Patient, family caregiver, and economic outcomes of an integrated screening and novel stepped collaborative care intervention in the oncology setting in the USA (CARES): a randomised, parallel, phase 3 trial

BACKGROUND

The current standard of care of screening and referring patients for treatment for symptoms, such as depression, pain, and fatigue, is not effective. This trial aimed to test the efficacy of an integrated screening and novel stepped collaborative care intervention versus standard of care for patients with cancer and at least one of the following symptoms: depression, pain, or fatigue.

METHODS

This randomised, parallel, phase 3 trial was conducted in 29 oncology outpatient clinics associated with the UPMC Hillman Cancer Center in the USA. Patients (aged ≥21 years) with any cancer type and clinical levels of depression, pain, or fatigue (or all of these) were eligible. Eligible family caregivers were aged 21 years or older and providing care to a patient diagnosed with cancer who consented for this study. Patients were randomly assigned (1:1) to stepped collaborative care or standard of care using a central, permuted block design (sizes of 2, 4, and 6) stratified by sex and prognostic status. The biostatistician, oncologists, and outcome assessors were masked to treatment assignment. Stepped collaborative care was once-weekly cognitive behavioural therapy for 50-60 min from a care coordinator via telemedicine (eg, telephone or videoconferencing). Pharmacotherapy for symptoms might be initiated or changed if recommended by the treatment team or preferred by the patient. Standard of care was screening and referral to a health-care provider for treatment of symptoms. The primary outcome was health-related quality of life in patients at 6 months. Maintenance of the treatment benefits was assessed at 12 months. Participants included in the primary analysis were per intention to treat, which included patients missing one or both follow-up assessments. This trial was registered with ClinicalTrials.gov (NCT02939755).

FINDINGS

Between Dec 5, 2016, and April 8, 2021, 459 patients and 190 family caregivers were enrolled. 222 patients were assigned to standard of care and 237 to stepped collaborative care. Of 459 patients, 201 (44%) were male and 258 (56%) were female. Patients in the stepped collaborative care group had a greater 0-6-month improvement in health-related quality of life than patients in the standard-of-care group (p=0·013, effect size 0·09). Health-related quality of life was maintained for the stepped collaborative care group (p=0·74, effect size 0·01). Patients in the stepped collaborative care group had greater 0-6-month improvements than the standard-of-care group in emotional (p=0·012), functional (p=0·042), and physical (p=0·033) wellbeing. No adverse events were reported by patients in either group and deaths were considered unrelated to the study.

INTERPRETATION

An integrated screening and novel stepped collaborative care intervention, compared with the current standard of care, is recommended to improve health-related quality of life. The findings of this study will advance the implementation of guideline concordant care (screening and treatment) and has the potential to shift the practice of screening and treatment paradigm nationwide, improving outcomes for patients diagnosed with cancer.

FUNDING

US National Cancer Institute.

The benefits and consequences of the COVID-19 pandemic for patients diagnosed with cancer and their family caregivers

BACKGROUND

The objectives of this study were to examine benefits and consequences of the COVID-19 pandemic for patients diagnosed with cancer and their family caregivers.

METHODS

A 23-item questionnaire assessing COVID-19-related issues, the Patient Health Questionnaire-2, Generalized Anxiety Disorder-2, Pittsburgh Sleep Quality Index, and the Perceived Stress Scale (PSS)-4 were administered to patients diagnosed with cancer and their family caregivers.

RESULTS

Of the 161 patients and 78 caregivers who participated, 38.1% and 32.8 were male, 95% and 84.6% Caucasian, and the mean age was 66 and 64.6 years, respectively. A total of 16.5% and 15.2% reported depressive symptoms, 18.4% and 19% reported anxiety; 35.5% and 26.6% reported poor sleep quality, and 66% and 63.3% scored one standard deviation above the norms for the PSS, respectively. Predictors of poorer patient- and caregiver-reported outcomes included greater loneliness, worry about self or family being infected by the COVID-19, and worsening relationships with family. The fear of COVID-19 led to 20.8% of patients and 24.4% of family caregivers cancelling medical appointments, procedures, and treatments. A total of 52.5% of patients and 53.2% caregivers reported that the pandemic led to benefit finding but these changes were not associated with any of the measured patient- or caregiver-related outcomes.

CONCLUSIONS

Psychological functioning for patients and caregivers was similar to that of pre-pandemic levels, however the decrease in health care utilization secondary to fear of COVID-19 was notable. While there were many negative effects of the pandemic, the majority of patients and caregivers reported some benefit to the pandemic.

Trait mindfulness and the mental and physical health of caregivers for individuals with cancer

BACKGROUND

Mindfulness plays a role in moderating the negative mental and physical health outcomes associated with caregiving. The aims of this study were to examine the relationship between trait mindfulness and the (1) psychological functioning, (2) health behaviors, (3) and physical health of caregivers for individuals diagnosed with cancer.

METHODS

Caregivers completed a battery of questionnaires and examinations assessing sociodemographic characteristics, trait mindfulness, depression, perceived stress, caregiver stress, sleep, diet, physical activity, tobacco use, alcohol use, blood pressure, and BMI. Demographics and cancer diagnostics were collected for the individuals whom caregivers supported. Linear regression, multivariate analyses, and moderator analyses were performed.

RESULTS

Of the 78 caregivers, the mean age was 63.9 (S.D.=13.1); 59% identified as female; 97% identified as White. Regression analyses indicated that caregivers who reported higher levels of trait mindfulness reported significantly less perceived stress (b= -4.38, SE= 0.88, p <.001), lower levels of depression (b= -3.74, SE= 1.10, p = .001), greater caregiver quality of life (b= -9.05, SE=2.12, p < .001), better sleep quality (b= -0.98, SE=0.44, p = 0.03), and lower rates of tobacco use (b= -10.12, SE= 3.43, p =.003). Trait mindfulness was not significantly related to diet, alcohol use, blood pressure, or BMI.

CONCLUSIONS

Higher levels of trait mindfulness are associated with positive mental and physical health measure for caregivers. Future research would benefit from further examining mindfulness-based interventions and their impacts in mitigating the negative toll of caregiving in the context of cancer.

The next generation of collaborative care: The design of a novel web-based stepped collaborative care intervention delivered via telemedicine for people diagnosed with cancer

BACKGROUND

The NIH consensus statement on cancer-related symptoms concluded the most common and debilitating were depression, pain and fatigue [1-6]. Although the comorbidity of these symptoms is well known and may have similar underlying biological mechanisms no intervention has been developed to reduce these symptoms concurrently. The novel web-based stepped collaborative care intervention delivered by telemedicine is the first to be tested in people diagnosed with cancer.

METHODS

We plan to test a web-based stepped collaborative care intervention with 450 cancer patients and 200 caregivers in the context of a randomized controlled trial. The primary endpoint is quality of life with other primary outcomes including patient-reported depression, pain, fatigue. Secondary outcomes include patient serum levels of pro-inflammatory cytokines and disease progression. We also will assess informal caregiver stress, depression, and metabolic abnormalities to determine if improvements in patients' symptoms also relate to improvement in caregiver outcomes.

RESULTS

The trial is ongoing and a total of 382 patients have been randomized. Preliminary analyses of the screening tools used for study entry suggest that Center for Epidemiological Studies-Depression (CESD) scale has good sensitivity and specificity (0.81 and 0.813) whereas the scale used to assess pain (0.47 and 0.91) and fatigue (0.11 and 0.91) had poor sensitivity but excellent specificity. Using the AUROC, the best cut point for the CES-D was 19, for pain was 4.5; and for fatigue was 2.5. Outcomes not originally proposed included health care utilization and healthcare charges. The first 100 patients who have been followed a year post-treatment, and who were less than 75 years and randomized to the web-based stepped collaborative care intervention, had lower rates of complications after surgery [χ² = 5.45, p = 0.02]. For patients who survived 6 months or less and were randomized to the web-based stepped collaborative care intervention, had lower rates of 90-day readmissions when compared to patients randomized to the screening and referral arm [χ² = 4.0, p = 0.046]. Patients randomized to the collaborative care intervention arm had lower overall health care activity-based costs of $16,758 per patient per year when compared to the screening and referral arm.

DISCUSSION

This novel web-based stepped stepped collaborative care intervention, delivered via telemedicine, is expected to provide a new strategy to improve the quality of life in those diagnosed with cancer and their caregivers.

TRIAL REGISTRATION

ClinicalTrials.govNCT02939755.

A phase II study of weekly docetaxel in combination with capecitabine in advanced gastric and gastroesophageal adenocarcinomas

OBJECTIVE

Docetaxel and capecitabine are active agents in advanced gastric and gastroesophageal (GE) carcinomas. This multi-institutional phase II trial evaluates the combination of docetaxel and capecitabine as first- or second-line treatment in patients with advanced gastric and GE adenocarcinomas.

METHODS

Patients who had received 1 or no prior chemotherapy regimens were eligible. The chemotherapy regimen consisted of a 21-day cycle with docetaxel 30 mg/m(2) administered on days 1 and 8 and capecitabine 825 mg/m(2) administered twice daily on days 1-14. The primary end point of the study was overall survival (OS).

RESULTS

Forty patients were enrolled in the study; 39 received treatment and were evaluable for response and toxicity. The median patient age was 61 years (range 21-84); 8 patients had received prior chemotherapy in the advanced or metastatic setting. Grade 3/4 adverse events occurred in 15 patients (38%), including diarrhea in 5 patients (13%) and hand-foot syndrome in 5 patients (13%). The overall response rate was 32% [95% confidence interval (CI) 16.7-51.4]. The median time to progression and OS were 3.4 months (95% CI 2.7-5.8) and 10.7 months (95% CI 6.1-12.1), respectively.

CONCLUSIONS

The regimen of docetaxel and capecitabine is a well-tolerated, easily administered and active outpatient regimen for advanced gastric and GE adenocarcinoma.

Phase II study of rubitecan, an oral camptothecin in patients with advanced colorectal cancer who have failed previous 5-fluorouracil based chemotherapy

BACKGROUND

Rubitecan (RFS-2000, 9NC, Orathecin) is an orally bioavailable camptothecin analogue, with evidence of preclinical activity in colon cancer cell lines. We evaluated oral rubitecan (5 days on, 2 days rest per week) on a continuous schedule, in patients with advanced colorectal cancer (CRC), who progressed after 5-fluorouracil based chemotherapy.

PATIENTS AND RESULTS

Fourteen eligible patients were treated with rubitecan at 1.5 mg/m2/day on a 5 day/week continuous schedule. Therapy was well tolerated with most adverse events in the mild to moderate category. Grade 3/4 toxicity consisting of anemia, diarrhea and elevated bilirubin was seen in 4 patients. No responses were seen in 13 evaluable patients. Overall median survival (95% confidence interval) was 10.1 (range 3.1-12.6) months, and median time to progression was 2.1 months.

CONCLUSIONS

Administration of rubitecan was well tolerated, but this schedule does not appear to have clinical activity in patients with advanced previously treated CRC.

[Mansonella perstans filariasis after stay in Cameroon. A 19-year-old patient born in Cameroon, in Switzerland for the last 10 years]

After a spending three weeks in Cameroon, a 19-year-old woman presented in the emergency room with sudden lancinating pain in the lower abdomen, predominantly on the right side. A blood smear tested for presumed malaria showed subperiodic microfilariae of the species Mansonella perstans. The patient was treated with mebendazole (Vermox).

Correlation of postoperative axial length growth and intraocular pressure in congenital glaucoma--a retrospective study in trabeculotomy and goniotomy

BACKGROUND

This paper investigates the correlation of postoperative intraocular pressure (IOP) with axial length growth in children who underwent either trabeculotomy (TO) or goniotomy (GO) as primary surgery for congenital glaucoma.

METHODS

Thirty-seven eyes of 21 children with congenital glaucoma who underwent one or two TOs from 1992 to 1997 and 26 eyes of 16 children with congenital glaucoma who underwent one or more GOs from 1974 to 1993 were retrospectively analyzed. None of the eyes had undergone other surgery previously. Thirteen of the TOs were combined with a small trabeculectomy. IOP was measured by handheld applanation tonometry (Perkins). Axial length was measured by ultrasound. The data were analyzed for correlation of postoperative IOP reduction with postoperative axial length growth.

RESULTS

Mean duration of follow-up was 27.3 months in the TO eyes and 37.1 months in the GO eyes. Mean pretreatment IOP before surgery was 28.4+/-6.9 mmHg in the TO eyes and 30.8+/-8.5 mmHg in the GO eyes. Mean IOP at the end of follow-up was 17.5+/-5.8 mmHg in the TO eyes and 17.4+/-10.2 mmHg in the GO eyes. Axial length growth was normalized (proportional or slowed down compared with the nomogram of axial length growth) in 31 of the 37 TO eyes and in 20 of the 26 GO eyes, and was increased in 6 of the TO eyes and 6 of the GO eyes at the end of follow-up. Regarding axial length growth, 6 of 37 TO eyes had increased axial length growth at the end of follow-up. Three of these eyes also did not fulfill the IOP success criterion; 2 of the 3 eyes with normalized IOP had only borderline increased axial length growth. Six of 26 GO eyes had increased axial length growth at the end of follow-up. Five of these eyes did not fulfill the IOP success criterion; 1 eye with normalized IOP had only borderline increased axial length growth.

CONCLUSION

The data show remarkably good correlation of postoperative IOP with postoperative axial length growth. Axial length measurements can therefore help to ascertain halting or progression of congenital glaucoma and thus are considered an important parameter for congenital glaucoma follow-up.

Ankle and first metatarsophalangeal joint dorsiflexion in children with clubfoot

It has been hypothesised that the stiffness of the plantar aponeurosis after clubfoot surgery affects push-off. Because the first metatarsophalangeal (MTP) joint motion relies on the plantar aponeurosis, it was important to determine whether there was a lack of first MTP joint motion in children with clubfoot that also affected push-off. By examining the motion of the first MTP joint using a motion analysis system and passive motion techniques, then correlating these with gait characteristics, the authors found that the first MTP joint was not affected in children with clubfoot. The authors found that a motion analysis system could be used to determine range of motion accurately.

Kinematics and kinetics of the hip, knee, and ankle of children with clubfoot after posteromedial release

Clubfoot is a bony deformity characterized by inversion, adduction, and equinus that often require surgical intervention. This study assessed the gait kinetics and kinematics of children with unilateral and those with bilateral clubfoot, comparing them with age-and gender-matched normal (control) children. Patient satisfaction also was examined using a questionnaire, and muscle strength was evaluated at the ankle and knee. In evaluating the kinematics, it was important to note that deviations occurred at the ankle of children with clubfoot. Differences in kinematics and kinetics at the hip and knee between normal children and those with clubfoot resulted from lack of motion at the ankle. Furthermore, the strength of ankle plantarflexors was weak, which reduced plantarflexion during push-off. This restricted motion may have been caused by residual bony deformities and muscle tightness resulting from the original condition that contributed to muscle stiffness during gait.

A comparison of early intensive methotrexate/mercaptopurine with early intensive alternating combination chemotherapy for high-risk B-precursor acute lymphoblastic leukemia: a Pediatric Oncology Group phase III randomized trial

A prospective, randomized multicenter study was performed to evaluate the relative efficacy of two different concepts for early intensive therapy in a randomized trial of children with B-precursor acute lymphoblastic leukemia (ALL) at high risk (HR) for relapse. Four hundred and ninety eligible children with HR-ALL were randomized on the Pediatric Oncology Group (POG) 9006 phase III trial between 7 January 1991 and 12 January 1994. After prednisone (PDN), vincristine (VCR), asparaginase (ASP) and daunorubicin (DNR) induction, 470 patients received either 12 intensive parenteral treatments of intermediate dose (1 g/m2 each) methotrexate (MTX) and mercaptopurine (MP) over 24 weeks (regimen A) or 12 intensive course of alternating myelosuppressive drug combinations given over 30 weeks (regimen B). These drug combinations included MTX/MP, teniposide (VM-26)/cytosine arabinoside (AC) and VCR/PDN/DNR/AC/ASP. Central nervous system (CNS) prophylaxis was age-adjusted triple intrathecal chemotherapy. Patients with CNS disease at diagnosis were treated with craniospinal irradiation after the intensive phase. Continuation was standard doses of MTX and MP for 2 years. This trial was closed early because of an apparent early difference favoring regimen B. Results show that 470 patients achieved remission (97%). Two hundred and thirty two were randomized to regimen A and 238 to regimen B. The estimated 4-year event-free survival (EFS) for patients treated with regimen A is 61.6 % (s.e. = 3.3%) and with regimen B is 69.4% (s.e. = 3.1%), P = 0.091. Toxicities were more frequent on regimen B. In conclusion, for children with B-precursor ALL at high risk to relapse, early intensification with myelosuppressive combination chemotherapy was more toxic but produced no significant difference in EFS when compared to those treated with parenteral methotrexate and mercaptopurine.

Effects of amitriptyline, amitriptylinoxide, doxepine and clozapine on N-methyl-D-aspartate-evoked release of [3H]-acetylcholine in rat caudatoputamen

The tricyclic antidepressants amitriptyline (CAS 549-18-8), amitriptylinoxide (CAS 4317-14-0) and doxepine (CAS 1229-29-4) as well as the atypical neuroleptic clozapine (CAS 5786-21-0)--all of them substances with well-established clinical efficacy--were investigated in order to elucidate their effect on N-methyl-D-aspartate (NMDA) receptor-mediated events. Modulation of NMDA receptor function was studied using the model of NMDA-evoked [3H]-acetylcholine ([3H]-ACh) release in slices of rat caudatoputamen. All substances reduced [3H]-ACh release in a concentration dependent manner. Significant inhibition occurred in the low micromolar range with the exception of amitriptylinoxide which was less potent in vitro (amitriptylinoxide is not being metabolized in vitro). Amitriptyline and clozapine at 10 mumol/l both decreased the maximum effect of NMDA by around 17%, but left its EC50 unchanged. This suggests a "classical" non-competitive antagonism and excludes an uncompetitive or "use-dependent" antagonism. Considering the important role of NMDA receptor-mediated effects in spinal nociception the analgesic properties of tricyclic antidepressants may partly be explained by their inhibitory action on spinal NMDA receptors, in addition to their enhancement of monoaminergic transmissions in the dorsal horn.

Intensive alternating drug pairs after remission induction for treatment of infants with acute lymphoblastic leukemia: A Pediatric Oncology Group Pilot Study

PURPOSE

Infants with acute lymphoblastic leukemia (ALL) often enter remission; however, they have a high rate of relapse. To prevent relapse, infants' tolerance of and benefits from early intensive rotating drug pairs as part of therapy were studied.

METHODS

After prednisone, vincristine, asparaginase, and daunorubicin induction, 12 intensive treatments (ABACABACABAC) were administered in 30 weeks: A, intermediate dose methotrexate (MTX) and intermediate dose mercaptopurine (MP); B, cytosine arabinoside (Ara-C) and daunorubicin (DNR); C, Ara-C and teniposide (VM-26). Triple intrathecal chemotherapy (Ara-C, MTX, and hydrocortisone) was administered for central nervous system prophylaxis. Continuation therapy consisted of weekly MTX and daily MP for a total of 130 weeks of continuous complete remission.

RESULTS

Thirty-three infants (1 year old or younger) with newly diagnosed ALL were treated. Two infants did not respond to induction, 1 died from sepsis during continuation, 1 received a bone marrow transplant, and 24 relapsed. Median time to relapse was 39 weeks. The event-free survival rate at 5 years was 17% (standard error +/- 7.7%). The most significant toxicities occurred during intensification and included fever-neutropenia and bacterial sepsis.

CONCLUSION

Although early intensive rotating therapy is tolerable, the relapse-free survival rate remains poor for infants treated with the schedule on this protocol.

[Data on the epidemiology of head and neck neoplasms in Hungary]

Oral and pharyngeal cancer mortality of the male population increases in the fastest rate in Hungary. Both oral and pharyngeal as well as laryngeal cancer mortality is the highest in Europe for both sexes. The leading risk factors of them are smoking and drinking together. The per capitam cigarette and alcohol consumption of Hungarian population belong also among the highest in Europe. The authors have examined these damaging habits taking in account the collected data of Hungarian patient's group, the presence of them as risk factors have been compared to the smoking and alcohol consuming habits of the average population collected by microcensus data. Only 4 patients were nonsmokers and nondrinkers among the 145 patients who were interviewed. On the other hand from the same number of the population with the same sex and age distribution 73 did not smoke and drink while 123 patients were smokers and drinkers against the 48 from the population mentioned before. They have found that the two groups have diverged at a level 0.1% significance. Taking in account the fact that the number of patients is relatively low, further data collection is carried on in order to analyse in a more detailed way, but they regard it as proved, according to the recent tests the serious risk role of the two factors for the Hungarian population.

Comparisons of weight-bearing and non-weight-bearing tests of knee proprioception performed by patients with patello-femoral pain syndrome and asymptomatic individuals

OBJECTIVE

To compare non-weight-bearing (sitting) and weight-bearing (standing, with approximately 95% of body weight on the test leg) tests of knee proprioception performed by patients with patello-femoral pain syndrome (PFPS) and asymptomatic individuals.

DESIGN

A repeated measures design, repeated on two occasions.

SETTING

Athletic injuries clinic.

PARTICIPANTS

Seven men and 17 women with PFPS, and age- and sex-matched asymptomatic individuals.

INTERVENTIONS

With their eyes closed, subjects extended their knee in sitting, or flexed their knees in standing, attempting to replicate target angles (15 degrees, 30 degrees, 45 degrees, and 60 degrees knee flexion) measured using an electrogoniometer.

MAIN OUTCOME MEASURE

Observed angle of knee flexion during joint angle replication tests.

RESULTS

Test-retest reliability coefficients (0.17-0.79) and between-session measurement error (+/-2.0 degrees to +/-6.4 degrees) varied widely. There was a tendency for reliability coefficients to be greater and between-session measurement error to be lower, for PFPS subjects, and for sitting tests. No significant differences were observed between the scores of the PFPS and asymptomatic subjects, at any of the four target knee angles.

CONCLUSIONS

Scores in sitting should not be compared with those in standing. Clinically, the low reliability coefficients, large between-session measurement error, and finding of no statistically significant difference between PFPS and asymptomatic subjects suggest that the diagnostic value of the proprioceptive tests used is questionable. Further research is required to develop more precise tests of knee proprioception and to determine if the present results are applicable to other pathologies.

Cytotoxic effects by microinjection of ADP-ribosylated skeletal muscle G-actin in PtK2 cells in the absence of Clostridium perfringens iota toxin

The ADP-ribosylating toxins Clostridium botulinum C2 toxin and C. perfringens iota toxin, which ADP-ribosylate monomeric G-actin at Arg-177 but not the polymeric F-actin, induce depolymerization of the actin cytoskeleton in cultured cells. Since ADP-ribosylated G-actin has properties of a barbed-end-capping protein, we studied whether the ADP-ribosylated actin affects the actin cytoskeleton of PtK2 cells even in the absence of ADP-ribosylating toxin. Skeletal muscle actin was ADP-ribosylated by C. perfringens iota toxin and the toxin was removed using an anti-iota toxin antibody. Microinjection of ADP-ribosylated actin caused retraction of the cell body, redistribution and depolymerization of the actin cytoskeleton in a concentration- and time-dependent manner. The finding that ADP-ribosylated actin affects per se the actin cytoskeleton explains the cytopathic effects of ADP-ribosylating toxins on microfilaments, although F-actin is not directly modified by the toxins.

[The Bullard laryngoscope. An aid in unforseen difficult intubation]

The standard procedure when difficulties are anticipated with intubation, e.g. following the clinical classification as per Mallampati, is the fibreoptic bronchoscopic method applied while the patient is awake. In the case of unexpected difficulties encountered during intubation while the patient is anaesthetized, a scenario that cannot be absolutely ruled out, e.g. in an emergency resection when there is no longer a simple method of returning the patient to the waking condition, and when problems are accentuated by seriously hampered mask respiration, aspiration risk, danger of hypoxia, and visual obstruction by secretions and blood, the fibrebronchoscope is no longer the instrument of choice. A larynx mask or a combination tube is probably a better option. Our experience has shown that the Bullard laryngoscope (BL) can help to improve the situation because, while it has similar advantages to the flexible bronchoscope, it can be operated almost exactly as quickly as a Macintosh intubation spatula. In contrast to the bronchoscope, fibreoptic orientation under impeded visual conditions caused by secretions and blood is, in our experience, much easier. The BL is routinely deployed, as an alternative to the Macintosh instrument, for practice purposes by all our colleagues in the department. It has proved to be remarkably effective: to date it has led to the target quickly and without complications in every case. As examples three case histories selected from a series of cases in which the BL was used have been highlighted.

Intensive alternating drug pairs for treatment of high-risk childhood acute lymphoblastic leukemia. A Pediatric Oncology Group pilot study

BACKGROUND

To prevent drug resistance, the authors designed a protocol that featured early intensive rotating drug pairs as part of the therapy for acute lymphoblastic leukemia (ALL).

METHODS

After prednisone, vincristine, asparaginase, and daunorubicin induction, 12 intensive treatments (ABACABACABAC) were given in 30 weeks: A--intermediate-dose methotrexate (IDMTX) plus intermediate-dose mercaptopurine (MP); B--cytosine arabinoside (AC) plus daunorubicin (DNR); C--AC plus teniposide (VM-26). Triple intrathecal chemotherapy (AC, MTX, and hydrocortisone) was given for central nervous system (CNS) prophylaxis. Continuation therapy consisted of weekly MTX and daily MP until 2.5 years of continuous complete remission had been achieved.

RESULTS

Seventy-four children (age range, 1-19 years) at high risk of relapse were treated. Of 55 with B-lineage (early pre-B, pre-B) ALL, 24 have failed (2 induction failures, 2 deaths from infection, and 20 relapses). The event-free survival (EFS) rate at 4 years was 55.5% (standard error [SE] +/- 7.7%). Of 19 patients with T-cell ALL, 12 have failed (2 induction failures and 10 relapses). The EFS rate at 4 years was 32.6% (SE +/- 26.8%). Toxicities were significantly more common after AC and DNR or AC and VM-26 than IDMTX and MP. There were no toxicity-related deaths during intensive treatments.

CONCLUSION

Early intensive rotating therapy is tolerable and warrants consideration for additional trials of patients with high-risk, B-lineage ALL.

DNA cytophotometric analysis of breast cancer. Follow-up for 10 years

Forty-four cases of newly diagnosed invasive ductal breast cancer were studied by static cytometry at the time of diagnosis and were followed for 10 years to determine if the survival rate correlated with the nuclear DNA measurements. In 22 cases the stem line was in the 2c range, in 15 cases in the 3c range and in 7 cases in the 4c range. Thirty-four percent (n = 15) of the patients died of metastases during the first five years, 11% (n = 5) died of metastases between 5 and 10 years, and 55% (n = 24) survived for > 10 years without metastases. No correlation between increased tumor cell proliferation and recurrence of tumors could be found. In this study all patients with diploid tumors, tumor size T1 and negative lymph node status survived for > 10 years. In the presence of node metastasis (T1N1M0) all patients (n = 4) having tumors with the stem line in the 2c range survived for 5 years but only 2/4 for > 10 years. The percentage of patients surviving for 10 years showed no significant differences between the groups: in the 2c range, 59% (13/22); in the 3c range, 53% (8/15); and in the 4c range, 43% (3/7). The small number of cases does not allow definitive statistical conclusions, although the logistic regression analyses showed that stem line, pT and pN were the important prognostic factors for five-year survival. However, only pT and especially pN were of prognostic value for 10-year survival.

Effects of a three-drug antineoplastic protocol of wound healing in rats: a biomechanical and histologic study on gastrointestinal anastomoses and laparotomy wounds

Using biomechanical and histologic approaches, the effect of perioperative administration of a drug protocol containing 5-fluoruracil, Adriamycin, and mitomycin C (FAM) on the healing of gastrointestinal anastomoses and laparotomy wounds in rats was examined. Application of FAM immediately before operation resulted in significant impairment of wound healing in the early postoperative period. Once the proliferation of fibroblasts and collagen synthesis had led to an increase of mechanical strength, no negative effect on wound healing could be detected applying the same chemotherapeutic agents. These findings indicate the early inflammatory phase of the wound healing process to be most vulnerable to the chemotherapeutic effects. This has significant implications if the theoretical advantages of starting adjuvant chemotherapeutic treatment in the immediate postoperative period are implemented.

Triploidy syndrome in a liveborn female

We present the autopsy report of a liveborn triploid female, born after 36 weeks of gestation, who died at the age of 20 hours. External features were diagnostic: fetal hypoplasia, hypertelorism, microstomia, micro-and retrognathia, preauricular skin tag, low-set ears, and 3-4 syndactylia. All internal organs were hypoplastic. There were atrial and ventricular septal defects. Adrenals and kidneys were fused, the gallbladder was absent, and ovarian hilum cell were found to be hyperplastic. Triploidy, 69xxx, was confirmed cytogenetically. The placenta was hypoplastic and, microscopically, revealed a peculiar type of immaturity, so-called hydatidiform villous hypoplasia, findings which have not been previously reported. We suggest that the generalized fetal and placental hypoplasia and the severe hypoplasia of all internal organs are caused by a proliferative deficiency of the triploid cells. In addition, the nuclear DNA content was determined by cytophotometrically from placental stromal cells and was found to be about 50% above the normal diploid DNA value; i.e., a triploid DNA value was confirmed.

Failed anterior acromioplasty. A review of 51 cases

This report is a retrospective review of 51 patients, each of whom had a failed acromioplasty that was performed after presumptive diagnoses of impingement tendinitis. The purpose of the review is to analyze the failures, define their causes, and make recommendations regarding further management. Average age at time of initial surgery was 40 years (range, 20-64 years), and the follow-up period averaged 5.5 years (range, three to nine years). Thirty-four patients were found to have symptoms and signs that corresponded to a recognized clinical diagnosis and were thought to be sufficient to be a major cause of their pain. Twenty-three had a diagnosis other than continuing impingement. Success of a second surgical procedure was significantly greater in nonworker's compensation (WC) patients than in WC patients. Repeat acromioplasties in WC patients have poor results and are not recommended. Seventeen patients had no clear cause for their continuing shoulder tendinitis; however, time and supportive therapy allowed five patients to improve over an average 18-month period. In all categories, WC patients fared poorly, so prognosis must be guarded in this group. Non-WC patients may be helped with repeat surgery following an appropriate diagnosis for the cause of failure.

Macrophage size determinations in the diagnosis of tuberculous effusions

This study investigated the usefulness of macrophage size determinations in lymphocyte-rich pleural effusions to improve the cytologic diagnosis of tuberculous pleurisy. The size of pleural macrophages was analyzed by quantitative morphometric planimetry in 18 effusions due to tuberculosis, 21 effusions following radiotherapy for malignant disease and 10 effusions due to congestive heart failure. Macrophages were identified and clearly separated from mesothelial cells by latex phagocytosis and immunostaining with the monoclonal antibody My4 (CD14). The mean macrophage area (+/- standard deviation) in tuberculous effusions (92 +/- 14 sq micron) was significantly smaller than in postradiation (141 +/- 28 sq micron) and heart-failure effusions (154 +/- 22 sq micron) (P less than .0001). There was also a smaller ratio of mesothelial cells in tuberculous effusions (0.5 +/- 0.9%) in comparison with effusions following radiotherapy (4 +/- 5%) or congestive heart failure (10 +/- 12%). In summary, this study demonstrated some cytomorphologic parameters that may be helpful in the differential diagnosis of tuberculous effusions.

Antitumor cell and antimetabolic effects of 5-ethyl-2'-deoxyuridine and 5'-substituted 5-ethyl-2'-deoxyuridine derivatives

A series of forty 5'-ester derivatives of 5-ethyl-2'-deoxyuridine (EDU) have been evaluated for their inhibitory effects on the growth and metabolism of murine leukemia L1210 cells. Several EDU esters proved as potent as EDU in their inhibitory effects on L1210 cell growth (inhibitory dose-50:5-10 micrograms/ml), suggesting that these esters were readily hydrolyzed to release the parent compound EDU. That the EDU esters had to be hydrolyzed first to EDU was further suggested by the dependence of their antiproliferative action on the thymidine kinase activity of the cells. It was further ascertained that EDU and its esters acquired their antiproliferative effects by an interaction with dCTP biosynthesis, possibly at the CDP ribonucleotide reductase step. Under conditions where thymidine was readily incorporated, we were unable to demonstrate any incorporation of EDU into L1210 cell DNA.

2-14C-1-Allyl-3,5-diethyl-6-chlorouracil I: Synthesis, absorption in human skin, excretion, distribution, and metabolism in rats and rabbits

With 14C-potassium cyanate as the starting material, 2-14C-1-allyl-3,5-diethyl-6-chlorouracil was synthesized for in vitro and in vivo absorption studies in human skin and for metabolic studies in rats and rabbits. The radioactivity in the horny layer, epidermis, and dermis of the human skin was determined after different intervals of time, and the radioactivity excreted in the urine was measured by collecting samples for 5 days from a patient and also under occlusion conditions. Almost 90% of the radioactivity remained on the surface and approximately 6.28% penetrated and was systemically absorbed. Over a 5-day period, a total of 3.25% was excreted. Almost 3% was systemically absorbed and cumulated in the system. After intraperitoneal application in male and female rats, most of the radioactivity was excreted in the feces and urine, with female rats excreting more in the urine than male rats. The radioactivity rose in the organs in the first 3 hr and then decreased. At the end of 144 hr, no appreciable radioactivity could be found in the organs and tissues, except in the carcass where the cumulation was maximum (1%). After intravenous injection in rabbits, most of the radioactivity (80%) was excreted in the urine and only 4% in the feces. At the end of 96 hr, approximately 3% was cumulated in the body. The drug was quantitatively metabolized in both rats and rabbits: Metabolite 1 (70-85%), Metabolite 2 (10-15%), Metabolite 3 (5-10%), and Metabolite 4 (0.3%).

2-14C-1-Allyl-3,5-diethyl-6-chlorouracil II: Isolation and structures of the major sulfur-free and three minor sulfur-containing metabolites and mechanism of biotransformation

The metabolites of 1-allyl-3,5-diethyl-6-chlorouracil in rabbit urine were isolated by preparative thick-layer, liquid-column, and gas chromatography. With the aid of mass and 1H-NMR spectra, and by comparison with an authentic sample, the major metabolite, 1, was identified as 6,8-diethyl-2-hydroxymethyl-tetrahydrooxazolo-[3,2-c]-pyrimidine-5,7(4H,6H)-dione, Metabolite 2 as 1-allyl-3-ethyl-5-(1-hydroxyethyl)-6-methylthiouracil, Metabolite 3 as 1-allyl-3,5-diethyl-6-methylthiouracil, and Metabolite 4 as 6,8-diethyl-2-hydroxymethyl-tetrahydrothiazolo-[3,2-c]pyrimidine-5,7(4H,6H)-dione. The mechanism of the formation of sulfur-containing metabolites is discussed, and a new metabolic pathway for the formation of methylthio compounds is proposed.

A simple method for the use of gallocyanin-chrome alum as an electron strain

A method has been elaborated for the demonstration of DNA in the electron microscope. The method uses glutaraldehyde fixed tissue pieces from which RNA has been removed by incubation with RNase. DNA is stained by gallocyanin-chrome alum in the tissue block. Embedding and cutting is done in the usual manner. The method is based on histochemical observations at the light microscope level which show sufficient specificity and a good stoichiometry of the staining reaction.

2-14C-1-(2'-deoxy-beta-D-ribofuranosyl)-5-ethyluracil: synthesis and biotransformation in rats

With 14C-urea as the starting material, 2-14C-1-(2'-deoxy-beta-D-ribofuranosyl)-5-ethyluracil [2-14C-beta-5-ethyl-2'-deoxyuridine] was synthesized for metabolic studies. After intravenous administration in rats, the radioactivity disappeared in the blood within 72 hr, being eliminated primarily in the urine (97%). The major elimination took place in the first 24 hr (92%). Little radioactivity was detected in the organs and tissues after 3 days. Approximately 50% of the urine radioactivity probably was due to an unidentified conjugate, 30% was due to Metabolite II, and 20% was unchanged drug. Metabolite II was identified as 5-ethyluracil by mass and 1H-NMR spectra and by comparison with an authentic sample.

Attempts to standardize the screening for antiviral drugs by in vitro tests

Plaque reduction (PR) and persistent infection cell culture (PICC) tests were used as a standard procedure for the selection of effective and well-tolerated antiviral compounds. Antiviral activity and cytotoxicity as well as other characteristics of the test compound, i.e., the development of drug resistance or the potential for activating the multiplication of other viruses can be examined by this method. In the described system analogues of 2'-deoxyuridine were tested against herpes simplex virus.

[Florid oral papillomatosis. A contribution to cytostatic therapy]

Based on the recent clinical experience in treating florid oral papillomatosis (FOP), the only successful therapy appears to be the use of cytostatic agents. The case report of a patient with clinically and histologically confirmed FOP is described to emphasize the advantages of administering Bleomycin intra-arterially (external carotid artery) by means of a Holter catheter. This catheter is used to release pressure in the treatment of internal hydrocephalus and is designed to remain in place for a number of years. The successful treatment of FOP points out the possibility of employing a Holter catheter for administering cytostatic agents in the treatment of malignant neoplasms in the facial area. Cytophotometric examinations of the prickle cells within the FOP mass showed a diploid pattern of DNA distribution similar to that of benigh tumors. However, it is not possible to definitely establish the malignant or benign nature of FOP in this manner.

DNA content of mycosis fungoides cells

DNA content of mycosis infiltrate cells was measured in 5 patients with the Feulgen cytophotometric method in the plaque and tumor stages. In addition, the infiltrate cells were differentiated cytochemically into histiocytes and atypical lymphoid cells with NaF-sensitive naphthol-AS-D-acetate esterase. In no case was an aneuploid stem line demonstrated. However, increasing duration of the tumor stage was associated with a larger proportion of tetraploid and octoploid cells. The DNA histograms also exhibited a local proliferation of atypical lymphoid cells. This proliferation was arrested by cytostatic therapy. Comparison with semi-thin-sections of tumor tissue showed that the mycosis fungoides cells are atypical lymphoid cells. These DNA measurements do not contradict the concept of limited aneuploidy, as reported in cytogenic studies. Thus mycosis fungoides fits in with the DNA distribution pattern in the group of lymphomas.

Comparative studies of the incorporation inhibition of radioactive nucleotides and amino acids in vitro under the influence of adriamycin, bleomycin, and sodium arsenate

The incorporation of 14C-marked nucleotides and amino acids into the nucleic acids and into the cellular protein of PHA-stimulated human lymphocytes was inhibited variably by increasing doses of Adriamycin, Bleomycin and Na2HAsO4. The findings, which were obtained with the aid of the liquid scintillation counter and partly by means of 14C-thymidine-marked autoradiographies shows clearly that Adriamycin causes the strongest incorporation inhibition. In contrast to this, the inhibition caused by Bleomycin and arsenate is considerably less destructive. It was shown by means of cytophoto metrical examinations that Adriamycin is capable of fixing cells in the G2 phase and in the S phase. Cells react similarly to Bleomycin and arsenate. The differential inhibition of nucleic acid and protein metabolism induced by Adriamycin, Bleomycin and arsenate is correlated with a varying responsiveness of lymphocytes to the cytostatically effective substances.

DNA and the cell cycle

The cell cycle and its significance for pathology is reviewed. The molecular basis and questions of regulation in the cell cycle are discussed, along with deviations from the normal cycle in the form of polyploidy formation and aneuploidy in tumor cells. Automated prescreening processes may play a role in the future in daily routine diagnosis. Methods of cytophotometry with the possibility for objective pattern recognition will become significant in pathology in many ways, both in research and in routine work.

[Fumaric acid monoethylester: Effect on DNA-synthesis and preliminary findings in experimental studies in animals (author's transl)]

The incorporation of 14C-Thymidin into DNA of cultured human lymphocytes is depressed by added fumaric acid monoethylester (FSME) depending on the dosage of FSME. The decreased radioactivity in DNA as measured by scintillation counting is paralleled by a concomitant decrease in the labelling index in autoradiograms. Decreasing radioactivity is therefore due to a lower number of DNA synthesizing cells. No selective inhibition of proliferation during one of the cell cycle phases was observed. Especially a G2-block known from other cytostaties is absent. A mean dosis of 6.88 mg FSME per g body weight administered intraperitoneally is lethal to mice. The animal die from diffuse necroses of heart muscle cell. Alterations of other organs are less prominent. At lower doses of FSME the morphology of the organs investigated is altered to a smaller degree.

Mitochondriosis of the hepatocytic cytoplasm in rachitic rat liver after calcitonin-treatment (a cytophotometric and morphometric study)

A calcium-rich rachitogenic vitamin-D deficiency and additional doses of calcitonin cause serious changes in cell structure and metabolism, which can be demonstrated by cytophotometry and morphometry. The experiments were made with 9 male juvenile Wistar rats. 6 animals were kept on a vitamin-D deficient diet for 6 weeks and 3 of these animals got injections with salmon-calcitonin S.C. during the last 14 days every second day. The remaining 3 animals, fed with altromin-R standard diet were kept for control purposes only. The morphometric analysis of the liver parenchymal cells was based on the statements by Weibel and the cytophotometric examinations were made according to the Sandritter technique. As a consequence of the altered metabolic condition a great volume reduction of cells and cell nuclei is found in the animals with vitamin-D deficiency, which were treated with calcitonin. In comparison with the control animals the hepatocytes show hardly any tetraploid nuclei, which points to an inhibited polyploidization. The cytoplasm shows an oncocytic transformation with megamitochondria. As reason for this mitochondriopathy an extreme and abnormal growth as well as a mutation of the mitochondrial genom are under discussion. Furthermore the total endoplasmic reticulum (volume and membrane surface), the peroxisomes and the ribosomes are strongly reduced. Due to the serious cell injury the other organelles are also reduced in number and volume, which points to a chronic hypocalcemia.

Nuclear images of cells in different functional states

To gain further insight into the supramolecular structure and behavior of chromatin, a set of parameters has been developed for the description of cell nuclear images. These images are obtained from Feulgen-stained nuclei in semithin sections. Data are extracted by a scanning microphotometer, printed on paper tape and processed by an electronic computer. The essential principles for the selection of descriptors were that: (a) they should correspond to characteristics that are employed in classical morphology and (b) they should be subject to interpretation in categories of biochemistry or molecular biology insofar as possible. Some of these parameters deal with the size and shape of the nucleus and its deoxyribonucleic acid content or staining behavior. Efforts were made to determine the relative amount of chromatin in the condensed state, because it may be assumed that the degree of condensation correlates with the activity of the chromatin. To demonstrate the power of the method, results from methylthiouracil-activated thyroid nuclei are presented. In stimulated nuclei the diffuse chromatin expands and fills the increasing nuclear volume, while the condensed chromatin retains its degree of condensation, and, probably, does not change in amount.