Demographics, natural history and treatment outcomes of non-molar gestational choriocarcinoma: a UK population study

OBJECTIVE

To investigate the demographics, natural history and treatment outcomes of non-molar gestational choriocarcinoma.

DESIGN

A retrospective national population-based study.

SETTING

UK 1995-2015.

POPULATION

A total of 234 women with a diagnosis of gestational choriocarcinoma, in the absence of a prior molar pregnancy, managed at the UKs two gestational trophoblast centres in London and Sheffield.

METHODS

Retrospective review of the patient's demographic and clinical data. Comparison with contemporary UK birth and pregnancy statistics.

MAIN OUTCOMES

Incidence statistics for non-molar choriocarcinoma across the maternal age groups. Cure rates for patients by FIGO prognostic score group.

RESULTS

Over the 21-year study period, there were 234 cases of non-molar gestational choriocarcinoma, giving an incidence of 1:66 775 relative to live births and 1:84 226 to viable pregnancies. For women aged under 20, the incidence relative to viable pregnancies was 1:223 494, for ages 30-34, 1:80 227, and for ages 40-45, 1:41 718. Treatment outcomes indicated an overall 94.4% cure rate. Divided by FIGO prognostic groups, the cure rates were low-risk group 100%, high-risk group 96% and ultra-high-risk group 80.5%.

CONCLUSIONS

Non-molar gestational choriocarcinoma is a very rare diagnosis with little prior detailed information on the demographics and natural history. The data in this study give age-related incidence data based on a large national population study. The results also demonstrated the widely varying natural history of this rare malignancy and the marked correlation of disease incidence with rising maternal age.

TWEETABLE ABSTRACT

National gestational choriocarcinoma database indicates a close association between increasing maternal age and incidence.

Discrete element simulation studies of angles of repose and shear flow of wet, flexible fibers

A discrete element method (DEM) model is developed to simulate the dynamics of wet, flexible fibers. The angles of repose of dry and wet fibers are simulated, and the simulation results are in good agreement with experimental results, validating the wet, flexible fiber model. To study wet fiber flow behavior, the model is used to simulate shear flows of wet fibers in a periodic domain under Lees-Edwards boundary conditions. Significant agglomeration is observed in dilute shear flows of wet fibers. The size of the largest agglomerate in the flow is found to depend on a Bond number, which is proportional to liquid surface tension and inversely proportional to the square of the shear strain rate. This Bond number reflects the relative importance of the liquid-bridge force to the particle's inertial force, with a larger Bond number leading to a larger agglomerate. As the fiber aspect ratio (AR) increases, the size of the largest agglomerate increases, while the coordination number in the largest agglomerate initially decreases and then increases when the AR is greater than four. A larger agglomerate with a larger coordination number is more likely to form for more flexible fibers with a smaller bond elastic modulus due to better connectivity between the more flexible fibers. Liquid viscous force resists pulling of liquid bridges and separation of contacting fibers, and therefore it facilitates larger agglomerate formation. The effect of liquid viscous force is more significant at larger shear strain rates. The solid-phase shear stress is increased due to the presence of liquid bridges in moderately dense flows. As the solid volume fraction increases, the effect of fiber-fiber friction coefficient increases sharply. When the solid volume fraction approaches the maximum packing density, the fiber-fiber friction coefficient can be a more dominant factor than the liquid bridge force in determining the solid-phase shear stress.

Abstract P1-10-03: Precision therapeutic combinations are synergistic against triple negative breast cancer using compensatory pathways

Introduction: Triple negative breast cancer (TNBC) accounts for 15% of all breast cancer cases in the United States, and despite its lower incidence, contributes to a disproportionately higher rate of morbidity and mortality compared to other breast cancer subtypes. In an effort to treat TNBC, a cancer that has no targeted therapies, many have chosen to experiment with combinations of drugs that are chosen for their genomic expression or “hard targets”. It has been previously noted however, that single agent therapeutics can change the genomic landscape of both mice and human cells and may be responsible for resistance. Here we show that targeting a compensatory pathway after treatment with a single therapy, results in synergistic combinations and can outperform the choice of hard target therapies.

Methods: Eight TNBC cell lines were chosen based on their abundance of clinically actionable targets. The primary hard target combinations were chosen using data from TCGA and a board consisting of oncologists and researchers at Indiana University School of Medicine. Compensatory therapies were found using RNA sequencing data from untreated versus single therapeutic treated TNBC cell lines. The merged transcript RPKMs were transformed and analyzed for differential expression. Statistically significant genes were imported into Ingenuity Pathway Analysis (IPA) to identify either therapeutics or genomic targets using the Causal network analysis and Upstream regulator functions. All drug combinations were tested in their respective cell lines and cell viability was assessed via Celltiter-Fluor. Synergy of the combinations was calculated using the Chou-Talalay method.

Results: Using genomically chosen hard targets for drug combinations, all eight cell lines displayed additive or antagonistic results except low nanomolar doses for the MDA-MB-231 cell line. Dosing of MDA-MB-231s with Debrafinib and Pazopanib however, turned highly antagonistic as dosing increased. Using next-generation RNA sequencing data of TNBCs, IPA analysis identified several compensatory targets for each cell line when treated with one of the primary genomically driven drug at its IC50. Using dose escalation of the new drugs with a single hard target drug, we found that each compensatory combination displayed a striking increase in synergy across all TNBC cell lines treated when compared to their original hard target combination.

Conclusion: RNA sequencing of TNBC cells lines treated with single therapies chosen by actionable genomic landscape has revealed compensatory pathways, indicating further druggable targets. These compensatory pathways have been observed to more efficacious in treating TNBC cell lines. Using therapeutics that are either FDA approved or in clinical trials we have found that each compensatory combination shows a higher level of synergy across all cell lines. These data show that choosing a secondary therapy based on compensatory pathways may outperform hard target combinations in the clinic.

Citation Format: Solzak J, Hancock B, Paul R, Radovich M. Precision therapeutic combinations are synergistic against triple negative breast cancer using compensatory pathways [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P1-10-03.

Abstract P6-13-09: Dual PI3K and Wnt pathway inhibition is a synergistic combination against triple negative breast cancer

Introduction: Triple negative breast cancer (TNBC) accounts for 15% of all breast cancer cases in the United States, and despite its lower incidence, contributes to a disproportionately higher rate of morbidity and mortality compared to other breast cancer subtypes. Because these tumors lack expression of the estrogen, progesterone, or HER-2 receptors ("triple negative"), TNBC patients do not respond to targeted therapies that have been successfully used against tumors that over-express these proteins. Thus, there exists a critical need to improve the outcomes of TNBC patients through the implementation of novel targeted agents.

Methods: RNA-seq data from 94 TNBCs (from Indiana University and TCGA) and 20 microdissected normal breast tissues (Komen Tissue Bank) were merged and analyzed using Partek Genomics Suite. Statistically significant genes were imported into Ingenuity Pathway Analysis (IPA) to identify therapeutic targets. For in vitro studies, we tested a panel of TNBC cell lines using Buparlisib (a PI3K pathway inhibitor) and WNT974 (a WNT pathway inhibitor), individually and in combination. Cell viability was assessed via Celltiter-Fluor. Synergy between the two drugs was calculated using the Chou-Talalay method. In vivo studies were performed using the TMD-231 cell line and a patient derived xenograft (PDX) from the Jackson Laboratory. Dosing of the mice was performed using 30 mg/kg and 3 mg/kg of Buparlisib and WNT974 respectively, both in combination and individually.

Results: Using next-generation RNA sequencing data of TNBCs and microdissected normal breast tissue, Ingenuity Pathway Analysis identified over-expression and hyper-activation of the PI3K/AKT/mTOR pathway. When treating cell lines with the PI3K inhibitor Buparlisib, RNA sequencing revealed compensatory induction of the WNT pathway across TNBC cell lines. In particular, we observed induction of Porcupine, a Wnt maturation protein, which is the protein target of the Wnt pathway inhibitor, WNT974. When anti-tumor efficacy against these pathways was assessed, a significant reduction in cell viability using Buparlisib and WNT974 in combination was observed. Using the Chou-Talalay method, we found for MDA-MB-231 and Hs578T cell lines, a ∼50% reduction in cell viability at 100nM concentration of each drug that was highly synergistic (Combination Index = 0.33, and 0.36 respectively). In our in vivo PK study of the combination, there was no drug-drug interaction observed. Furthermore, in our PD analysis using a TMD-231 xenograft, we observed a ∼40% reduction in tumor volume after seven days. In a subsequent in vivo PDX experiment, we observed an 80% survival rate using combination therapy compared to 40% when administering the drugs individually or with vehicle control after 30 days.

Conclusion: PI3K/mTOR/AKT and Wnt pathways are strong candidates for the development of novel targeted agents for TNBC. Using two small molecule inhibitors that are currently in clinical trials as single agents (Buparlisib and WNT974) we observe significant in vitro synergy when inhibiting both pathways at low nanomolar doses. Furthermore, confirmatory in vivo xenograft studies display a similar synergy for the combination compared to single agent and vehicle controls.

Citation Format: Solzak JP, Atale R, Hancock B, Radovich M. Dual PI3K and Wnt pathway inhibition is a synergistic combination against triple negative breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P6-13-09.

Mindfulness-based cancer stress management: impact of a mindfulness-based programme on psychological distress and quality of life

Within the area of cancer care, mindfulness-based therapeutic interventions have been found to be efficacious in reducing psychological distress related to a cancer diagnosis; however, the impact of mindfulness-based interventions on quality of life is unclear. This study explores the impact of a Mindfulness-Based Cancer Stress Management programme on psychological distress and quality of life. Research methodology included a single-group quasi-experimental study of 26 participants experiencing distress related to a cancer diagnosis, including carers, who completed an MBCSM programme and all assessments. Participants completed the Functional Assessment of Cancer Therapy - General version 4 (FACT-G) and its associated spirituality index (FACIT-Sp-Ex), Hospital Anxiety and Depression Scale (HADS), Freiburg Mindfulness Inventory (FMI), and the Distress Thermometer at baseline, post-intervention, and three months after programme completion. Significant improvements were observed on all measures (ranges: P ≤ 0.001 to 0.008, r = -0.53 to -0.79) following the intervention, which were maintained at 3-month follow-up. Mindfulness was significantly correlated with all main outcome measures at post-intervention (range: r = -0.41 to 0.67) and 3-month follow-up (range: r = -0.49 to 0.73), providing evidence for the internal validity of the study. Our findings indicate that the MBCSM programme is effective in reducing psychological distress and improving quality of life, including spiritual well-being.

Reduced Myxobolus cerebralis actinospore production in a Colorado reservoir may be linked to changes in Tubifex tubifex population structure

Elucidating the dynamics of a parasitic infection requiring two hosts in a natural ecosystem can be a daunting task. Myxobolus cerebralis (Mc), the myxozoan parasite that causes whirling disease in some salmonids, was detected in the Colorado River upstream of Windy Gap Reservoir (WGR) in 1988. Subsequently, whirling disease was implicated in the decline of wild Rainbow Trout Oncorhynchus mykiss in the river when WGR was identified as a point source of Mc triactinomyxons (TAMs). Between 1997 and 2004, numerous investigations began to elucidate the etiology of Mc in WGR. During this period, Mc TAM production in WGR declined more than 90%. Explanations for the decline have included differences in stream discharge between years, changes in the thermal regime of the lake, severe drought, changes in the fish population structure in WGR, and reductions in the prevalence and severity of Mc infection in salmonids in the Colorado and Fraser rivers upstream of WGR. All of these have been discredited as explanations for the reduced TAM production. In 2005, a new study was conducted to replicate the studies completed in 1998. In this paper, the results of a new real-time polymerase chain reaction assay utilized to quantify the mitochondrial 16S rDNA specific to each of four lineages of Tubifex tubifex in pooled samples of 50 oligochaetes are presented. These results suggest that compared with 1998, the densities of aquatic oligochaetes and T. tubifex have increased, TAM production has been greatly reduced, and the decline is congruent with the dominance of lineages I, V, and VI of T. tubifex-three lineages that are refractory or highly resistant to Mc infection-in the oligochaete population. While it is possible that the resistant lineages function as biofilters that deactivate Mc myxospores, the reason for the decline in TAM production in WGR remains an enigma.

Multivariate analysis of cartilage degradation using the support vector machine algorithm

An important limitation in MRI studies of early osteoarthritis is that measured MRI parameters exhibit substantial overlap between different degrees of cartilage degradation. We investigated whether multivariate support vector machine analysis would permit improved tissue characterization. Bovine nasal cartilage samples were subjected to pathomimetic degradation and their T(1), T(2), magnetization transfer rate (k(m) ), and apparent diffusion coefficient (ADC) were measured. Support vector machine analysis performed using certain parameter combinations exhibited particularly favorable classification properties. The areas under the receiver operating characteristic (ROC) curve for detection of extensive and mild degradation were 1.00 and 0.94, respectively, using the set (T(1), k(m), ADC), compared with 0.97 and 0.60 using T(1), the best univariate classifier. Furthermore, a degradation probability for each sample, derived from the support vector machine formalism using the parameter set (T(1), k(m), ADC), demonstrated much stronger correlations (r(2) = 0.79-0.88) with direct measurements of tissue biochemical components than did even the best-performing individual MRI parameter, T(1) (r(2) = 0.53-0.64). These results, combined with our previous investigation of Gaussian cluster-based tissue discrimination, indicate that the combinations (T(1), k(m)) and (T(1), k(m), ADC) may emerge as particularly useful for characterization of early cartilage degradation.

Serum potassium, calcium and magnesium in patients receiving ESHAP chemotherapy for relapsed lymphomas

Etoposide, methylprednisolone, cytarabine and cisplatin (ESHAP) is one of the mostly widely used chemotherapy regimens for patients with relapsed lymphomas. Cisplatin administration is commonly associated with electrolyte imbalance. Careful monitoring of renal function and serum electrolytes is therefore essential in this setting.

AIMS

To review the practice of electrolyte monitoring - potassium (K), calcium (Ca) and magnesium (Mg) - in patients receiving ESHAP and the frequency and severity of abnormalities and their management.

METHODS

Twenty-one consecutive patients received ESHAP. The medical records of 16 patients were retrievable and reviewed retrospectively. Results of serum K, Ca and Mg were collected prior to and after cycles 1, 2 and 3 of ESHAP, if measured.

RESULTS

Serum K levels prior to every cycle did not show any noticeable change. The means were 4.42, 4.34 and 4.43 mmol/l before cycles 1, 2 and 3, respectively. In one patient hypokalaemia was severe, refractory and symptomatic when preceded by hypomagnesaemia. Serum-adjusted calcium levels showed only minimal reduction. The means were 2.46, 2.40 and 2.38 mmol/l before cycles 1, 2 and 3 respectively. Mean serum Mg levels prior to every cycle showed progressive reduction; 0.84, 0.75 and 0.67 mmol/l before cycles 1, 2 and 3, respectively. This was associated with a progressive increase in the amount of required Mg supplementation. Serum K, Ca and Mg was measured prior to 100%, 67% and 35% of administered cycles, respectively.

CONCLUSION

In patients receiving ESHAP, hypokalaemia can occasionally be seen, especially if preceded by hypomagnesaemia. Mild cumulative hypocalcaemia is recognised. Hypomagnesaemia is a progressive complication and physicians need be aware of its importance. alcaemia is recognised. Hypomagnesaemia is a progressive complication and physicians need be aware of its importance.

Compatibility of superparamagnetic iron oxide nanoparticle labeling for ¹H MRI cell tracking with ³¹P MRS for bioenergetic measurements

Labeling of cells with superparamagnetic iron oxide nanoparticles permits cell tracking by (1)H MRI while (31)P MRS allows non-invasive evaluation of cellular bioenergetics. We evaluated the compatibility of these two techniques by obtaining (31)P NMR spectra of iron-labeled and unlabeled immobilized C2C12 myoblast cells in vitro. Broadened but usable (31)P spectra were obtained and peak area ratios of resonances corresponding to intracellular metabolites showed no significant differences between labeled and unlabeled cell populations. We conclude that (31)P NMR spectra can be obtained from cells labeled with sufficient iron to permit visualization by (1)H imaging protocols and that these spectra have sufficient quality to be used to assess metabolic status. This result introduces the possibility of using localized (31)P MRS to evaluate the viability of iron-labeled therapeutic cells as well as surrounding host tissue in vivo.

Next-Generation Whole Transcriptome Sequencing of Triple-Negative Breast Tumors and Normal Tissues

Background: Triple-negative breast cancer predominately affects pre-menopausal women and women of African-American descent and has been plagued by the absence of targeted therapies leading to poor survival. Using a new cutting edge technology, next-generation sequencing, we embarked on a study to analyze the whole transcriptomes of triple-negative tumors and normal tissues from pre-menopausal women in order to comprehensively identify new targets by analyzing all full length transcripts expressed in these tissues. This approach is independent of pre-determined gene selection as is common with microarrays, and allows for the analysis of RNA species that have not been previously profiled in breast cancer.Methods: cDNA libraries were created from RNA isolated from 8 triple-negative tumors and 2 normal breast tissues. Triple negative tumors were procured from Origene Technologies and normal breast tissues were procured from the Susan G. Komen for the Cure tissue bank at Indiana University. Normal samples were from healthy pre-menopausal volunteers with no history of disease. In order to eliminate bias from stromal tissue, normal samples were laser capture microdissected for ductal cells and RNA extracted from the excised tissue. cDNA libraries were prepared and subsequently sequenced on an Applied Biosystems (ABI) SOLiD3 sequencer using a 50bp fragment run. Mapping of whole reads to the human genome was performed using the SOLiD Analysis Pipeline Tool software (ABI) followed by a split-read alignment in order to map reads crossing exon-exon junctions. Gene expression profiles for each sample were then created and statistically compared to identify the most differentially expressed genes. In order to analyze for fusion genes, a split-read alignment of non-mapping reads to a composite transcriptome formed from previously mapped reads (clusters) was performed.Results: Sequencing of the 10 samples produced 513 million filtered reads equaling 25.66GB of data. Mapping of the reads to the genome revealed 1.14 million transcribed regions (exons). A preliminary analysis of gene expression shows 55.2% of the transcribed loci to have significant differential expression between tumor and normal. In a further analysis for gene fusions, several candidate fusions were bioinformatically detected. These are currently being reviewed and validated.Discussion: Herein we present a preliminary analysis of the transcriptomes of triple-negative breast cancers in comparison to normal tissues. A multitude of analyses are ongoing, including but not limited to: gene fusions, differentially expressed novel genes, novel transcripts, alternative splicing, intrinsic subtyping, and presence of viral genes. In addition 2 more triple-negative tumors and 8 normal samples will also be sequenced. In the current analysis, differentially expressed non-coding RNAs was highly pervasive among the samples indicating a major role of this RNA species in tumorigenesis. In addition, triple-negative breast cancers may contain fusion genes that could be “drivers” of this malignancy. Further validation of these differentially expressed RNAs and fusion genes in a larger set of samples with subsequent functional studies is planned.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 6134.

Resequencing of the Vascular Endothelial Growth Factor Promoter Reveals Haplotype Structure and Functional Diversity

Our group has previously reported that SNPs in the VEGF promoter are strongly associated with efficacy and toxicity to the anti-VEGF antibody bevacizumab in metastatic breast cancer. In order to better understand the biologic mechanism for our previously reported biomarkers, we embarked on a comprehensive evaluation of the genetic variation in the VEGF promoter coupled with a study of its intrinsic function. By resequencing 96 DNA samples (48 Caucasians, 48 African-Americans) for the VEGF promoter, we elucidated its complete haplotype structure and identified SNPs that were not previously reported in prior resequencing efforts. SNPs that were identified included twenty previously reported SNPs/insertions/deletions, one novel SNP, and one novel deletion. Among these variants, we identified five SNPs (VEGF-3818G/T, -2305G/T, -1210C/A, -1154G/A, & -7C/T) that tag six haplotypes capturing 74% of the genetic variation of the VEGF promoter. Subsequently, we cloned the six major haplotypes into reporter constructs in order to determine the effect of genetic variation on function. The reporter assays were performed in 5 breast cancer cell lines representing all ER and HER-2 statuses along with an inflammatory breast cancer cell line. We demonstrate that there is significant variation in promoter-induced expression among the haplotypes. More importantly, we show that the haplotypes containing the SNPs previously reported to be associated with increased survival with the use of bevacizumab are high-expressing haplotypes, thus lending putative functional evidence to the prior clinical finding. Further, we also report the presence of a low-expressing haplotype predominantly in African-Americans. Altogether, these results set the foundation for future studies elucidating the role of VEGF genetic variation with response to anti-angiogenic therapy and associations with angiogenesis-related diseases.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 2122.

The impact of follicular lymphoma on health-related quality of life

BACKGROUND

The purpose of this study was to determine whether there was a relationship between disease activity and health functioning, as measured by a range of patient-reported outcome (PRO) measures in patients with follicular lymphoma (FL).

PATIENTS AND METHODS

A total of 222 patients with FL were recruited from eight sites across the UK and they completed a number of PRO measures. The participants were analyzed across five disease states: 'active disease-newly diagnosed', 'active disease-relapsed', 'partial response', 'complete response' and 'disease free'. The relationship between these disease states and their level of health functioning was assessed as well as the relationship between being 'on' or 'off' chemotherapy and disease state.

RESULTS

In terms of health-related quality of life (HRQoL), participants in the relapsed category had the lowest mean physical well-being, emotional well-being, functional well-being and social well-being score. In a regression analysis, the 'active disease-relapsed' group acted as a significant predictor for each PRO variable. In addition, the remission group acted as a significant predictor of high anxiety scores as measured by the Hospital Anxiety and Depression Scale.

CONCLUSION

The results of this study demonstrate that various aspects of patient-reported health outcomes differ according to disease state in patients with FL. For those patients who have relapsed, they are more likely to experience worse HRQoL and other patient-reported health outcomes than patients newly diagnosed, in partial or complete remission or when completely disease free.

Interferon-α as adjuvant therapy for melanoma: An individual patient data meta-analysis of randomised trials

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Background: Many randomised trials have evaluated the role of adjuvant interferon-a (IFN) in high-risk melanoma, some suggesting benefit and others not. To assess the totality of current evidence, an individual patient data (IPD) meta-analysis of all available trials was performed. Methods: Standard IPD meta-analysis methods were used to assess event-free (EFS) and overall survival (OS), with odds ratios (OR) and 95% confidence intervals (CI) calculated. Trials were divided by dose of IFN - high (20 MU/m2), intermediate (5–10 MU), low (3 MU) and very low (1 MU). Subgroup analyses by patient age, gender and disease characteristics were also performed. Results: IPD was provided for 10 of 13 reported trials of IFN vs. no IFN (for the other 3 trials published data were used). 6067 patients (IPD available for 85%) were included in the analysis, with over 3,700 and 3,000 events for EFS and OS. There was statistically significant benefit for IFN for both EFS (OR=0.87, CI=0.81–0.93, p=0.00006) and OS (0.9, 0.84–0.97, p=0.008). There was no evidence of differences according to dose (Table 1; trend p>0.1) or duration of IFN. This proportional survival advantage translates into an absolute benefit of about 3% (CI 1%-5%) at 5 years. The effect of IFN did not differ with age, gender, tumor site, Breslow thickness, clinical nodes or disease stage. Only for ulceration was there some evidence of an interaction (p=0.03); patients with ulcerated tumors had greater benefit from IFN (EFS: OR=0.76, OS: OR=0.77) than those with no ulceration (EFS: OR=0.94, OS: OR=0.98). Conclusions: This meta-analysis provides evidence that adjuvant IFN significantly reduces the risk of relapse and improves overall survival, although the absolute survival benefit is relatively small. This analysis does not however, clarify the optimal (high, intermediate or low) dose of IFN. Given the large number of subgroup analyses performed, the apparent increased benefit in patients with ulceration requires confirmation.

No significant financial relationships to disclose.

A phase III trial comparing CHOP to PMitCEBO with or without G-CSF in patients aged 60 plus with aggressive non-Hodgkin's lymphoma

The management of older patients with aggressive non-Hodgkin's lymphoma presents a challenge to the physician. Age is a poor prognostic indicator, due to reduced ability to tolerate and maintain dose-intensive chemotherapy. Generally, older patients demonstrate a lower response rate, reduced survival and increased toxicity, although the majority of large randomised trials exclude older patients. This randomised trial was conducted in patients 60 years or over to compare CHOP (cyclophosphamide 750 mg m⁻², doxorubicin 50 mg m⁻², vincristine 1.4 mg m⁻², prednisolone 100 mg) with PMitCEBO (mitoxantrone 7 mg m⁻², cyclophosphamide 300 mg m⁻², etoposide 150 mg m⁻², vincristine 1.4 mg m⁻², bleomycin 10 mg m⁻² and prednisolone 50 mg). Due to the myelosuppressive nature of these regimens, patients were also randomised to the addition of G-CSF. The formal results of this trial with long-term follow-up are now reported. Data were analysed to assess efficacy and toxicity. Overall response rate was 84% in the CHOP arm and 83% in the PMitCEBO arm, with overall response rates of 83% for the use of G-CSF and 84% for no G-CSF. At median 44 months follow-up, there was no significant difference in failure-free, progression-free or overall survival between the CHOP and PMitCEBO arms. At 3 years, the actuarial failure-free survival was 44% in CHOP recipients and 42% in PMitCEBO recipients and the 3-year actuarial overall survival was 46% and 45% respectively. There was no significant difference in the failure-free, progression-free or overall survival with the addition of G-CSF.

Comparison of CHOP versus CIOP in good prognosis younger patients with histologically aggressive non-Hodgkin lymphoma

CHOP (cyclophosphamide, doxorubicin, vincristine and prednisolone) has been the standard chemotherapy regimen used for diffuse large cell lymphomas for over 30 years. Idarubicin is a 4-demethoxy-anthracycline analogue of daunorubicin that has proven activity in non-Hodgkin lymphoma, and has been reported to cause less cardiotoxicity. We therefore initiated a randomised trial of standard dose CHOP versus CIOP (cyclophosphamide, idarubicin, vincristine and prednisolone), in which doxorubicin 50 mg/m2 was substituted by idarubicin 10 mg/m2, a dose thought to have equivalent anti-lymphoma activity. This trial was closed prematurely after 211 patients had completed therapy when a lower complete remission (CR) rate was noted in the CIOP arm. The formal results with long-term follow up are now reported. Overall response rate was 84% in the CHOP arm and 78% in the CIOP arm, CR rates were 70% and 52% respectively in all patients (P=0.013) and 73% and 52% respectively for the eligible patients (P=0.0084). At a median of 8 years follow-up, 4-year progression-free survival for all patients was 56% in the CHOP arm and 40% in the CIOP arm (P=0.0096). Overall survival for all patients was 65% in the CHOP arm and 56% in the CIOP arm (P=0.14). Results for eligible patients were comparable. CIOP containing idarubicin at a dose of 10 mg/m2 is clearly inferior to standard CHOP.

Nature of the nucleosomal barrier to RNA polymerase II

In the cell, RNA polymerase II (pol II) efficiently transcribes DNA packaged into nucleosomes, but in vitro encounters with the nucleosomes induce catalytic inactivation (arrest) of the pol II core enzyme. To determine potential mechanisms making nucleosomes transparent to transcription in vivo, we analyzed the nature of the nucleosome-induced arrest. We found that the arrests have been detected mostly at positions of strong intrinsic pause sites of DNA. The transient pausing makes pol II vulnerable to arrest, which involves backtracking of the elongation complex for a considerable distance on DNA. The histone-DNA contacts reestablished in front of pol II stabilize backtracked conformation of the polymerase. In agreement with this mechanism, blocking of backtracking prevents nucleosome-induced arrest. Transcript cleavage factor TFIIS reactivates the backtracked complexes and promotes pol II transcription through the nucleosome. Our findings establish the crucial role of elongation factors that suppress pol II pausing and backtracking for transcription in the context of chromatin.

Fludarabine, adriamycin and dexamethasone (FAD) in newly diagnosed advanced follicular lymphoma: a phase II study by the British National Lymphoma Investigation (BNLI)

The optimal first-line treatment for symptomatic patients with advanced stage follicular lymphoma remains unclear. Fludarabine-based combination regimens have been extensively used in relapsed disease and merit consideration as first-line therapy. We here report the results of a phase II study of FAD (fludarabine, adriamycin, dexamethasone) regimen in 30 patients with advanced stage follicular lymphoma requiring treatment. The response rate was in excess of 90% with 39% achieving a complete remission. The major toxicity was myelosuppression, but only 3% of cycles were associated with grade IV leucopenia. The high response rate has not translated into major improvements in failure-free survival and consideration must be given to alternative treatment modalities to consolidate the high rate of initial responses.

Maintenance treatment with interferon for advanced ovarian cancer: results of the Northern and Yorkshire gynaecology group randomised phase III study

A randomised phase III trial was conducted to assess the role of interferon-alpha (INFalpha) 2a as maintenance therapy following surgery and/or chemotherapy in patients with epithelial ovarian carcinoma. Patients were randomised following initial surgery/chemotherapy to interferon-alpha 2a as 4.5 mega-units subcutaneously 3 days per week or to no further treatment. A total of 300 patients were randomised within the study between February 1990 and July 1997. No benefit for interferon maintenance was seen in terms of either overall or clinical event-free survival. We conclude that INF-alpha is not effective as a maintenance therapy in the management of women with ovarian cancer. The need for novel therapeutics or strategies to prevent the almost inevitable relapse of patients despite increasingly effective surgery and chemotherapy remains.

Long-term follow-up of patients treated with radiotherapy alone for early-stage histologically aggressive non-Hodgkin's lymphoma

Historically localised aggressive non-Hodgkin's lymphoma (NHL) has been treated with involved field radiotherapy (RT), chemotherapy, or a combination of both modalities. The current weight of evidence supports a preference for combined modality treatment (CMT). Increased patient age at diagnosis is well recognised as a poor prognostic indicator in NHL, but despite this some perceive CMT as too toxic for use in the elderly. As a result, some older patients continue to be offered RT alone. Here, we present long-term follow-up of 377 adults of all ages treated with RT alone for early-stage diffuse large-cell lymphoma on British National Lymphoma Investigation trials between 1974 and 1997. 10-year cause-specific survival in patients older than 60 years was poor and significantly inferior to that in younger patients (47 and 75% respectively; P<0.001). There is growing evidence that short-course chemotherapy, with or without RT, is superior to RT alone in early-stage aggressive NHL, in elderly as well as in younger patients. Increased age alone should not exclude patients from systemic treatment for early-stage aggressive NHL.

A multicentre phase II trial of bryostatin-1 in patients with advanced renal cancer

Protein kinase C (PKC) has a critical role in several signal transduction pathways, and is involved in renal cancer pathogenesis. Bryostatin-1 modulates PKC activity and has antitumour effects in preclinical studies. We conducted a multicentre phase II clinical trial in patients with advanced renal cancer to determine the response rate, immunomodulatory activity and toxicity of bryostatin-1 given as a continuous 24 h infusion weekly for 3 out of 4 weeks at a dose of 25 μg m⁻². In all, 16 patients were recruited (11 males and five females). The median age was 59 years (range 44–68). Patients had been treated previously with nephrectomy (8) and/or interferon therapy (9) and/or hormone therapy (4) and/or radiotherapy (6). Eight, five and three patients had performance statuses of 0, 1 and 2, respectively. A total of 181 infusions were administered with a median of 12 infusions per patient (range 1–29). Disease response was evaluable in 13 patients. Three patients achieved stable disease lasting for 10.5, 8 and 5.5 months, respectively. No complete responses or partial responses were seen. Myalgia, fatigue, nausea, headache, vomiting, anorexia, anaemia and lymphopenia were the commonly reported side effects. Assessment of biological activity of bryostatin-1 was carried out using the whole–blood cytokine release assay in six patients, two of whom had a rise in IL-6 levels 24 h after initiating bryostatin-1 therapy compared to pretreatment values. However, the IL-6 level was found to be significantly lower at day 28 compared to the pretreatment level in all six patients analysed.

The attitudes of GPs towards the nurse-practitioner role

In recent years, nursing and health-care policy have promoted the advanced role of the nurse -- that of nurse practitioner. But such a role has not been integrated widely into the primary health-care team. This study investigates the knowledge and attitudes of GPs who do not employ nurse practitioners to find out what prevents them doing so. Ten GPs who did not already employ a nurse practitioner took part in semi-structured interviews. Our findings show that GPs, although confused about the role, were generally supportive of advanced nursing practice. Skills identified with the role were prescribing, disease diagnosis and minor-illness management. GPs thought that protocols and guidelines should govern practice, which differs fundamentally from the Royal College of Nursing definition. None of the GPs had encountered the role in primary care, and the lack of professional regulation and role definition for practice nurses and nurse practitioners who work in primary care may have affected GPs' perceptions.

Suppression of intestinal polyps in Msh2-deficient and non-Msh2-deficient multiple intestinal neoplasia mice by a specific cyclooxygenase-2 inhibitor and by a dual cyclooxygenase-1/2 inhibitor

Epidemiological studies suggest that nonsteroidal anti-inflammatory agents decrease the risk of colorectal cancer. This is believed to be mediated, at least in part, by inhibition of cyclooxygenase (COX) activity. There are two COX isoenzymes, namely the constitutively expressed COX-1 and the inducible COX-2. COX-2 is overexpressed in adenomas and colorectal cancers, and COX-2-specific inhibitors have been shown to inhibit intestinal polyps in Apc(Delta716) mice more effectively than dual COX-1/COX-2 inhibitors such as sulindac. Various Apc knockout mice, including the multiple intestinal neoplasia (Min) mouse and the Apc(Delta716) mouse, are limited by their lack of large numbers of colonic adenomas and aberrant crypt foci, the putative precursors of large-bowel polyps and cancers. Our DNA mismatch-repair-deficient Min mouse model (Apc+/-Msh2-/-) has genetic features of both familial adenomatous polyposis and hereditary nonpolyposis colorectal cancer, and most importantly, rapidly develops numerous small- and large-bowel adenomas, as well as colonic aberrant crypt foci. The purpose of this study was to determine the effects of COX inhibitors on intestinal adenomas and colonic aberrant crypt foci in this accelerated polyposis, mismatch-repair-deficient Min mouse model, in addition to a standard Min mouse model. Weanling Apc+/-Msh2-/- and Min mice were fed diets containing no drug, sulindac, or a specific COX-2 inhibitor (MF-tricyclic). Apc+/-Msh2-/- and Min mice were sacrificed after 4 weeks and 5 months on diet, respectively. Apc+/-Msh2-/- mice treated with MF-tricyclic had significantly fewer small-bowel polyps (mean +/- SD, 178 +/- 29) compared with mice on sulindac (278 +/- 80), or control diet (341 +/- 43; P < 0.001). There was no difference in numbers of large-bowel polyps or aberrant crypt foci in mice in the three groups. MF-tricyclic was also effective in reducing both small- and large-bowel polyps in Min mice. Western analysis demonstrated COX-2 expression in both large- and small-bowel polyps from mice of both genotypes. This study demonstrates that a specific COX-2 inhibitor is effective in preventing small-bowel polyps in mismatch-repair-deficient Min mice and both small- and large-bowel polyps in standard Min mice. Therefore, specific COX-2 inhibitors may be useful as chemopreventive and therapeutic agents in humans at risk for colorectal neoplasia.

Mitoxantrone is superior to doxorubicin in a multiagent weekly regimen for patients older than 60 with high-grade lymphoma: results of a BNLI randomized trial of PAdriaCEBO versus PMitCEBO

A prospective, multicenter, randomized trial was undertaken to compare the efficacy and toxicity of adriamycin with mitoxantrone within a 6-drug combination chemotherapy regimen for elderly patients (older than 60 years) with high-grade non-Hodgkin lymphoma (HGL) given for a minimum of 8 weeks. A total of 516 previously untreated patients aged older than 60 years were randomized to receive 1 of 2 anthracycline-containing regimens: adriamycin, 35 mg/m(2) intravenously (IV) on day 1 (n = 259), or mitoxantrone, 7 mg/m(2) IV on day 1 (n = 257); with prednisolone, 50 mg orally on days 1 to 14; cyclophosphamide, 300 mg/m(2) IV on day 1; etoposide, 150 mg/m(2) IV on day 1; vincristine, 1.4 mg/m(2) IV on day 8; and bleomycin, 10 mg/m(2) IV on day 8. Each 2-week cycle was administered for a minimum of 8 weeks in the absence of progression. Forty-three patients were ineligible for analysis. The overall and complete remission rates were 78% and 60% for patients receiving PMitCEBO and 69% and 52% for patients receiving PAdriaCEBO (P =.05, P =.12, respectively). Overall survival was significantly better with PMitCEBO than PAdriaCEBO (P =.0067). However, relapse-free survival was not significantly different (P =.16). At 4 years, 28% of PAdriaCEBO patients and 50% of PMitCEBO patients were alive (P =.0001). Ann Arbor stage III/IV, World Health Organization performance status 2-4, and elevated lactate dehydrogenase negatively influenced overall survival from diagnosis. In conclusion, the PMitCEBO 8-week combination chemotherapy regimen offers high response rates, durable remissions, and acceptable toxicity in elderly patients with HGL.

Adjuvant interferon alpha 2b in high risk melanoma - the Scottish study

In 1989, the Scottish melanoma group initiated a randomized trial, comparing observation alone with 6 months' therapy with low dose interferon (given subcutaneously 3 MU day-1, twice weekly), for patients with primary melanomas of at least 3 mm Breslow thickness, or with evidence of regional node involvement. The trial was closed in 1993 with only 95 eligible patients randomized. There were no toxic deaths, and no patient failed to complete the treatment for reasons of toxicity. 6 months' treatment with low-dose interferon- resulted in a statistically significant improved disease-free survival for up to 24 months after randomization (P< 0.05). However, at a median follow-up of over 6 years, although there was an apparent improvement in disease-free survival (from 9 to 22 months), and overall survival (from 27 to 39 months), consistent with larger studies powered to detect such differences, these differences were not statistically significant. The data therefore suggest that 6 months of low-dose interferon is active, and confirm the importance of the large randomized studies, such as the UKCCCR AIM-High and EORTC trials, that seek to confirm a possible survival advantage for low or intermediate dose interferon.

Guidelines for the stratification of patients recruited to trials of therapy for low-risk gestational trophoblastic tumor

OBJECTIVE

The aim of the study was to initiate a search for factors which might independently predict the need for salvage therapy in patients with low-risk gestational trophoblastic tumor.

METHODS

The independent effect of six factors on the need for salvage chemotherapy was assessed in patients with low-risk gestational trophoblastic tumor who were treated with low-dose methotrexate and folinic acid. The accuracies of World Health Organization and Charing Cross Hospital scores were also compared.

RESULTS

Age, pretreatment beta hCG, antecedent pregnancy-treatment interval, and the presence of chest metastases detected on chest X ray were not significantly predictive. The size of tumor (P = 0.001) and the presence of chest metastases on chest computerized tomography (P = 0. 00028) had independent, statistically significant predictive power, and a simple prognostic index was derived from these variables. The World Health Organization score was found to be significantly better than the Charing Cross Hospital score. The accuracy of the simple prognostic index was slightly greater than that of the World Health Organization score, although this was not statistically significant.

CONCLUSIONS

These results confirm that patients entered into studies of different therapies for low-risk gestational trophoblastic tumor should be stratified and that a simple score, derived from the results of tumor size and chest computerized tomography, is potentially as good as the World Health Organization score for predicting the need for salvage therapy.

A UK multicentre phase II study of rituximab (chimaeric anti-CD20 monoclonal antibody) in patients with follicular lymphoma, with PCR monitoring of molecular response

Follicular lymphoma (FL) cells express CD20 and are associated in most cases with the t(14;18) chromosomal translocation. A multicentre study was undertaken between January 1997 and January 1998 to assess the complete response rate (CR) and overall response rate (RR) to rituximab, a chimaeric anti-CD20 monoclonal antibody. Seventy patients with previously treated FL received rituximab (375 mg/m2/week x4, by intravenous infusion). Restaging studies were performed 1 and 2 months after therapy. Molecular monitoring for the presence of cells harbouring the Bcl-2/JH gene rearrangement in the peripheral blood (PB) and bone marrow (BM) was performed before and after treatment using a two-step semi-nested polymerase chain reaction (PCR) assay. The overall RR was 32/70 (46%), being highest in patients who had received only one previous treatment (12/15, 80%). However, only two patients achieved a CR. The median duration of response was 11 months. Thirteen of 21 evaluable 'PCR-positive' patients (62%) became 'PCR-negative' in PB and/or BM samples 1 month after rituximab, although this did not correlate with clinical response. Treatment was generally well tolerated, although one patient developed Stevens-Johnson syndrome. Rituximab was shown to be active in FL, and in some cases PB and/or BM became PCR negative. Studies in combination with cytotoxic chemotherapy to increase the CR rate are warranted.

Are nursing theories holistic?

Nursing theories, while claiming to present models of holistic nursing care, do not deal adequately with human spirituality. This article reviews several nursing theories to find out which of them incorporate holism, and, if they do, whether the theorist's definition of holism includes spirituality.

Postal consent for upper gastrointestinal endoscopy

BACKGROUND

Standards for good practice in clinical risk management issued by the Clinical Negligence Scheme for Trusts indicate that "appropriate information is provided to patients on the risks and benefits of proposed treatment, and of the alternatives available before a signature on a consent form is sought".

AIMS

To investigate the practicability and patient acceptability of a postal information and consent booklet for patients undergoing outpatient gastroscopy.

METHODS

Information about gastroscopy procedure, personalised appointment details, and a carbonised consent form were compiled into a single booklet. This was mailed to patients well in advance of their endoscopic procedure. Patient satisfaction for this new process was assessed by questionnaire.

RESULTS

275 patients received a patient information booklet. Of these, 150 (54.5%) returned the consent form by post when they confirmed their attendance; 141 (94%) had signed the form, and the other nine requested further information. Of the remaining 125 booklets sent out, 115 (92%) forms were brought back on the day of the investigation having been previously signed. The remaining 10 (8%) required further information before signing the form. An audit of 168 patients was used to test reaction to the booklet and the idea of filling in the form before coming to hospital; 155 patients (92. 2%) reported the information given in the booklet to be "very useful", and all reported it to be "clear and understandable".

CONCLUSION

A specifically designed patient information booklet with integral consent form is accepted by patients, and improves the level of understanding prior to the investigation being carried out.

High-dose BEAM chemotherapy with autologous haemopoietic stem cell transplantation for Hodgkin's disease is unlikely to be associated with a major increased risk of secondary MDS/AML

Hodgkin's disease is curable in the majority of patients, although a proportion of patients are resistant to or relapse after initial therapy. High-dose therapy with autologous stem cell support has become the standard salvage therapy for patients failing chemotherapy, but there have been reports of a high incidence of myelodysplasia/acute myeloid leukaemia (MDS/AML) following such treatment. Patients who receive such therapy form a selected group, however, who have already been subjected to other leukaemogenic factors, such as treatment with alkylating agents. In order to ascertain the true risk of MDS/AML, comparison must be made with other patients subjected to the same risks but not undergoing transplantation. We report a retrospective comparative study of 4576 patients with Hodgkin's disease from the BNLI and UCLH Hodgkin's databases, which includes 595 patients who have received a transplant. Statistical analysis including Cox's proportional hazards multivariate regression model with time-dependent covariates was employed. This analysis reveals that the risk of developing MDS/AML was dominated by three factors, namely quantity of prior therapy (relative risk [RR] 2.01, 95% confidence intervals [CI] 1.49-2.71, for each treatment block, P < 0.0001) and whether the patient had been exposed to MOPP (RR 3.61, 95% CI 1.64-7.95, P = 0.0009) or lomustine chemotherapy (RR 4.53, 95% CI 1.96-10.44, P = 0.001). Following adjustment for these factors in the multivariate model the relative risk associated with transplantation was 1.83 (95% CI 0.66-5.11, P = 0.25). This study provides no evidence of a significantly increased risk of MDS/AML associated with BEAM therapy and autologous transplantation in Hodgkin's disease. Concern over MDS/AML should not mitigate against the timely use of this treatment modality.

Beagle 2: a proposed exobiology lander for ESA's 2003 Mars Express mission

The aim of the proposed Beagle 2 small lander for ESA's 2003 Mars Express mission is to search for organic material on and below the surface of Mars and to study the inorganic chemistry and mineralogy of the landing site. The lander will have a total mass of 60kg including entry, descent, and landing system. Experiments will be deployed on the surface using a robotic arm. It will use a mechanical mole and grinder to obtain samples from below the surface, under rocks, and inside rocks. Sample analysis by a mass spectrometer will include isotopic analysis. An optical microscope, an X-ray spectrometer and a Mossbauer spectrometer will conduct in-situ rock studies.

Paraplegia

Nurses caring for people who have sustained an injury resulting in paraplegia must have an understanding of both the psychological and physical effects. This Update examines the nurse's role in preparing the patient for the future.

Results of interleukin-2-based treatment in advanced melanoma: a case record-based analysis of 631 patients

PURPOSE

In patients with stage IV melanoma, durable responses have been reported with treatment regimens that involve high-dose interleukin-2 (IL-2). We analyze long-term results of 631 melanoma patients from 12 institutions who had received IL-2 alone, in combination with interferon alfa 2a or 2b (IFNalpha), or with cytotoxic drugs.

METHODS

Case records that contained pretreatment parameters, response data, and updated survival information were collected. After univariate analysis, the multivariate evaluation of the impact of pretreatment parameters on response and survival was performed by logistic regression and Cox's regression, respectively.

RESULTS

Patients were divided into four groups according to treatment: IL-2 alone (n=117), IL-2 and chemotherapy (n=49), IL-2 and IFNalpha (n=153), and IL-2, chemotherapy, and IFNalpha (n=312). The median survival of all patients was 10.5 months and the 2- and 5-year survival rates were 19.9% and 10.4%, respectively. Independent prognostic factors for response and survival were entirely different, treatment group being the only significant factor for response, and serum lactate dehydrogenase (LDH), metastatic site, and performance predicting survival. The addition of IFNalpha to IL-2 was associated with prolonged survival, but the effect of additional chemotherapy was less obvious.

CONCLUSION

Serum LDH, metastatic site, and performance status are useful stratification factors for randomized trials in metastatic melanoma. The improved long-term survival rates observed in melanoma patients treated with IL-2/IFNalpha-containing regimens are notable in contrast to the reported 5-year survival rates of 2% to 6% achieved with chemotherapy, but because selection bias cannot be ruled out, the impact of IL-2, as well as all other components of the treatment regimens, on survival needs to be confirmed in prospective randomized trials.

Clinical and epidemiologic features of a massive waterborne outbreak of cryptosporidiosis in persons with HIV infection

During March and April 1993, a massive outbreak of Cryptosporidium infection resulted from contamination of the public water supply in Milwaukee, Wisconsin. The health impact of this outbreak in HIV-infected persons was unknown but was perceived as severe. We surveyed HIV-infected persons who resided in the greater Milwaukee area to examine the acute health impact of cryptosporidiosis on this population. Data from a random-digit dialing survey in the general population residing in the same area were used for comparison. The attack rate of watery diarrhea suggestive of cryptosporidiosis was lower in HIV-infected persons (32%) than in the general population (51%). There was no significant difference in attack rate in HIV-infected persons based on CD4+ T-lymphocyte count. In persons with watery diarrhea, HIV-infected persons were more likely to experience cough (42%), fever (52%), and dehydration (55%). In HIV-infected persons with watery diarrhea, persons with CD4+ T-lymphocyte counts <200/microl had longer duration of diarrhea and were more likely to seek medical attention and be hospitalized. During this massive waterborne outbreak, HIV-infected persons were not more likely to experience symptomatic Cryptosporidium infection than the general population. However, once infected, the duration and severity of illness was greater in HIV-infected persons, especially if the CD4+ T-lymphocyte count was <200/microl.

Suppression of intestinal polyposis in Apc delta716 knockout mice by inhibition of cyclooxygenase 2 (COX-2)

Two cyclooxygenase isozymes catalyze conversion of arachidonic acid to prostaglandin H2: constitutive COX-1 and inducible COX-2. To assess the role of COX-2 in colorectal tumorigenisis, we determined the effects of COX-2 gene (Ptgs2) knockouts and a novel COX-2 inhibitor on Apc delta716 knockout mice, a model of human familial adenomatous polyposis. A Ptgs2 null mutation reduced the number and size of the intestinal polyps dramatically. Furthermore, treating Apc delta716 mice with a novel COX-2 inhibitor reduced the polyp number more significantly than with sulindac, which inhibits both isoenzymes. These results provide direct genetic evidence that COX-2 plays a key role in tumorigenesis and indicate that COX-2-selective inhibitors can be a novel class of therapeutic agents for colorectal polyposis and cancer.

Self-administration of medicines

Self-administration of medicines by patients in hospitals and residential homes can lead to increased comprehension and compliance with treatment after discharge and thus to a reduction in readmission rates. It can also increase the self-esteem of chronically ill patients by allowing them to take responsibility for their own health.