Evidence-based telehealth interventions for posttraumatic stress disorder, depression, and anxiety: A systematic review and meta-analysis

INTRODUCTION

The goal of this systematic review was to examine the efficacy of behavioral health care treatments for posttraumatic stress disorder (PTSD), depression, and anxiety delivered via telehealth.

METHODS

We searched a combination of keywords related to telehealth, relevant mental health disorders, and evidence-based psychotherapies in three databases (PubMed, PsycInfo, and Embase) from database inception to April 2022. We included randomized controlled trials published in English wherein at least one arm received an evidence-based psychotherapy via telehealth. To be included, studies also had to enroll an adult population with symptoms or diagnosis of PTSD, depressive disorder, or anxiety disorder.

RESULTS

Moderate quality of evidence was consistent with only small differences, if any, in efficacy between video teleconferencing (VTC) and in-person delivery for patients with PTSD (d = 0.06, 95% CI -0.17, 0.28). However, for those with depression, in-person delivery was associated with better outcomes compared to VTC (d = 0.28, 95% CI 0.03, 0.54; low quality of evidence). We also found that evidence-based treatments delivered over telephone were more efficacious for depression compared to treatment as usual (d = -0.47, 95% CI -0.66, -0.28; very low quality of evidence). Very low quality of evidence supported the use of telehealth versus waitlist for anxiety (d = -0.48, 95% CI -0.89, -0.09).

CONCLUSIONS

A synthesis across 29 studies indicates that the efficacy of telehealth for delivery of evidence-based behavioral health interventions varies by target diagnosis and telehealth modality. More research is needed on the efficacy of telehealth treatments for depression and anxiety.

Diagnostic and functional outcomes of adjustment disorder in U.S. active duty service members

BACKGROUND

Adjustment disorder (AD) is a commonly diagnosed psychiatric disorder. However, little is known about its course, predictors of its diagnostic outcomes, or its association with functional impairment. Our primary aim was to examine diagnostic transitions of service members with an incident AD diagnosis (IADx) to one of three states: 1) another psychiatric diagnosis, 2) chronic AD, or 3) no psychiatric diagnosis. Secondary outcomes included predictors of diagnostic course and functional outcomes associated with follow-up diagnoses.

METHODS

Health records of a random sample of 10,720 service members with an IADx were analyzed using multinomial logit regression and hazard rate model with competing risks.

RESULTS

IADx transitions were 24.3 % to another psychiatric diagnosis, 8.9 % with chronic AD, and 43.7 % without a diagnosis. Nearly a quarter (23.1 %) separated from service. Deployment was the strongest predictor of transitioning to another diagnosis. Those who transitioned to another diagnosis separated at an increased rate and with more adverse outcomes.

LIMITATIONS

Diagnostic findings are based on data in the electronic health record, and we could not specifically identify the stressor that precipitated an AD diagnosis. These findings describe the course of AD in military personnel and may not generalize to civilians.

CONCLUSIONS

AD, as initially diagnosed, represents a heterogeneous disorder with an enduring impact across the military career for a considerable proportion of service members. As an early indicator of more severe psychiatric outcomes, an IADx may signal an opportunity for early intervention and screening, particularly in service members with a history of deployment.

Outcomes and prognosis of adjustment disorder in adults: A systematic review

Adjustment disorder (AD) is one of the most commonly diagnosed mental health disorders and is generally conceptualized to be mild and short-lived. Despite the frequent use of AD in clinical settings, little is known about the prognosis of this condition. Our goal was to systematically review research on a range of AD outcomes in order to provide a broad characterization of AD prognosis. We conducted searches in MEDLINE, EMBASE, and PsycINFO. We included 31 cohort or randomized controlled trials with a total of 1,385,358 participants. Many patients maintained an AD diagnosis or were diagnosed with another mental health disorder months to years after initial diagnosis. Patients with AD tended to show symptom improvement at higher rates and to utilize less treatment than did patients with other disorders. AD-diagnosed groups experienced subsequent development of numerous physical conditions, such as infection, cancers, Parkinson's disease, and cardiovascular events, at higher rates than did control groups. Results were mixed regarding suicidality and occupational impairment. We rated most studies as having a moderate risk of bias. Based on limited findings, AD appears to progress as a milder disorder than do other disorders, but it not uncommonly transitions to more severe mental health states and may predict the development of future health issues, both mental and physical. Future prospective research that conforms to prognosis study guidelines is needed to better understand the course of this common disorder.

Systematic review and meta-analysis of predictors of adjustment disorders in adults

BACKGROUND

The diagnosis of adjustment disorder is common in clinical practice, yet there is lack of research on the etiology and epidemiology of adjustment disorders. The goal of this systematic review was to evaluate predictors of adjustment disorders in adults.

METHODS

We conducted systematic searches in MEDLINE, EMBASE, and PsycINFO. We included 70 studies that examined thirteen theoretically-derived and predefined predictors of adjustment disorders with a total of 3,449,374 participants.

RESULTS

We found that female gender, younger age, unemployed status, stress, physical illness and injury, low social support, and a history of mental health disorders predicted adjustment disorders. Most of these predictors differentiated individuals with adjustment disorders from individuals with no mental health disorders. Participants with adjustment disorders were more likely to have experienced accidents than were those with posttraumatic stress disorder but were less likely to have experienced assaults and abuse, neglect, and maltreatment. More research is needed to identify factors that differentiate adjustment disorders from other mental health disorders.

LIMITATIONS

Because very few studies adjusted for confounders (e.g., demographic variables, mental health histories, and a variety of stressors), it was not possible to identify independent associations between predictors and adjustment disorders.

CONCLUSIONS

We identified a number of factors that predicted adjustment disorders compared to no mental health diagnosis. The majority of studies were rated as moderate or high in risk of bias, suggesting that more rigorous research is needed to confirm the relationships we detected.

A systematic analysis and prioritization of suicide prevention research gaps

OBJECTIVE

This study identified and prioritized research gaps for suicide prevention in the Department of Defense to inform future research investments.

METHODS

The 2019 VA/DoD Clinical Practice Guideline for the Assessment and Management of Patients at Risk for Suicide was the primary source document for research gaps, supplemented by an updated literature search. Institutional stakeholders rated the identified research gaps and ranked the gap categories. We used Q factor analysis to derive a list of the prioritized research gaps and category rankings.

RESULTS

Thirty-five research gaps were identified and prioritized. The highest rated research gap topic was lethal means safety interventions and their effectiveness in increasing safety behaviors and/or reducing suicide-related outcomes. Research on the effectiveness of crisis response planning and several other non-pharmacological interventions (e.g., implementation of cognitive-behavioral therapy, technology-based behavioral interventions, and applications of dialectical behavior therapy to non-Borderline patients) were also rated highly by stakeholders.

CONCLUSIONS

This work generated a list of priorities for future suicide research as evaluated by Departments of Defense and Veterans Affairs stakeholders. Our findings can help guide the efforts of suicide researchers and inform decisions about future research funding for suicide prevention.

Adjustment disorders: A research gaps analysis

Adjustment disorders are among the most commonly diagnosed mental health disorders in both civilian and military clinical settings. Despite their high prevalence, adjustment disorders have received little research attention. The many gaps in our understanding of this group of disorders hinder the development of adequate, evidence-based treatment protocols. This study utilizes a systematic methodology to identify and prioritize research gaps in adjustment disorders. We used authoritative source reports to identify gaps in research domains from foundational science to services research. Subject-matter experts conducted literature searches to substantiate and refine research gaps, and stakeholders assessed the importance and impact of this work for researchers and policy-makers. We identified 254 possible research-needs statements, which were ultimately reduced to 11 final, prioritized research gaps. Two gaps addressed prevention and screening and three addressed treatment and services research. Six gaps addressed foundational science, epidemiology, and etiology research domains, highlighting the need for basic research. Until some of the basic science questions are resolved (e.g., diagnostic clarity, valid screening, and assessment measures) about adjustment disorders, we may not be able to develop adequate evidence-based interventions for the disorders, and it will be difficult to understand the trajectory of these disorders throughout treatment. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Women in combat: The effects of combat exposure and gender on the incidence and persistence of posttraumatic stress disorder diagnosis

Recent expansions in the roles of women in combat have prompted increased interest in the psychological toll combat exposure may have on female service members as compared to males. This study examined the interactive effects of gender and combat exposure on transitions in posttraumatic stress disorder (PTSD) diagnostic status (presence or absence of PTSD diagnosis). We used administrative data of 20,000 U.S. Army soldiers whose combat exposure was assessed after return from deployment between January 1, 2008 and June 30, 2014; soldiers' PTSD diagnostic status was determined using International Classification of Diseases-9 diagnoses at four time points separated by 12 months. We used a mixed-effects logit transition model to examine the effects of combat and gender on incidence, persistence, and prevalence of PTSD diagnosis. Incidence and prevalence of PTSD diagnosis were higher among women, but persistence of PTSD diagnosis was higher in men. Higher rates of new PTSD diagnosis among women were not dependent on combat exposure, suggesting that other types of trauma may be responsible for increased rates among women. Gender differences in prevalence and persistence of PTSD diagnosis were greater among combat-exposed soldiers than among those not exposed to combat. Men maintained a PTSD diagnosis over longer periods of time than women suggesting greater PTSD persistence, and this pattern was particularly pronounced among soldiers exposed to combat. These results have implications for the recent policy changes and gender-based prevention strategies, and suggest that women in combat roles may be no more vulnerable to PTSD than are their male counterparts. Though the gender differences were small, they are indicative of healthcare utilization patterns that may be important for prevention and that warrant further exploration.

Typologies of Combat Exposure and Their Effects on Posttraumatic Stress Disorder and Depression Symptoms

The present study identified distinct classes of U.S. military service members based on their combat experiences and examined mental health outcomes and longitudinal growth curves of posttraumatic stress disorder (PTSD) and depression symptoms associated with each class. Participants were 551 active duty service members who screened positive for PTSD and/or depression based on DSM-IV-TR criteria. All participants completed the Combat Experiences Scale at baseline as well as PTSD and depression measures at baseline and at 3-, 6-, and 12-month follow-ups. A latent class analysis identified four classes of service members based on their combat experiences: limited exposure, medical exposure, unit exposure, and personal exposure. Service members in the personal exposure class were characterized by a distinct mental health profile: They reported a higher level of PTSD symptoms at baseline and a higher prevalence of traumatic brain injury and PTSD diagnoses during the course of the study. The limited exposure class was more likely to receive diagnoses of depression and adjustment disorders. All classes except the medical exposure class demonstrated a slight decrease in PTSD and depression symptoms over time. However, participants in the limited exposure class had a larger decrease in PTSD and depression symptoms earlier in care but did not demonstrate superior long-term symptom improvements at 12 months compared to the other groups. These results inform PTSD development models and have implications for the screening and clinical management of combat-exposed service members.

Establishing an Evidence Synthesis Capability For Psychological Health Topics in the Military Health System

BACKGROUND

To promote evidence-based health care, clinical providers and decision makers rely on scientific evidence to inform best practices. Evidence synthesis (ES) is a key component of this process that serves to inform health care decisions by integrating and contextualizing research findings across studies.

OBJECTIVE

This paper describes the process of establishing an ES capability in the Military Health System dedicated to psychological health topics.

RESEARCH DESIGNS

The goal of establishing the current ES capability was to facilitate evidence-based decision-making among clinicians, clinic managers, research funders, and policymakers, through the production and dissemination of trustworthy ES reports. We describe how we developed this capability, provide an overview of the types of evidence syntheses products we use to respond to different stakeholders, and detail the procedures established for selecting and prioritizing synthesis topics.

RESULTS

We report on the productivity, acceptability, and impact of our efforts. Our reports were used by a variety of stakeholders and working groups, briefed to major committees, included in official reports and policies, and cited in clinical practice guidelines and the peer-reviewed literature.

CONCLUSIONS

Our experiences thus far suggest that the current ES capability offers a needed service within our health system. Our framework may help inform other agencies interested in developing or sponsoring a similar capability.

Final report on serial phase II trials of all-intraperitoneal chemotherapy with or without bevacizumab for women with newly diagnosed, optimally cytoreduced carcinoma of Müllerian origin

BACKGROUND

Intraperitoneal (IP) chemotherapy can improve outcomes for women with optimally cytoreduced epithelial ovarian cancer but toxicities are a concern. We conducted 2 phase 2 trials of an IV/IP regimen using carboplatin and paclitaxel without (Trial A) and with bevacizumab (Trial B).

METHODS

Both trials consisted of carboplatin AUC 6 day 1, and paclitaxel 60 mg/m² on days 1,8, 15 of a 21-day cycle; in Trial B, patients received IV bevacizumab 15 mg/kg every cycle starting cycle 2. Chemotherapy was administered IV for cycle 1 and then IP for all subsequent cycles. Primary objectives included safety and tolerability, pathologic CR rate (Trial A), and the rate of completion of IP cycles of therapy (Trial B). Progression-free (PFS), overall survival (OS), and pharmacokinetic analysis were secondary endpoints.

RESULTS

81 patients were treated on both trials (n = 40 and 41 in trials A and B, respectively). Median age for trials A and B was 59 (range, 36-76) and 55 (range, 19-69) years, respectively. 68% and 85% of patients, respectively for A and B, completed at least 4 cycles of treatment in both trials. Treatment with bevacizumab resulted in higher rates of grade 3 fatigue (37 versus 33%) and grade 3-4 diarrhea (22 versus 8%). Median PFS was 23.5 (95%CI 16.2-35.3) and 25 (95%CI 16.4-42.7) months, respectively; median OS was 68 (95%CI 49.5-NR) and 79.7 (95%CI 59.0-79.7) months, respectively for Trial A and B.

CONCLUSIONS

Weekly administered IP carboplatin and IP paclitaxel is tolerable and safe with similar activity with and without concommittant bevacizumab in these 2 trials.

Comparison of testing approaches for Clostridium difficile infection at a large community hospital

Multiple diagnostic approaches are available for Clostridium difficile infection (CDI); current guidelines support two-step testing (2ST) as the preferred approach. We retrospectively evaluated the impact of switching from toxin enzyme immunoassay (EIA) to 2ST, and then to polymerase chain reaction (PCR), on CDI rates, test utilization and CDI treatment at a 900-bed tertiary care community teaching hospital. All inpatients tested for CDI between December 2008 and February 2011 were included. A positive toxin EIA or PCR was diagnostic of CDI; 2ST was performed using glutamate dehydrogenase EIA, followed by PCR if positive. Repeat tests within 8 weeks on the same patient were considered part of the same testing episode. Data were collected electronically and studied in aggregate from 9725 unique inpatients tested for CDI, representing 20 836 individual tests. PCR detected 41% more patients with CDI than toxin EIA (p <0.0001), and 15% more than 2ST (p 0.02), corresponding to higher hospital-onset and community-onset CDI rates. The number of CDI tests performed per patient decreased by 48% with PCR (p <0.0001) compared with toxin EIA. For patients with CDI, time to the first positive test result was shortest with PCR. For patients without CDI, a negative PCR, but not 2ST, was associated with 22% fewer CDI treatment days, compared with toxin EIA (p <0.0001). Compared with both toxin EIA and 2ST, PCR detected more CDI patients faster and with less frequent testing, and negative PCR results were associated with less empirical CDI treatment.

Obstetrician-gynaecologist knowledge of and access to information about the risks of medication use during pregnancy

OBJECTIVE

To assess opinions, knowledge, and informational resources of obstetrician-gynaecologists regarding the safety of medication use during pregnancy.

METHODS

A questionnaire was mailed to 770 members of the American College of Obstetricians and Gynecologists who participate in the Collaborative Ambulatory Research Network.

RESULTS

The response rate was 58%. Of these, 305 respondents provide both routine gynecologic and obstetric care and are the focus of the study. There was wide variation in obstetrician-gynaecologists' assessments of the safety for the foetus of medications ranging from aspirin to valproic acid. The Physicians' Desk Reference was most frequently (75%) cited as a source of information about medication safety. Forty-two percent of obstetrician-gynaecologists selected lack of sufficient information on medications as the greatest barrier to counselling pregnant women about their use, while only 4% selected lack of access to information as the greatest barrier. Most (79%) obstetrician-gynaecologists indicated they would be willing to participate in pregnancy exposure registries, but far fewer (24%) reported having done so.

CONCLUSION

These results emphasise the need for safety information about the effects of medication use during pregnancy and suggest that pregnancy exposure registries are underutilised.

Management of prescription and nonprescription drug use during pregnancy

OBJECTIVE

To assess screening and treatment patterns of obstetrician-gynecologists regarding medication use during pregnancy.

METHODS

A questionnaire was mailed to 770 members of the American College of Obstetricians and Gynecologists who participate in the Collaborative Ambulatory Research Network.

RESULTS

The response rate was 58%. Most respondents reported always asking pregnant patients about use of over-the-counter (OTC) (86%) and prescription (98%) drugs; 24% reported not always asking about alternative medications. Far fewer reported always asking nonpregnant patients about use of alcohol (67%), illegal drugs (51%) and OTC medications (52%) than pregnant patients. Two-fifths (41%) reported prescribing a medication during pregnancy for which they had insufficient information about potential effects on the fetus; nearly half (47%) reported that there are medical conditions for which they would like to prescribe medications but do not due to insufficient safety information. Physician responses indicate that they are less likely to refer pregnant than nonpregnant patients to a specialist for treatment of certain conditions.

CONCLUSIONS

These results indicate that obstetrician-gynecologists sometimes prescribe medications for pregnant patients under less than optimal conditions and emphasize the importance of generating up-to-date information on effects of medications during pregnancy and having it readily available to health care providers.

Stage-for-stage comparison of definitive chemoradiotherapy, surgery alone and neoadjuvant chemotherapy for oesophageal carcinoma

BACKGROUND

Definitive chemoradiotherapy (dCRT) has been proposed as an alternative therapy for selected patients with oesophageal cancer. The aim of this study was to determine the outcomes of dCRT, surgery alone, and neoadjuvant chemotherapy followed by surgery (CS) in patients with oesophageal cancer.

METHODS

Consecutive patients diagnosed with oesophageal cancer and managed by a multidisciplinary team were staged by computed tomography and endoluminal ultrasonography. Those deemed unsuitable for surgery on the grounds of performance status, bulky local disease or personal choice received dCRT. The primary outcome measure was overall survival measured from date of diagnosis.

RESULTS

Of 417 patients, 173 received dCRT, 126 underwent surgery alone and 118 received CS. The incidence of grade III/IV toxicity after dCRT and CS was 39.3 and 60.2 per cent respectively. Operative morbidity rates were 42.9 and 44.4 per cent after surgery alone and CS respectively. Thirty-day mortality rates were zero, 7.9 and 0.8 per cent after dCRT, surgery alone and CS respectively. Overall 2-year survival rates were 44.3, 56.2 and 42.4 per cent (P = 0.422).

CONCLUSION

These findings support the need for a randomized trial of dCRT versus CS for resectable oesophageal cancer.

Screening for Down syndrome: changing practice of obstetricians

OBJECTIVE

We sought to assess the impact of American College of Obstetrician and Gynecologists (ACOG) guidelines on the practices and knowledge of obstetricians regarding screening for Down syndrome 1 year later.

STUDY DESIGN

A questionnaire on Down syndrome screening was mailed to 968 ACOG Fellows and Junior Fellows.

RESULTS

The response rate was 53%. The majority (95%) of respondents offer Down syndrome screening to all pregnant patients; 70% of general obstetricians offer the first-trimester screen and 86% the quad screen. Almost two-thirds (63%) of respondents are offering patients >/= 1 combination of first- and second-trimester screening tests. For women aged < 35 years, 70% offer amniocentesis selectively and 15% routinely. Chorionic villus sampling is offered less frequently. Respondents who more closely read the bulletin were more likely to say their practice had changed, answered more knowledge questions correctly, and felt more qualified to counsel patients. Most (85%) obstetricians personally counsel patients about Down syndrome risk and screening tests. The majority (94-95%) of respondents have access to adequate resources for screening within a 90-minute drive.

CONCLUSION

Obstetricians have adopted a new paradigm for Down syndrome screening. First-trimester screening has been incorporated into prenatal care. Experience with these current screening tests will likely influence future guidelines and challenge the long-standing tradition of offering diagnostic testing based on maternal age. This study highlights the need for concise, unambiguous guidelines and a need to address unresolved issues in Down syndrome screening.

Workload and resource implications of upper gastrointestinal cancer surgical centralisation in South East Wales

INTRODUCTION

The aim of this study was to determine whether one specialist unit could manage all patients diagnosed with oesophagogastric cancer in Gwent and Cardiff and Vale NHS Trusts over a 6-month period with regard to workload, resource and training opportunities.

PATIENTS AND METHODS

All patients diagnosed with oesophagogastric (OG) cancer in Gwent and Cardiff and Vale NHS Trusts and referred to the regional South East Wales Upper GI multidisciplinary team over the 6-month period from 1 July to 31 December 2005 were studied prospectively and compared with the previous 6-month caseload at Cardiff and Vale.

RESULTS

Out-patient workload increased from 160 new (33 OG cancers) and 533 follow-up patients (161 OG cancers) between 1 January and 30 June 2005, to 290 new (68 OG cancers, 106% increase) and 865 follow-up patients (230 OG cancers, 43% increase) between 1 July, and 31 December 2005. The number of patients undergoing radical surgery increased from 14 to 23 (D2 gastrectomy 8 versus 13; oesophagectomy 6 versus 10). Cancer-related workload in the latter period generated 118 intermediate equivalents (IEs) of operative work for two specialist surgeons and one SpR occupying 38% of the total time available on 104 scheduled operating lists, compared with 64 IEs in the previous 6 months, representing an 84% increase in cancer-related operative training opportunities.

CONCLUSIONS

Centralisation of oesophagogastric cancer surgery is feasible and desirable if national guidelines are to be satisfied, and this strategy has significant positive implications for surgical training and audit.

United States obstetrician-gynecologists' accuracy in the simulation of diagnosing anxiety disorders and depression during pregnancy

The objective of this study was to examine obstetrician-gynecologists' diagnostic accuracy for mental health issues during pregnancy through utilization of clinical vignettes describing depressive and anxiety symptoms, as well as to explore factors associated with increased diagnostic accuracy and related practice patterns. Questionnaires were mailed to 1193 American College of Obstetricians and Gynecologists Fellows and Junior Fellows. The response rate was 44% after three mailings. Depression was correctly identified by over 90% of respondents, whereas significantly fewer correctly diagnosed panic disorder (55%) and generalized anxiety disorder (32%). Confidence ratings significantly predicted diagnostic accuracy in some cases. Approximately half of respondents reported referring anxiety disordered patients to a mental health professional. There may be an education gap in ob-gyns' diagnostic knowledge of anxiety disorders, which may addressed by increasing physician confidence in diagnosis through increased training.

Obstetrician-gynecologists' screening patterns for anxiety during pregnancy

As obstetrician-gynecologists (ob-gyns) take on a greater role in women's healthcare, it is important that they are aware of the high prevalence of anxiety disorders in their patient population. Anxiety disorders present during pregnancy can have detrimental effects on both mother and child. In this study, we queried 1,193 ob-gyns on their screening rates, practice patterns, training, and knowledge as they relate to anxiety disorders during pregnancy. We achieved a 44% response rate (n=397) after three mailings. Physicians reported a moderate interest in screening for and diagnosing anxiety, but less interest in treatment. Only 20% of respondents (n=79) screen for anxiety during pregnancy, and they typically refer anxiety-disordered patients to mental health professionals. Ob-gyns with comprehensive or adequate training were significantly more likely to screen than those who stated that their training was inadequate. Having a friend who has been diagnosed with an anxiety disorder also significantly increased both the likelihood that these physicians would screen and the reported level of interest in screening of anxiety disorders during pregnancy. At present, the majority of ob-gyns feel that their training in this area was barely adequate to inadequate. Specifically, generalized anxiety disorder may be the least understood. Increased training in this area would allow ob-gyns to overcome what they list as the primary barrier to anxiety screening during pregnancy--that is, inadequate training about anxiety disorders.

Phase II multicenter open-label study of karenitecin in previously treated epithelial ovarian and primary peritoneal cancer: a Gynecologic Oncology Group Study

The topoisomerase I agents are established as a therapy in recurrent ovarian cancer. Karenitecin, an analog of topotecan with solubility and pharmacologic advantages, was tested in a phase II trial in previously treated patients with recurrent or persistent ovarian cancer. The drug was administered intravenously over 1 h at a dose of 1.0 mg/m(2) daily for 5 days every 21 days. Patients were treated until disease progression, intolerable toxicity, or voluntary withdrawal. Response was evaluated according to modified RECIST criteria. Twenty-seven patients were entered into the study. One patient was inevaluable for not receiving any treatment. Of the 26 evaluable patients, there were two partial responses and one complete response for a total response rate of 12%. This response rate was insufficient to justify accrual to the second stage. The most common grade 3 or 4 toxicities were neutropenia (19%) and gastrointestinal (15%). Karenitecin is a well-tolerated topoisomerase compound but has minimal activity in extensively pretreated ovarian cancer with the dose-schedule employed.

Prognostic significance of failure to cross esophageal tumors by endoluminal ultrasound

Failure to intubate and cross esophageal tumors by endosonography is reported in as many as 30% of cases and is thought to be associated with an especially poor prognosis. The aim of this study was to audit the above in a large consecutive case series of Endoscopic Ultrasound (EUS) examinations for esophageal cancer performed in a regional specialist cancer network with particular reference to outcome. A consecutive series of 411 patients underwent EUS examination by a specialist radiologist over a period of 9 years. Forty (10%) of patients required dilation, and there was total failure to cross the tumor in 12 patients (2.9%). Failure to traverse the primary tumor was associated with a diagnosis of squamous cell cancer (8 of 12 patients, 66%, rho = -0.182, P = 0.011). Limited staging information was obtained in 7 of these patients, which altered the computed tomography stage in 5 patients (71%, 3 upstaged, 2 downstaged). Six patients received definitive chemoradiotherapy, two patients surgery and four patients palliative chemotherapy. The median and 5-year survival in patients whose tumors were not crossed was 10 months and 28%, respectively, compared with 24 months and 24%, respectively in patients whose tumors were fully assessed. Failure to cross esophageal tumors in practice was far less common than the literature suggests, and esophageal tumor luminal stenosis should no longer be considered a limitation of endosonography.

Prospective cohort comparison of neoadjuvant chemoradiotherapy versus chemotherapy in patients with oesophageal cancer

Background

Chemotherapy and chemoradiotherapy are common neoadjuvant treatments for resectable T3 N0–1 M0 oesophageal carcinoma. The aim of this study was to compare the outcomes of these therapies in consecutive cohorts of patients.

Methods

Between January 1998 and December 2001, 88 patients received neoadjuvant chemoradiotherapy (two cycles of cisplatin and 5-fluorouracil (5-FU), prior to 45 Gy in 25 F concurrent radiotherapy with cisplatin and 5-FU). From 2002, 117 patients received neoadjuvant chemotherapy (76 patients had two cycles of cisplatin and 41 had four cycles of epirubicin, cisplatin and 5-FU). The primary outcome measure was survival, and analysis was by intention to treat.

Results

Postoperative morbidity and mortality rates were 56 per cent (40 patients) and 10 per cent (seven patients) respectively in the chemoradiotherapy group, compared with 47 per cent (46 patients) and 1 per cent (one patient) in the chemotherapy group (P = 0·008). The cumulative 5-year survival rate by intention to treat was 35 per cent after chemoradiotherapy versus 21 per cent after chemotherapy (P = 0·188). The cumulative corrected 5-year survival rate after completed treatment was 44 per cent for chemoradiotherapy compared with 25 per cent for chemotherapy (P = 0·032).

Conclusion

Neoadjuvant chemoradiotherapy should remain an option for patients with satisfactory performance status.

Prospective comparison of transthoracic versus transhiatal esophagectomy following neoadjuvant therapy for esophageal cancer

Transthoracic esophagectomy (TT) has been championed as a better cancer operation than transhiatal esophagectomy (TH) because the approach facilitates meticulous wide tumor excision and lymphadenectomy. However, neoadjuvant chemoradiotherapy (CRTS) and chemotherapy (CS) have been reported to improve outcomes, and we aimed to compare outcomes after multimodal therapy related to the operative approach. One hundred and fifty-one consecutive patients were studied prospectively. All patients were staged with computed tomography and endoluminal ultrasound, and treatment decisions were related to stage and performance status. One hundred and nineteen TT (median age 58 years, 92 male, 54 CRTS, 65 CS) were performed compared to 32 TH (median age 57 year, 27 male, 14 CRTS, 18 CS). Primary outcome measure was survival. Post-operative morbidity and mortality were 54% and 4%, respectively, after TT compared with 59% and 6% after TH (chi2 0.239 df 1, P=0.625). Recurrent cancer was no less frequent after TT (52%) than after TH (37.5%, chi2 2.151 df=1, P=0.142). Cumulative uncorrected 5-year survival was 34% after TT compared with 53% after TH (log rank 1.44, df=1, P=0.2298). Median survival was also similar in lymph node positive patients (TT vs. TH, 23 months vs. 22 months, respectively, log rank 0.25, df=1, P=0.6199). Despite the fact that patients receiving multimodal therapy and a TH esophagectomy were less fit, operative morbidity, mortality and recurrence were similar, and survival did not differ significantly when compared with multimodal TT esophagectomy.

Influence of targeted basic surgical training lists on SHO operative experience in the EWTD era

Presented at the Association of Surgeons of Great Britain and Ireland, Edinburgh, May 2006.

What obstetrician-gynecologists think of preconception care

Objectives: To describe obstetrician-gynecolog-ists’ opinions of preconception care (PCC) and ascertain patient uptake for this service. Methods: A questionnaire was mailed to 1105 ACOG members in August 2004. Results: There was a 60% response rate. Most physicians think PCC is important (87%) and almost always recommend it to women planning a pregnancy (94%); 54% do so with women who are sexually active. Around a third (34%) thought their patients usually do not plan their pregnancies and 49% said very few pregnant patients came in for PCC. Of those who obtain PCC, they were believed to do so more likely to assure a healthy pregnancy (83%) than because of an elevated risk for birth defects (20%). Of 11 issues presented, cigarette smoking and folic acid supplementation were rated the most important for PCC counseling; exercise and environmental concerns were the least important. Conclusions: Physicians are willing to provide PCC but few patients are accessing such services.

Targeting the RAS Signaling Pathway in Malignant Hematologic Diseases

Molecularly targeting signaling pathways that are involved in the pathogenesis of hematopoietic malignancies may lead to more specific and efficacious therapies. Activation of the RAS signal transduction cascade is a common feature in the molecular pathogenesis of hematologic malignancies. A number of novel agents targeting RAS signaling have been developed over the past decade. This review will focus on these agents, which include inhibitors of RAS post-translational modification (farnesyl transferase (FTase)-, geranylgeranyl transferase-I (GGTase-I)-, isoprenylcysteine carboxylmethyltransferase (ICMTase)-inhibitors, statins, bisphosphonates), and inhibitors of RAF and MEK activity. Although some of these inhibitors (e.g. FTase, RAF and MEK inhibitors) were developed to specifically inhibit RAS signaling, it has become clear that RAS may not be the only critical target of these compounds. This review provides a background on RAS signaling in hematologic malignancies and discusses opportunities to exploit aberrant cancer cell signaling in order to develop better treatment options for patients suffering from these diseases.

Prognostic significance of body mass indices for patients undergoing esophagectomy for cancer

The aim of this study was to determine the role of body mass index (BMI) in a Western population on outcomes after esophagectomy for cancer. Two hundred and fifteen consecutive patients undergoing esophagectomy for esophageal cancer of any cell type were studied prospectively. Patients with BMIs > 25 kg/m were classified as overweight and compared with control patients with BMIs below these reference values. Ninety-seven patients (45%) had low or normal BMIs, 86 patients (40%) were overweight, and a further 32 (15%) were obese. High BMIs were associated with a higher incidence of adenocarcinoma versus squamous cell carcinoma (83%vs. 14%, P = 0.041). Operative morbidity and mortality were 53% and 3% in overweight patients compared with 49% (P = 0.489) and 8% (P = 0.123) in control patients. Cumulative survival at 5 years was 27% for overweight patients compared with 38% for control patients (P = 0.6896). In a multivariate analysis, age (hazard ratio [HR] 1.492, 95% CI 1.143-1.948, P = 0.003), T-stage (HR 1.459, 95% CI 1.028-2.071, P = 0.034), N-stage (HR 1.815, 95% CI 1.039-3.172, P = 0.036) and the number of lymph node metastases (HR 1.008, 95% CI 1.023-1.158, P = 0.008), were significantly and independently associated with durations of survival. High BMIs were not associated with increased operative risk, and long-term outcomes were similar after R0 esophagectomy.

Targeting EGF-receptor-signalling in squamous cell carcinomas of the head and neck

Despite significant advances in the use of surgery, chemotherapy and radiotherapy to treat squamous cell carcinoma of the head and neck (SCCHN), prognosis has improved little over the past 30 years. There is a clear need for novel, more effective therapies to prevent relapse, control metastases and improve overall survival. Improved understanding of SCCHN disease biology has led to the introduction of molecularly targeted treatment strategies in these cancers. The epidermal growth factor receptor (EGFR) is expressed at much higher levels in SCCHN tumours than in normal epithelial tissue, and EGFR expression correlates with poor prognosis. Therefore, much effort is currently directed toward targeting aberrant EGFR activity (e.g. cell signalling) in SCCHN. This review discusses the efficacy of novel therapies targeting the EGFR (e.g. anti-EGFR antibodies and EGFR tyrosine kinase inhibitors) that are currently tested in SCCHN patients.

Interactions of doctors with the pharmaceutical industry

OBJECTIVE

To assess the opinions and practice patterns of obstetrician-gynaecologists on acceptance and use of free drug samples and other incentive items from pharmaceutical representatives.

METHODS

A questionnaire was mailed in March 2003 to 397 members of the American College of Obstetricians and Gynecologists who participate in the Collaborative Ambulatory Research Network.

RESULTS

The response rate was 55%. Most respondents thought it proper to accept drug samples (92%), an informational lunch (77%), an anatomical model (75%) or a well-paid consultantship (53%) from pharmaceutical representatives. A third (33%) of the respondents thought that their own decision to prescribe a drug would probably be influenced by accepting drug samples. Respondents were more likely to think the average doctor's prescribing would be influenced by acceptance of the items than theirs would be (p<0.002). Respondents who distributed drug samples to patients indicated doing so because of patients' financial need (94%) and for their convenience (76%) and less so as a result of knowledge of the efficacy of the sample product (63%). A third (34%) of respondents agreed that interactions with industry should be more strictly regulated.

CONCLUSION

Obstetrician-gynaecologists largely indicated that they would act in accordance with what they think is proper regarding accepting incentive items from pharmaceutical representatives. Although accepting free drug samples was considered to be appropriate more often than any other item, samples were most commonly judged to be influential on prescribing practices. The widely accepted practice of receiving and distributing free drug samples needs to be examined more carefully.

Obstetrician-gynecologists and self-identified depression: personal and clinical

A survey was designed to explore the effect of obstetrician-gynecologists' subjective awareness of depression in themselves and close family/friends on screening patients for depression and on assessing and treating depression in three scenarios describing hypothetical patients during the adolescence, postpartum, and perimenopausal periods. Questionnaires were mailed to 397 members of the American College of Obstetricians and Gynecologists (ACOG) who participate in the Collaborative Ambulatory Research Network (CARN). Fifty-five percent of the questionnaires were returned. One third of physicians reported having suffered from depression occasionally (28.1%), often (3.8%), or all the time (2.4%) during the past year. Having personally suffered from depression was associated with elevated assessment of depression in the scenarios but not with elevated rates of screening for depression in actual practice, nor with aggressiveness of treatment choices in the scenarios. Awareness that a close friend suffered from depression was not associated with lowered mood as measured, but was associated with increased rates of screening for depression in adolescent, postpartum, and perimenopausal patients, and with elevated assessment of depression and more aggressive treatment practices for depression in hypothetical patients at these three life stages. As such, physicians' practices regarding depression may be influenced by something other than reactivity to their own emotional state.

Screening for Down syndrome: practice patterns and knowledge of obstetricians and gynecologists

OBJECTIVE

To assess obstetricians' practice patterns and knowledge regarding screening for Down syndrome.

METHODS

A questionnaire was mailed to 1,105 American College of Obstetricians and Gynecologists Fellows and Junior Fellows in 2004.

RESULTS

Sixty percent of questionnaires were returned. Statistical analyses were limited to the 532 practicing obstetricians. Greater than 80% felt their training and experience qualified them to counsel patients about genetic issues in pregnancy. However, 45% rated their residency training regarding prenatal diagnosis as barely adequate or nonexistent. American College of Obstetricians and Gynecologists publications were rated by 86% as an important source of information on genetic counseling. Seventy-eight percent of practitioners counsel all obstetric patients about risks for fetal aneuploidy, and 67% provide counseling for heritable genetic abnormalities. Although the majority (99%) offer second-trimester Down syndrome screening, only 55% also offer first-trimester screening for Down syndrome. Almost one half (49%) use the quad screen, and 6% offer integrated first- and second-trimester screening. The majority (88%) routinely offer amniocentesis to patients who are at elevated risk for genetic abnormalities, whereas 44% also offer chorionic villus sampling. Few (2%) perform chorionic villus sampling.

CONCLUSION

Most obstetricians manage patients at risk for fetal genetic abnormalities according to American College of Obstetricians and Gynecologists educational materials. This survey identified deficiencies related to Down syndrome screening, including a limited number of practitioners performing chorionic villus sampling and physicians' own perception that training regarding genetic counseling should be improved. Educational strategies are needed to address these deficiencies before first-trimester screening programs are widely implemented.

LEVEL OF EVIDENCE

III.

Clinical Approach to Mental Health Issues Among Obstetrician???Gynecologists: A Review

In recent years, obstetrician-gynecologists have taken on a greater role in the provision of primary care. Mental health has been a topic worthy of further exploration as a result of the high prevalence rates of women presenting in gynecologic settings with depressive, anxiety, or eating-disordered symptoms. The detrimental effects of psychopathology have been well documented in the literature, especially if present during pregnancy. This article provides a review of the literature in the area of clinical practice related to mental health among obstetrician-gynecologists based on searches of the Psyc Info and MEDLINE databases. Lack of recognition and underdiagnosis are common problems that need to be addressed by focused educational initiatives.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader should be able to recall the importance of screening for various types of mental disease during an ob/gyn visit; describe the detrimental effects of psychopathology, especially during pregnancy; and explain the importance of educational initiatives in detecting and treating mental disorders.

A neuroendocrine mechanism for sustaining fear

Fear is an adaptive response to recognition of a potentially dangerous event. Glucocorticoids are essential for maintaining a wide variety of behavioral events by their regulation of numerous genes; one such gene encodes corticotrophin-releasing hormone (CRH). CRH is involved in diverse behavioral responses to changing environmental demands. In this review, we focus on one aspect of glucocorticoid regulation of CRH--namely, fear-related responses to diverse classes of adverse events, such as those represented by contextual and cue-specific stimuli. Three extra-hypothalamic forebrain sites appear crucial for fear-related behavioral responses: the amygdala and the bed nucleus of the stria terminalis for sustaining adaptive fear-related behaviors, and the medial prefrontal cortex for modulating fear-related behaviors. Central regulation of CRH by glucocorticoids is important for adaptive and sustained fear-related behaviors, and its aberration is associated with anxiety and depressive disorders.

Neonatal encephalopathy and cerebral palsy revisited: the current state of knowledge and the impact of american college of obstetricians and gynecologists task force report

OBJECTIVES

To re-assess obstetrician-gynecologists' knowledge of neonatal encephalopathy and cerebral palsy after publication of the ACOG/AAP Task Force report.

STUDY DESIGN

A questionnaire investigating knowledge of neonatal encephalopathy and cerebral palsy was mailed to 1060 members of ACOG, 337 of whom participated in a similar study in 2001.

RESULTS

There was a strong association between familiarity with ACOG documentation and knowledge of neonatal encephalopathy (NE) and cerebral palsy (CP) (p<0.001). As with obstetricians surveyed in 2001, knowledge gaps remain. Performance was better on practices questions than knowledge questions. About one-third (34.2%) of the physicians said their knowledge of neonatal encephalopathy was poor or deficient; the majority (76%) rated their residency training as inadequate to marginal.

CONCLUSION

The results indicate better knowledge of neonatal encephalopathy and cerebral palsy among physicians more familiar with the Task Force report. There is a clear need for emphasis on these topics during training and continuing medical education.

Impact of Self-Reported Familiarity With Guidelines for Cystic Fibrosis Carrier Screening

OBJECTIVE

To assess the impact of self-reported familiarity with published guidelines on knowledge, implementation, and opinions of obstetrician-gynecologists regarding carrier screening for cystic fibrosis.

METHODS

A questionnaire pertaining to cystic fibrosis screening guidelines was mailed to 1,165 members of the American College of Obstetricians and Gynecologists.

RESULTS

Sixty-four percent of questionnaires were returned. Statistical analyses were limited to the 632 respondents whose primary medical specialty was gynecology (GynOnly) or obstetrics and gynecology (ObGyns). More ObGyns had thoroughly read or skimmed the guidelines (67.1%) than had GynOnlys (41.6%). Correctly responding to basic questions regarding cystic fibrosis was associated with having read the guidelines, although responding to a more complex question was not. Familiarity with the guidelines was associated with correctly identifying the recommendations for offering screening, with practice implementation of cystic fibrosis screening, and with self-ratings of qualifications and training to offer screening and to provide counseling. In contrast, familiarity with the guidelines was not associated with ObGyn's opinion that burden of disease is likely to be influential in patient acceptance of screening. Physicians who had thoroughly read the guidelines were more likely to disagree that the cystic fibrosis screening test is too inaccurate to risk influencing reproductive decision making (thoroughly read = 79% disagree, skimmed = 69%, not read = 58%, not heard of it = 50%).

CONCLUSION

There was a strong association between self-reported familiarity with the American College of Obstetricians and Gynecologists/American College of Medical Genetics guidelines and physicians' knowledge, implementation, and ratings of training for offering cystic fibrosis carrier screening.

Practice patterns of obstetrician-gynecologists regarding preconception and prenatal screening for cystic fibrosis

OBJECTIVE

To assess practices of obstetrician-gynecologists regarding carrier screening for cystic fibrosis (CF).

METHODS

A questionnaire investigating practice patterns and opinions pertaining to CF screening was mailed to 1165 members of the American College of Obstetricians and Gynecologists (ACOG), of whom 565 participate in the Collaborative Ambulatory Research Network (CARN) and 600 were randomly selected.

RESULTS

Of the questionnaires, 64% were returned. Statistical analyses were limited to the 632 respondents whose primary medical specialty was gynecology (Gyn Only) or obstetrics and gynecology (ObGyn). CARN membership was not a significant factor on any nondemographic measure. Almost one-half of physicians do not ask nonpregnant patients their family history of CF or provide them with information about CF screening. The majority of ObGyns (88.7%) ask obstetric patients their family history of CF, and offer CF carrier screening. Almost two-thirds (65.8%) offer screening to all prenatal patients. Among those ObGyns who selectively offer CF screening to pregnant patients, only 27.4% utilized all of the selection criteria in the guidelines. Liability for not offering screening, familiarity with CF, and the ability to interpret a positive screening test were important physician concerns.

CONCLUSION

The results indicate a need for minimizing the complexity of clinical guidelines for population-based genetic screening, prospective assessment of implementation and focused continuing education for providers.

Multiple Pregnancy: Knowledge and Practice Patterns of Obstetricians and Gynecologists

OBJECTIVE

We sought to assess knowledge and practices of obstetricians regarding multiple gestation.

METHODS

A questionnaire investigating knowledge and practice patterns pertaining to multiple gestation was mailed to randomly selected American College of Obstetricians and Gynecologists (ACOG) Fellows and Junior Fellows in January 2003. Fifty-one percent (589/1,146) of the surveys were returned.

RESULTS

Statistical analysis included the responses from 430 practicing obstetricians. More than 60% rated their training regarding management of multiples as adequate. Men (56.5%) were older and had been in practice longer than females. Sixty-two percent of general obstetrician-gynecologists managed twins without input from a maternal-fetal medicine specialist. An understanding of chorionicity was less than anticipated. The majority of practitioners managed twins according to recent ACOG educational materials. They did not use prophylactic cerclage, home uterine-activity monitoring, or tocolytics. Fort-six percent encouraged prophylactic bed rest. The management of breech second twins varied.

CONCLUSION

Most obstetricians manage multiples according to current ACOG educational materials independent of maternal-fetal medicine specialists. This survey identified knowledge gaps, specifically in chorionicity, indicating the need to develop educational strategies addressing these insufficiencies.

The role of Bcl-X(S) in radiation sensitivity

Bcl-X(S) is a pro-apoptosis member of the Bcl2 family that has been shown to induce cell death and enhance chemosensitivity. We have investigated the effect of Bcl-X(S) overexpression on radiation sensitivity. Using a tetracycline-repressible system, we found that removal of tetracycline for 16 h induced Bcl-X(S) and reduced the surviving fraction of NIH 3T3 cells to 25%. However, radiation sensitivity was not significantly affected by Bcl-X(S) expression; the mean inactivation doses for Bcl-X(S) repressed and Bcl-X(S) induced cells were 2.7 +/- 0.3 and 2.3 +/- 0.1 Gy, respectively. We conclude that Bcl-X(S) induces cell death without affecting radiation sensitivity. These results suggest that mitochondrial pathways to apoptosis may not have a significant role in survival after irradiation.

Estrogens and non-reproductive behaviors related to activity and fear

Estrogens affect a variety of behaviors in addition to sexual responses, some of them related to motor activity and emotional reactivity. This is true in experimental animals and in humans. The literatures on these subjects are confusing because not all of the experimental results point in the same direction. Here we propose the following theoretical suggestion, hoping to account for the variety of reports extant: following the generally arousing effects of estrogens, their hormonal actions on motor activity and fear depend on context. In a safe environment, estrogen treatment causes increased activity. But in a novel environment or in contexts otherwise perceived as threatening, activity is reduced by estrogen, due to the hormone's arousing action, which heightens fear. Many hormone-dependent neural circuits involving several neuropeptides could provide mechanisms for this dynamic. We suggest a causal route could involve the activation of corticotropin releasing hormone gene expression in the brain. In sum, estrogenic effects on arousal states, as manifest differently according to details of the environmental context during behavioral test, could account for some of the discrepancies in the literature.

Ventral medial prefrontal cortex and emotional perseveration: the memory for prior extinction training

Several years ago, we found that lesions of ventral medial prefrontal cortex (mPFCv) disrupted performance during the extinction component of a classical fear conditioning task without affecting acquisition performance. We called this emotional perseveration, hypothesizing that mPFCv may normally act to inhibit fear responses to a conditioned stimulus (CS) when the CS no longer signals danger. Subsequent studies have supported this hypothesis, showing that mPFCv is crucial for the memory of prior extinction training. The present study examined the effects of mPFCv lesions made after training. Such lesions resulted in reduced freezing to contextual stimuli and normal responding to the CS presented alone during a retention test. Rats were then subjected to extinction trials (CS without US) over multiple days. In contrast to pre-training lesions, post-training lesions had little effect on extinction rate. All rats were given additional training. Lesioned rats expressed greater fear reactions than controls, indicating that prior extinction was less effective in them. Lesioned rats also showed resistance to extinction during reextinction trials, confirming our earlier finding that lesions made before training weaken the effectiveness of extinction trials. These results suggest three conclusions. First, an intact mPFCv during acquisition may protect the animal from prolonged responding during extinction trials following brain insult. Second, changes in mPFCv may predispose subjects toward enhanced fear reactions that are difficult to extinguish when reexposed to fearful stimuli, due to a diminished capacity to benefit from the fear-reducing impact of prior extinction experience. Third, contextual cues processed by mPFCv may influence extinction performance.

Duty hours and pregnancy outcome among residents in obstetrics and gynecology

OBJECTIVE

To assess the present status of resident duty hours in obstetrics and gynecology, identify existing policies concerning work schedules during pregnancy, and evaluate pregnancy outcome in female house officers.

METHODS

A questionnaire-based study was administered to residents taking the 2001 Council on Residency Education in Obstetrics and Gynecology examination.

RESULTS

More than 90% of the residents reported that their institution had a maternity leave policy. The leave was usually 4-8 weeks long and was paid. Nearly 95% of residents reported that they had to take over the work of residents on maternity leave. Most women residents worked more than 80 hours weekly throughout pregnancy, and few took time off before delivery. Most pregnancies occurred during the fourth year of training and did not seem to be adversely affected by the long work hours.

CONCLUSION

This study, performed before the institution of the new Accreditation Council for Graduate Medical Education resident duty hour policies, demonstrated that, although women house officers continued to work more than 80 hours per week during pregnancy, most had a good pregnancy outcome. Nevertheless, there was a higher frequency of preterm labor, preeclampsia, and fetal growth restriction in female residents than in spouses or partners of male residents.

Therapeutic efficacy of prenylation inhibitors in the treatment of myeloid leukemia

Farnesyltransferase inhibitors (FTIs) represent a new class of anticancer agents that specifically target post-translational farnesylation of various proteins that mediate several cellular processes such as signal transduction, growth, differentiation, angiogenesis and apoptosis. These compounds were originally designed to block oncogenic RAS-induced tumor growth by impeding RAS localization to the membrane, but it is now evident that FTIs also affect processing of several other proteins. The need for novel therapies in myeloid leukemia is underscored by the high rate of treatment failure due to high incidences of relapse- and treatment-related toxicities. As RAS deregulation is important in the pathogenesis of myeloid leukemias, targeting of RAS signaling may provide a new therapeutic strategy. Several FTIs (eg BMS-214662, L-778,123, R-115777 and SCH66336) have entered phase I and phase II clinical trials in myeloid leukemias. This review discusses recent clinical results, potential combination therapies, mechanisms of resistance and the clinical challenges of toxicities associated with prenylation inhibitors.