throughout the suckling period, irrespective of the nutritional state of the animals either at weaning or in the adult.

Case report: high-dose intravenous immunoglobulin as therapy for thrombotic thrombocytopenic purpura

Thrombotic thrombocytopenic purpura is a clinical syndrome defined by the pentad of thrombocytopenia, microangiopathic hemolytic anemia, fever, and renal and neurologic abnormalities. The pathogenesis of this syndrome remains enigmatic, though appropriate management usually involves plasma administration. The authors report on an alternative therapy, high-dose intravenous immunoglobulin, used in the patient after the failure of plasmapheresis. The implications and potential applications of this therapy are discussed.

Denial and the discrepancy between heart rate and reported negative affect: a study of convergent and discriminant validity

This study examined the convergent and divergent validity of heart-rate (HR)-based response discrepancy scores as measures of denial. After standardizing measures of stressor-related anxiety, hostility, and HR, response discrepancy scores were calculated by subtracting each measure of negative affect from the HR value. Analyses revealed the response discrepancy scores to correlate positively with measures of denial, negatively with a measure of trait anger, and to not correlate with measures of the nondefensive need for approval and the positive trait of curiosity. These findings support the construct validity of response discrepancy scores as markers of denial.

Effect of single amino acid substitutions on the formation of the PlA and Bak alloantigenic epitopes

The subunits that comprise the platelet-specific integrin alpha IIb beta 3 are polymorphic in nature, with several allelic forms present in the human gene pool. Minor changes in the secondary and tertiary structures of platelet membrane glycoproteins (GP) IIb and IIIa encoded by these alleles can result in an alloimmune reaction after transfusion or during pregnancy. To better understand the molecular structure of the PlA alloantigen system, located on GPIIIa, and the Bak alloantigen on GPIIb, we used a heterologous mammalian expression system to express these integrin subunits in their known polymorphic forms. An expression vector containing the PlA1 form of a GPIIIa cDNA, which encodes a leucine at amino acid 33 (Leu33), was modified to express the PlA2-associated form encoding a proline at amino acid 33 (Pro33). Similarly, a Baka GPIIb cDNA expressing an isoleucine at amino acid 843 (IIe843) was modified to express the Bakb form containing a serine at the same position (Ser843). Transfection of these vectors into COS cells resulted in the synthesis of GPIIb and GPIIIa molecules that were identical in size to those present in platelet lysates. Immunoprecipitation of the GPIIIa-transfected COS lysates with PlA)-specific alloantisera indicated that the Leu33 form was recognized only by anti-PIA1 sera while the Pro33 form was bound only by anti-PlA2 sera, showing that single amino acid polymorphisms are necessary and sufficient to direct the formation of the PlA1 and PlA2 alloepitopes. Similar experiments with Bak allele-specific expression vectors indicated that while the amino acid polymorphism (IIe843 in equilibrium Ser843) was necessary, posttranslational processing of pro-IIb was required for efficient exposure of both the Baka and Bakb alloepitopes.