Abstract P5-08-07: Appropriate use of the 21-gene recurrence score (RS) assay across Michigan

Background: The 21-gene RS assay is used to assess prognosis and to predict response to adjuvant chemotherapy in patients with early stage hormone receptor positive, Her2 negative invasive breast cancer. The National Comprehensive Cancer Network (NCCN) first recommended consideration of testing of appropriate patients with the RS assay in 2008. We examined trends in the use of testing with the RS assay in hospitals across Michigan from 2006 through 2013 using data from the Michigan Breast Oncology Quality Initiative (MiBOQI), a Blue Cross Blue Shield of Michigan/Blue Care Network-sponsored quality initiative.

Methods: Demographic, pathologic, and treatment data for women with breast cancer treated at all 25 hospitals participating in MiBOQI were abstracted from the medical record. Patients were excluded if they had stage 0 or IV disease at diagnosis, received neoadjuvant therapy, had bilateral breast cancer, or had a prior history of breast cancer. The primary outcome was the percentage of patients eligible for testing according to NCCN criteria (version 2010) who underwent testing with the RS assay. Analyses were performed using the statistical software R, Version 3.0.1.

Results: Of the 18,046 patients in the MiBOQI Registry from 2006-2013 who met inclusion and exclusion criteria, 7133 (39.5%) met the NCCN criteria for testing (eligible). The rate of testing increased from 2006 to 2013 in both the eligible and ineligible cohorts, and varied by site.

21-Gene Recurrence Score (RS) Testing in MiBOQI, 2006-2013FactorEligible (n=7133)Ineligible (n=10913)Tested with RS assay3920 (55.5%)1424 (13.0%)Testing rate in 200643.8%7.3%Testing rate in 201362.3%19.6%Testing by site, 2006-2013 (range)35.8% - 73.3%6.8% - 26.2%

Testing of the eligible cohort was statistically significantly associated with younger age, lower tumor grade, and lack of nodal involvement. Overall, 73.4% of patients whose tumors were tested with the RS assay met the NCCN criteria for testing and were deemed appropriately tested. This rate of appropriate testing ranged from 60.8% to 85.4% across sites. Of all patients who underwent testing, 498 (9.3%) had 1 or more positive lymph nodes (>0.2 cm). Receipt of chemotherapy was lower in eligible patients who were tested compared to those not tested (25.5% vs 29.9%, p<0.001). Of the 2387 eligible patients with RS < 18, 117 (5.5%) received chemotherapy, which ranged from 0% - 13.6% across the 25 sites. Of the 341 patients with RS > 30, 56 (9.8%) did not receive treatment with chemotherapy, which ranged from 0% - 50% across the sites. Of the 1192 patients with RS 18-30, 502 (45.7%) received chemotherapy, ranging from 14.5% for RS 18 to 72.5% for RS 30.

Conclusions: In sites across Michigan the majority of patients whose tumors were tested with the RS assay were in accordance with the NCCN guidelines, although there was considerable variability across sites. The rate of testing for patients who do not meet the NCCN criteria is increasing. There is very low inappropriate use of the recurrence score for making chemotherapy treatment decisions.

Citation Format: Ali HY, Munir K, Braun T, Griggs JJ, Silver SM, Gorski DH, Breslin TM, Henry NL. Appropriate use of the 21-gene recurrence score (RS) assay across Michigan. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P5-08-07.

Clinical presentation of breast cancer: Age, stage, and treatment modalities in a contemporary cohort of Michigan women

1

Background: The U.S. Preventative Services Task Force (USPSTF) revised their breast cancer screening recommendations in 2009 changing their stance on age and frequency of mammography screening to biannual exams starting at age 50. The purpose of this study is to analyze data from a statewide breast cancer registry managed by the Michigan Breast Oncology Quality Initiative (MiBOQI) to determine the impact of these new recommendations on diagnosing and treating breast cancer.

Methods: De-identified data were collected on women participating in the MiBOQI registry at seventeen statewide institutions from 2006-2009. Data included method of detection, cancer stage, age at detection, treatment type, and patient demographics. Participants were stratified based on age, and data analyzed using NCSS software (chi-square and t-tests).

Results:5903 women with breast cancer with an average age at diagnosis of 59.4 years were included. 65.5% of breast cancers were detected via mammography, 29.8% by palpation, and 4.7% by other methods. In women under 50 years of age, cancers were detected by mammography in 48.3% (69.3% >50yr) and by palpation in 46.1% (24.1% >50yr). Patients with palpable presentations were younger (55.8 yr vs. 61.2 yr; p <0.001). Cancers with a palpable presentation were diagnosed at higher stages (50.0% stage II) than with mammography (52.5% stage I; p<0.001). Breast conservation surgery occurred more frequently than mastectomy (palpation 54.2%; mammography 72.9%, p<0.001) but cancers detected through palpation were more likely to undergo mastectomy procedures.

Conclusions: Results of this study validate the importance of annual screening mammography in women older than 50 years, and women aged 40 to 49 years recently omitted from screening guidelines. There was an increased prevalence of palpation for the method of detection in women less than 50 years of age. If screening mammography is omitted in this group, cancers when detected may be of a more advanced stage and result in more mastectomies. This study also supports the use of palpation as a method of detection despite recent recommendations against teaching self breast exams by USPSTF.

Erythropoiesis-stimulating agents for cancer patients: Increasingly restrictive guidelines and policies in the United States and Europe

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Background: Erythropoiesis stimulating agents (ESAs) have transformed the treatment of cancer-associated anemia worldwide. However, recent reports of venous thromboembolism (VTE), tumor progression, and mortality risks associated with ESA administration to cancer patients have resulted in reassessments of the safety and appropriate usage of these agents. The present study investigated the disparate factors that contributed to the transformation of ESA policies. Methods: We reviewed meta-analyses, advisory committee recommendations, manufacturer label revisions, clinical guidelines, reimbursement policies from the Centers for Medicare and Medicaid Services (CMS), updated clinical guidelines, and ESA usage trends. Results: See Table . Conclusions: The risks and benefits of ESAs for cancer patients have been reassessed, resulting in increasingly restrictive guidelines and labels in the U.S. and Europe. In response to the 2008 ESA labeling change mandated by the U.S. Food and Drug Administration (FDA), the European advisory committee, Committee for Medicinal Products for Human Use (CHMP), convened to reassess the risk-benefit profile of ESAs and determined that for patients with reasonably long life expectancies, the benefits of ESAs do not outweigh the risks. Additionally, the U.S. National Comprehensive Cancer Network (NCCN) revised clinical guidelines in accordance with the FDA labeling change. Therefore, FDA actions combined with the CMS reimbursement policy have provided the impetus for increasingly restrictive use of ESAs.

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Clinical trials: are they a good buy?

PURPOSE

Concern that clinical trials may be too costly has been used to justify traditionally restrictive insurer policies regarding clinical trials. Additionally, fear of insurer reimbursement denial can be a significant barrier to clinical trial participation. In this study, we reviewed the empirical data on costs of clinical trials versus standard care and summarized the current status of policy initiatives related to clinical trial insurance reimbursement.

METHODS

Electronic and print data sources were searched for studies on the costs of oncology clinical trials. Information on policy initiatives for clinical trial reimbursement was obtained from the American Society of Clinical Oncology, the American Society of Hematology, and the Coalition of National Cancer Cooperative Groups and from searches of World Wide Web sites.

RESULTS

Five pilot studies provided information for 377 patients on phase II/III clinical trials matched with controls on standard care. Cost estimates ranged from 10% lower to 23% higher costs/charges for clinical trials in comparison to standard medical care. Medicare, 14 states, and several private insurers now cover the costs of patient care in "qualifying" clinical trials.

CONCLUSION

Findings from small pilot studies suggest that phase II and III clinical trials result in at most modest increases in cost over standard treatment costs. Also, an increasing number of policy makers have decided to support clinical trial reimbursement initiatives. It is hoped that economic data from large observational studies will facilitate widespread and permanent decisions that support reimbursement for phase I, II, and III clinical trial participation.

Double dose-intensive chemotherapy with autologous stem cell support for relapsed and refractory testicular cancer: the University of Michigan experience and literature review

Testicular cancer patients refractory or in relapse after primary chemotherapy have < or =25% 5-year progression-free survival with salvage. To improve prognosis, patients entered a phase I/II tandem dose-escalation trial of carboplatin (1500-2100 mg/m(2)) and etoposide (1200-2250 mg/m(2)) with ABMT. Patients were eligible for a second cycle if disease progression was absent and performance status allowed. From August 1990 to June 1998, 29 males (25 NSGCT) were treated. At the time of ABMT, 10 were chemosensitive, four were chemoresistant, and 10 were absolutely refractory to platinum. Disease status (no. patients) at transplant: primary refractory disease (six), first relapse (10), second relapse (eight), third relapse (five). Fifteen (52%) received both transplants. Treatment-related mortality was 10%. Best response after ABMT included: two CR, one CR surgically NED, five PR, three PR surgically NED, seven SD, and eight PD. Eight (28%) patients are continuously progression-free a median 60 months (range, 31-93) from first ABMT. Three seminoma patients remain progression-free. Of five long-term NSGCT survivors, four were treated in first relapse with platinum-sensitive disease. Eighteen relapses occurred a median of 4 months after ABMT I (two late relapses at 28 and 44 months). The median PFS and OS for the whole group are 4 and 14 months, respectively. Patients with relapsed/ refractory testicular cancer benefit most from ABMT if they have platinum-sensitive disease in first relapse. Patients who do poorly despite ABMT have a mediastinal primary site, true cisplatin-refractory disease, disease progression prior to ABMT, and/or markedly elevated betaHCG at ABMT. New treatment modalities are needed for the latter group.

NCCN Practice Guidelines for Breast Cancer

The therapeutic options for patients with noninvasive or invasive breast cancer are complex and varied. In many situations, the patient and physician have the responsibility to jointly explore and ultimately select the most appropriate option from among the available alternatives. With rare exception, the evaluation, treatment, and follow-up recommendations contained within these guidelines were based largely on the results of past and present clinical trials. However, there is not a single clinical situation in which the treatment of breast cancer has been optimized with respect to either maximizing cure or minimizing toxicity and disfigurement. Therefore, patient and physician participation in prospective clinical trials allows patients not only to receive state-of-the-art cancer treatment but also to contribute to the improvement of treatment of future patients.

Anti-CD20 chimeric monoclonal antibody treatment of refractory immune-mediated thrombocytopenia in a patient with chronic graft-versus-host disease

BACKGROUND

Autoimmune thrombocytopenia in chronic graft-versus-host disease may represent an instance of B-cell dysregulation leading to clinical disease.

OBJECTIVE

To attempt to treat refractory immune-mediated thrombocytopenia in a patient with chronic graft-versus-host disease by using anti-CD20 chimeric monoclonal antibody.

DESIGN

Case report.

SETTING

Academic medical center.

PATIENT

A patient with chronic graft-versus-host disease after allogeneic peripheral blood stem-cell transplantation who had severe refractory immune-mediated thrombocytopenia.

INTERVENTION

Weekly infusion of rituximab, 375 mg/m2, for 4 weeks.

MEASUREMENTS

Platelet count, CD3+ cell count, and CD19+ cell count.

RESULTS

Rituximab therapy resulted in marked depletion of B cells in the peripheral blood and decreased levels of platelet-associated antibody. The increase in platelet count persisted despite tapering and discontinuation of immunosuppressive therapy for chronic graft-versus-host disease.

CONCLUSION

The efficacy of rituximab for the treatment of immune-mediated thrombocytopenia suggests that this drug may have activity in other autoimmune diseases or chronic graft-versus-host disease.

Patterns of swallowing after supraglottic laryngectomy

OBJECTIVE

To understand the anatomical and physiological basis for early recovery of swallowing function after supraglottic laryngectomy.

STUDY DESIGN

Retrospective review.

METHODS

The records of nine patients who had undergone supraglottic laryngectomy at the Stratton Veteran's Administration Hospital (Albany, NY) between 1994 and 1998 were reviewed. Videofluoroscopic swallowing studies were obtained on all patients as early as was safely possible and were reviewed by a multidisciplinary team of physicians, nurses, and speech pathologists with regard to anatomical and functional differences between successful and unsuccessful recovery of swallowing function.

RESULTS

Five of nine patients resumed regular diets including thin liquids within 1 year of surgery; three patients remained dependent on enteral support. Swallowing success was most closely associated with short oropharyngeal transit time and an anterosuperior position of the larynx. Laryngeal positioning, tongue base mobility, and placement and coordination of the bolus for maximum swallowing efficiency can be improved with time and speech therapy.

CONCLUSIONS

Factors that placed patients at significantly higher risk for aspiration included low laryngeal position and delayed oropharyngeal transit time. Tight lingual-laryngeal closure did not completely prevent aspiration. At the time of the initial surgical procedure it may be important to position the laryngeal remnant as far superior and anterior under the tongue base as possible.

Brain adaptation to acute hyponatremia in young rats

Brain swelling after acute hyponatremia in prepubescent rats, in contrast to adults, has recently been associated with an increase in brain sodium and a high mortality that could be prevented by preadministration of testosterone. To reexamine the effect of acute hyponatremia in young brain, we measured brain water and solute content in prepubescent rats after induction of hyponatremia over 4 h with water and arginine vasopressin. An 18% decrease in plasma sodium was associated with a 13% increase in brain water and a decrease in brain sodium and glutamate contents. No animals died. To assess the effect of sex hormones on brain adaptation, prepubescent rats were pretreated with estrogen or testosterone before acute hyponatremia. Brain sodium and potassium contents were significantly reduced in comparison to normonatremia in testosterone-pretreated but not estrogen-pretreated animals. However, there was no difference between estrogen-pretreated and testosterone-pretreated groups in mortality or in brain contents of water, electrolytes, or major organic osmolytes. In conclusion, we found that brain adaptation to acute hyponatremia in prepubescent rats is similar to that observed in adults.

Rapid eye movement sleep changes during the adaptation night in combat veterans with posttraumatic stress disorder

BACKGROUND

Hyperarousal in posttraumatic stress disorder (PTSD) is manifested during sleep as well as waking. Elevated rapid eye movement sleep (REMS) phasic activity, likely signifying central nervous system alerting, has been identified in PTSD. The authors reasoned that PTSD compared to control subjects would show particularly increased REMS phasic activity on the first night of polysomnography, with adaptation to a novel environment.

METHODS

First-night polysomnograms of 17 veterans with PTSD were compared with those of 11 control subjects. Sleep was also studied in subsets of both groups over two nights.

RESULTS

On the first night, the PTSD subjects had a higher density of rapid eye movements in the first REMS period. This measure was increased on the first compared to the second night, but there was no interaction effect between night and group.

CONCLUSIONS

REMS changes are again demonstrated in veterans with PTSD. Introduction to a novel environment activated a REMS phasic process, but not differentially in PTSD compared to control subjects.

A single session, group study of exposure and Eye Movement Desensitization and Reprocessing in treating Posttraumatic Stress Disorder among Vietnam War veterans: preliminary data

This report summarizes data gathered thus far from an ongoing study. Two groups (total N = 12) of Vietnam War veterans diagnosed with Posttraumatic Stress Disorder (PTSD) received a single session of exposure or Eye Movement Desensitization and Reprocessing (EMDR) focusing on the veterans' most distressing war experience. Group assignment was random, treatment providers were blind to assessment data, and the pre- and posttreatment assessor was blind to treatment assignment. Both groups showed improvement on the Impact of Event Scale. EMDR treatment resulted in greater positive changes in within-session Subjective Units of Discomfort levels and on self-monitored severity of intrusive recollection. A trend toward decreased heart rate reactivity was observed in both groups. Results must be considered carefully due to the small number of subjects used in the study.

Roundtable discussion: Incorporating bone marrow transplantation into NCCN guidelines

A newly formed National Comprehensive Cancer Network (NCCN) panel on bone marrow transplantation has the task of ensuring the incorporation of allogeneic and autologous transplantation into all disease guidelines where significant evidence exists to warrant their inclusion. The panel is further charged with ensuring that there is consistency among guidelines regarding the use of marrow transplantation. A preliminary review of existing NCCN guidelines found that marrow transplantation was appropriately included for the treatment of the common hematologic malignancies of adults, including acute myeloid leukemia, chronic myeloid leukemia, myelodysplasia, multiple myeloma, Hodgkin's disease, and the malignant lymphomas. Frequent refinements regarding lymphomas will be necessary, particularly in rapidly evolving areas, such as multiple myeloma and myelodysplasia, and conditions with changing definitions, such as malignant disease. The increasing volume of data supporting the use of autologous bone marrow transplantation in advanced primary and responding metastatic breast cancers needs to be reflected in the breast cancer guideline if it is to remain credible. Well-designed and well-conducted clinical trials are the most appropriate setting for all bone marrow transplantations and patient referral to these trials remains the standard of care in all settings.

Transplantation in patients with multiple myeloma: a multicenter comparative analysis of peripheral blood stem cell and allogeneic transplant

We performed a multicenter comparative analysis of autologous peripheral blood stem cell transplantation (PBSCT) and allogeneic bone marrow transplantation (alloBMT) in multiple myeloma. Forty-eight consecutive patients received either PBSCT (24 patients) or alloBMT (24 patients) at one of three institutions in the study group. Preparatory regimens consisted of melphalan and total body irradiation (TBI) or melphalan alone in the PBSCT group. The alloBMT group received one of four regimens: cyclophosphamide and TBI; cyclophosphamide, VP-16 and 1,3-bis(2-chloroethyl)-1-nitrosourea (CVB); busulfan and cyclophosphamide (BU/CY) and total marrow irradiation (TMI); or melphalan and TBI. Procedure-related mortality was 12.5% for the PBSCT group and 25% for the alloBMT group. With a median follow-up for survivors in the PBSCT and alloBMT groups of 11 months (range, 4-46) and 15 months (range, 2-84 months), respectively, there was no significant difference in median overall survival (33.5 versus 38.6 months, p = 0.7637) or event-free survival (16.7 versus 31 months, p = 0.8450). There was, however, a plateau in survival at 40% in the alloBMT group. No plateau in survival was seen in the PBSCT group. Clinical relapses occurred as late as 39 months posttransplant. Patients have survived up to 28 months postrelapse.

Tacrolimus and methotrexate for the prophylaxis of acute graft-versus-host disease in allogeneic bone marrow transplantation in patients with hematologic malignancies

We conducted a study to evaluate the efficacy of the combination of tacrolimus and short-course methotrexate for the prevention of acute GVHD in patients with hematologic malignancies. Patients received preparative regimens specific for their disease category. Twenty-six out of 28 received HLA-identical sibling transplants and the two remaining patients received one-antigen mismatched transplants from a family member. With a median follow-up of 14 months, the Kaplan-Meier estimate of event-free survival was 50 +/- 9%. The probability of grade II-IV GVHD was 15 +/- 7%. Four patients developed GVHD: two had grade II and one each developed grade III and IV GVHD. Administration of methotrexate was associated with severe mucositis and there was no correlation between the distribution of the GVHD grade and the cumulative dose of methotrexate given. Thirteen patients have died; nine from transplant-related complications and four from relapse. The major toxicity of tacrolimus was renal. Nine out of 28 patients (32%) developed renal dysfunction attributed to tacrolimus. The combination of tacrolimus and methotrexate is an effective regimen for GVHD prophylaxis but associated with significant renal and mucosal toxicity. Further studies of tacrolimus as a single agent or in combination with either steroids or with a lower dose of methotrexate or with other antiproliferative drugs to modify the adverse events may improve the therapeutic index of this useful and promising agent.

Pathogenesis of cerebral edema after treatment of diabetic ketoacidosis

We studied the roles of acidosis, plasma osmolality, and organic osmolytes in the pathogenesis of cerebral edema in an animal model of diabetes mellitus. Normonatremic rats with streptozotocin-induced non-ketotic (NKD) and ketotic (DKA) diabetes were sacrificed before or after treatment with hypotonic saline and insulin. Brains were analyzed for water, electrolyte, and organic osmolyte content. Brain water decreased by 2% in untreated DKA and NKD despite a 12% increase in plasma osmolality due to hyperglycemia. After treatment of both NKD and DKA, brain water increased equivalently by 8%. The cerebral edema that occurred after treatment was associated with decreased brain sodium content and no change in total major brain organic osmolytes in both NKD and DKA. However, brain content of the individual osmolytes glutamine and taurine increased after treatment of DKA. In a separate study, brain water and solute content of rats with DKA were compared after treatment with either hypotonic or isotonic fluid. Animals treated with isotonic fluid had significantly less cerebral edema and higher brain sodium content than those treated with hypotonic fluid. In our studies, brain swelling after treatment of DKA and NKD was primarily due to a rapid reduction of plasma glucose and osmolality, and was not caused by sodium movement into the brain. Acidosis did not appear to play a major role in the pathogenesis of cerebral edema after treatment of DKA.

Pedicled temporoparietal galeal myofascial flap for orbital and cheek lining following radical maxillectomy

Radical maxillectomy is indicated for stage III and IV antroethmoidal carcinoma. In those cases where the anterior bony wall of maxillary antrum or the anterior facial soft tissue is involved or a previous Caldwell-Luc antrostomy was performed, a generous amount of cheek soft tissue has to be resected with the surgical specimen in order to achieve tumour-free margins. In such cases survival of the cheek flap is in jeopardy. Following orbital exenteration the resultant defect requires covering to promote healing and to protect the underlying bone. Traditionally, a skin graft has been used to line the orbital defect and the cheek flap. The pedicled temporoparietal galeal myofascial flap offers well-vascularized, reliable, supple and plentiful tissue which can be used to line both the orbit and the cheek, thus covering both sites with one flap. Such a case is presented and the surgical anatomy and technique are described.

Eye movement desensitization and reprocessing: effectiveness and autonomic correlates

Eighteen subjects distressed by memories of a specific traumatic event were randomly assigned to a single session of one of three conditions: Eye Movement Desensitization and Reprocessing (EMDR), a Time Interval Condition (TIC), or Tapping Alternate Phalanges (TAP). All subjects treated in the EMDR group showed desensitization as monitored by SUDs, which correlated with the physiological data and cessation of pronounced symptomatology. Only one subject in a control group showed desensitization. Compared to TIC and TAP, autonomic measures showed distinct changes during EMDR: (1) respiration synchronized with the rhythm of the eye movements in a shallow, regular pattern; (2) heart rate slowed significantly overall; (3) systolic blood pressure increased during early sets, invariably declined during abreactions, and decreased overall; (4) finger tip skin temperature consistently increased; and (5) the galvanic skin response consistently decreased in a clear "relaxation response". This relaxing effect of the eye movements suggests that at least one of the mechanisms operating during EMDR is desensitization by reciprocal inhibition, by pairing emotional distress with an unlearned or "compelled" relaxation response.

Brain swelling after dialysis: old urea or new osmoles?

The pathogenesis of brain swelling and neurological deterioration after rapid hemodialysis (dialysis disequilibrium syndrome) is controversial. The "reverse urea hypothesis" suggests that hemodialysis removes urea more slowly from the brain than from the plasma, creating an osmotic gradient that results in cerebral edema. The "idiogenic osmole hypothesis" proposes that an osmotic gradient between brain and plasma develops during rapid dialysis because of newly formed brain osmoles. In this review, the experimental basis for the two hypotheses are critically examined. Based on what is known about the physiology of urea and water diffusion across the blood-brain barrier, and empiric observations of brain solute composition after experimental hemodialysis, we conclude that the "reverse urea hypothesis" remains a viable explanation for dialysis disequilibrium and that rapid reduction of a high urea level in and of itself predisposes to this condition.

Bone marrow transplants from HLA-identical siblings in advanced Hodgkin's disease

PURPOSE

To determine the outcome of HLA-identical sibling bone marrow transplants in advanced Hodgkin's disease.

PATIENTS AND METHODS

We reviewed the data on 100 consecutive patients with Hodgkin's disease who received HLA-identical sibling bone marrow transplants between April 1, 1982 and August 12, 1992, reported to the International Bone Marrow Transplant Registry (IBMTR). The median interval from diagnosis to transplant was 2.5 years (range, < 1 to 14). All had advanced disease. Eighty-nine of 100 patients were not in remission at the time of transplant. Fifty had pretransplant Karnofsky scores less than 90% and 27 had active infection in the week before transplant. Patients received a variety of conditioning regimens; 45 received total-body radiation.

RESULTS

The 100-day probability of acute graft-versus-host disease (GVHD) was 35% (95% confidence interval [CI], 26% to 46%); the 3-year probability of chronic GVHD was 45% (95% CI, 31% to 59%). The 3-year probability of relapse was 65% (95% CI, 50% to 78%). The 3-year probability of survival was 21% (95% CI, 14% to 30%). The 3-year disease-free survival rate was 15% (95% CI, 9% to 24%).

CONCLUSION

HLA-identical sibling bone marrow transplants have a limited role in advanced Hodgkin's disease.

Cerebral edema after rapid dialysis is not caused by an increase in brain organic osmolytes

Dialysis disequilibrium syndrome (DDS) is characterized by the neurologic deterioration and cerebral edema that occurs after hemodialysis. To investigate the pathogenesis of DDS, the effects of rapid hemodialysis on brain electrolytes, urea, and several organic osmolytes were studied in the rat. Forty-two h after bilateral ureteral ligation, 11 uremic rats were hemodialyzed for 90 min, yielding a decrease in plasma urea from 96 +/- 4 to 44 +/- 5 mM (p < 0.01). This group was compared with 10 uremic and 11 nonuremic animals that were not dialyzed. In dialyzed animals, compared with nondialyzed uremic controls, there was an increase in brain water (3.98 +/- 0.02 versus 3.77 +/- 0.02 L/kg dry wt; P < 0.01) and the brain to plasma (urea) ratio (1.32 versus 0.65). There was no significant difference in the brain content of sodium and potassium between groups. The retention of brain urea, despite the large decrease in plasma urea concentration, was able to account for the increase in brain water observed in rapidly dialyzed animals. Major organic osmolytes in the brain, including glutamine, glutamate, taurine and myoinositol, did not increase significantly after rapid dialysis. Cerebral edema in this model of DDS was primarily due to a large brain-to-plasma urea gradient, not to the formation of organic osmolytes.

Treatment of Vietnam War veterans with PTSD: a comparison of eye movement desensitization and reprocessing, biofeedback, and relaxation training

Analyses of scaled self-report data from Vietnam War veterans receiving inpatient treatment for Post-Traumatic Stress Disorder drawn during a program evaluation study suggested inpatient treatment as provided by the program resulted in significant improvement in the areas of Anxiety, Anger, Depression, Isolation, Intrusive Thoughts (of combat experiences), Flashbacks, Nightmares (of combat experiences), and Relationship Problems. Comparing the relative effects of the incremental addition of Eye Movement Desensitization and Reprocessing (EMDR), Relaxation Training, and Biofeedback found that EMDR was for most problems the most effective extra treatment, greatly increasing the positive impact of the treatment program.

Continuous ambulatory peritoneal dialysis complicated by Aureobasidium pullulans peritonitis

We describe a case of peritonitis caused by Aureobasidium pullulans in a patient on continuous ambulatory peritoneal dialysis (CAPD). This dematiaceous fungus rarely causes infection in humans and to date has not been reported as an etiology of CAPD-associated peritonitis. The patient was managed successfully with peritoneal catheter removal and a prolonged course of intravenous amphotericin B, allowing resumption of CAPD. In vitro susceptibility testing confirmed sensitivity of this organism to amphotericin B.

Glycine-induced hyponatremia in the rat: a model of post-prostatectomy syndrome

Post-prostatectomy syndrome (PPS) is characterized by hyponatremia after absorption of glycine irrigant. To study the pathogenesis of this syndrome, adult male rats with ligated ureters were infused over 15 minutes with 7.5 ml/100 g body weight of isosmotic glycine (N = 9) or mannitol (N = 9) and were compared to non-infused, ureter-ligated controls (N = 9). Immediately post-infusion, plasma sodium had decreased similarly in glycine- and mannitol-infused animals (111 +/- 2 vs. 106 +/- 1 mmol/liter), but plasma osmolality remained at control levels in both groups (285 +/- 1 vs. 288 +/- 1 mOsm/kg). Two hours post-infusion, hyponatremia was stable in the mannitol group (108 +/- 1 mmol/liter), but in the glycine group plasma sodium increased significantly (to 120 +/- 1 mmol/liter). Plasma osmolality two hours post-infusion was maintained in both the glycine (287 +/- 2) and mannitol (292 +/- 2) groups. Brain water in glycine-infused animals (3.90 +/- 0.01 liter/kg dry wt) was not significantly different from the mannitol-infused group (3.85 +/- 0.01) and only 1.8% higher than non-infused controls (3.83 +/- 0.02). Brain tissue glycine did not differ between the three groups. In contrast, muscle water two hours post-infusion in the glycine group was 6% higher than mannitol-infused and 13% higher than non-infused animals. Muscle glycine content in the glycine group (67 +/- 4 mM/kg dry tissue) was increased when compared to both mannitol-infused (25 +/- 1) and non-infused (20 +/- 1) groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Motor dysfunction during sleep in posttraumatic stress disorder

A subjective disturbance of sleep, including the occurrence of repetitive, stereotypical anxiety dreams, is characteristic of posttraumatic stress disorder (PTSD). The phenomenology of the PTSD anxiety dream has seemed most consistent with an underlying rapid eye movement (REM) sleep dysfunction. However, motor behavior reportedly can accompany PTSD dreams, and normal REM sleep typically involves a nearly total paralysis of the body musculature. As a means of understanding this discrepancy, anterior tibialis muscle activity during sleep was studied in a group of Vietnam combat veterans with current PTSD and in an age-matched normal control group. The PTSD subjects had a higher percentage of REM sleep epochs with at least one prolonged twitch burst; they also were more likely to have periodic limb movements in sleep, during nonrapid eye movement sleep. Both these forms of muscle activation also have been observed in REM behavior disorder (RBD), a parasomnia characterized by the actual enactment of dream sequences during REM sleep. The identification of RBD-like signs in PTSD adds to the evidence for a fundamental disturbance of REM sleep phasic mechanisms in PTSD.

Outcome of treatment for post-traumatic stress disorder in a primary care unit serving Vietnam veterans

Veterans diagnosed with PTSD (PTSD in-treatment, N = 39), newly admitted to a comprehensive 90-day inpatient treatment program, were tracked at 4-week intervals from admission to discharge. Two control groups were also tracked over 12-week periods--one of previously PTSD diagnosed and treated veterans (PTSD out-of-treatment, N = 26), and a second that combined non-PTSD Vietnam era veterans (N = 17) and non-veterans (N = 16) (non-PTSD nontreatment). As measured by the Penn Inventory for PTSD, 48% of those who completed treatment showed some or substantial gains, 39% showed no gain, and 13% reported some increase in symptoms at the time of discharge. Several patterns were observed on other assessment measures. One year follow-up for those who completed treatment showed a return to pretreatment levels on the PTSD symptom measures employed in this study. These results are discussed in relation to other treatment program outcome studies as a baseline for further research.

Rapid eye movement sleep disturbance in posttraumatic stress disorder

The subjective sleep disturbance in posttraumatic stress disorder (PTSD), including the repetitive, stereotypical anxiety dream, suggests dysfunctional rapid eye movement (REM) sleep mechanisms. The polysomnograms of a group of physically healthy combat veterans with current PTSD were compared with those of an age-appropriate normal control group. Tonic and phasic REM sleep measures in the PTSD subjects were elevated on the second night of recorded sleep. Increased phasic REM sleep activity persisted in the PTSD group on the subsequent night. During the study, an anxiety dream occurred in a PTSD subject in REM sleep. The results are consistent with the view that a dysregulation of the REM sleep control system, particularly phasic event generation, may be involved in the pathogenesis of PTSD. The finding of a specific disturbance of sleep unique to PTSD may have significant implications for the design of effective treatments for PTSD.

Neurologic sequelae after treatment of severe hyponatremia: a multicenter perspective

Severe, symptomatic hyponatremia is often treated urgently to increase the serum sodium to 120 to 130 mmol/L. Recently, this approach has been challenged by evidence linking "rapid correction" (> 12 mmol/L per day) to demyelinating brain lesions. However, the relative risks of persistent, severe hyponatremia and iatrogenic injury have not been well quantified. Data were sought on patients with serum sodium levels < or = 105 mmol/L from the membership of the American Society of Nephrology. Respondents were given a report form asking specific questions regarding the cause of hyponatremia, presenting symptoms, rate of correction, and neurologic sequelae. Data on 56 patients were analyzed. Fourteen developed posttherapeutic complications (10 permanent, 4 transient) after correction to a serum sodium > 120 mmol/L. Eleven of these 14 patients (including 3 with documented central pontine myelinolysis) had a biphasic course in which neurologic findings initially improved and then worsened on the second to sixth day. Posttherapeutic complications were not explained by age, sex, alcoholism, presenting symptoms, or hypoxic episodes. Increased chronicity of hyponatremia and a high rate of correction in the first 48 h of treatment were significantly associated with complications. No neurologic complications were observed among patients corrected by < 12 mmol/L per 24 h or by < 18 mmol/L per 48 h or in whom the average rate of correction to a serum sodium of 120 mmol/L was < or = 0.55 mmol/L per hour. It was concluded that patients with severe chronic hyponatremia are most likely to avoid neurologic complications when their electrolyte disturbance is corrected slowly.

Dialysis disequilibrium syndrome (DDS) in the rat: role of the "reverse urea effect"

DDS is characterized by neurologic deterioration and cerebral edema which occurs after hemodialysis. To investigate the pathogenesis of DDDS, we studied the effects of rapid hemodialysis on plasma and brain electrolytes, urea, and osmolality in the rat. Forty-two hours after bilateral nephrectomy, nine uremic rats were hemodialyzed for 90 minutes against dialysate without urea (model of DDS), yielding a decrease in plasma urea from 72 +/- 2 mM to 34 +/- 2 mM (P less than 0.01) and an 8% (29 mOsm/kg) decrease in plasma osmolality. This group was compared to three control groups: 11 uremic animals dialyzed against a bath with urea added so that no fall in plasma urea occurred, and 15 uremic and 12 nonuremic animals that were not dialyzed. In animals dialyzed without urea, compared to uremic non-dialyzed animals, there was a 6% increase in brain water (3.89 +/- 0.04 liter/kg dry wt vs. 3.67 +/- 0.03, P less than 0.01) and an increase in the brain to plasma (urea) ratio (1.30 +/- 0.06 vs. 0.79 +/- 0.05, P less than 0.01). Comparison of these parameters in animals dialyzed without urea versus other control groups yielded similar results. In animals dialyzed without urea, the 53% decrease in plasma urea was associated with only a 13% decrease in brain urea content. Brain content of sodium and potassium was not significantly different among groups. Retention of brain urea despite the large decrease in plasma urea was able to account for the increased brain water observed in animals dialyzed without urea.(ABSTRACT TRUNCATED AT 250 WORDS)

Pectoralis major myocutaneous flap: analysis of complications in a VA population

Forty-five cases of head and neck reconstruction with pectoralis major myocutaneous flaps (PMMF) between 1985 and 1990 were analyzed retrospectively for complications. Thirty-two cases were done at the VA Medical Center and 13 at Albany Medical Center, a private university hospital. Total complication rate was 58%. In the VA population, complication rate was 59% as compared to 54% at the Albany Medical Center, which appears statistically not significant. It has been suggested that VA populations tend to have poorer health and socioeconomic status and are more likely to have higher complication rates. This conjecture is not borne out by this study. Complications are described and compared.

Prognostic significance of Philadelphia chromosome-positive cells detected by the polymerase chain reaction after allogeneic bone marrow transplant for chronic myelogenous leukemia

Although rare cells expressing the bcr/abl fusion transcript can be detected by the polymerase chain reaction (PCR) in patient blood or marrow after allogeneic bone marrow transplant (BMT) for Philadelphia chromosome (Ph+)-positive chronic myelogenous leukemia (CML), the prognostic significance of this finding is unknown. This paper reports clinical, cytogenetic, and molecular data derived from 64 CML patients following allogeneic BMT. Nested primer PCR was performed on patient blood and bone marrow samples to detect the presence of residual bcr/abl (+) cells in CML patients considered to be in clinical remission at the time of study. Bcr/abl transcripts were detected in 37 of 64 patients for at least one timepoint post-BMT. Thirteen of these 37 bcr/abl (+) patients have subsequently relapsed, as defined by clinical and/or persistent cytogenetic findings, in contrast to 0 relapses among the 27 bcr/abl (-) patients (P = .0025). The median time from first (+) bcr/abl PCR signal to relapse was 150 days (range 90 to 832). Fifty-four patients were studied at two or more timepoints post-BMT: five of eight patients persistently bcr/abl (+) have relapsed; 5 of 23 patients with both bcr/abl (+) and (-) assays during follow-up have relapsed; and none of 23 patients persistently (-) have relapsed (cumulative actuarial relapse rates 77%, 20%, and 0%, respectively, P = .0017). These data indicate that among CML patients in apparent clinical remission after BMT, nested primer bcr/abl PCR can define subgroups with low, intermediate, and high risk of relapse. The pattern of bcr/abl PCR detection after transplant may aid in the development of trials designed to reduce the risk of relapse, or allow for early intervention in patients who fail to clear the malignant clone.

Acute lymphoblastic leukemia with eosinophilia

Acute lymphoblastic leukemia with eosinophilia is a rare but distinctive clinical entity. The eosinophilia in these patients can present before, concomitantly, or after the diagnosis of leukemia. Patients with this syndrome often suffer from the cardiovascular complications of severe eosinophilia, suffering excess morbidity and mortality as a result of their eosinophilia. Treatment of the eosinophilia in this syndrome consists of administration of induction chemotherapy, followed by prednisone and hydroxyurea if required for persistent eosinophilia. Eosinophilia often resolves with remission of leukemia, only to return at the time of relapse in a high percentage of cases. Patients with this syndrome characteristically have cytogenetic abnormalities involving the long arms of chromosomes 5 and 14. These cytogenetic abnormalities are not commonly seen in acute lymphoblastic leukemia and suggest that this syndrome may have a distinct pathophysiology and etiology. The affected region on chromosome 5 contains genes that control hematopoiesis, including eosinophilopoiesis. Further investigations into these cytogenetic abnormalities may provide insight into the etiology of the leukemia and eosinophilia characteristic of this syndrome.

Colonic pseudoobstruction associated with patient-controlled analgesia after total joint arthroplasty

Patient-controlled analgesia (PCA) is a concept that permits patients to administer a prescribed dose of narcotic to themselves when they experience pain. Six patients developed colonic pseudoobstruction after the use of morphine sulfate administered via a PCA infuser. Early recognition and prompt treatment make this a transient, reversible illness. Treatment includes discontinuing the use of the PCA morphine, eliminating oral intake, ensuring adequate hydration and electrolyte balance, placing a nasogastric tube, rolling the patient, and closely observing for signs and symptoms of worsening colonic distention and possible rupture.

Habituation of the startle reflex in posttraumatic stress disorder

The authors investigated habituation of the eye-blink component of the startle reflex to repeated affectively neutral tactile and auditory stimuli in nine subjects with posttraumatic stress disorder and nine controls. Each group showed rapid habituation in both tactile and auditory modalities.

Structure of the platelet membrane glycoprotein IIb. Homology to the alpha subunits of the vitronectin and fibronectin membrane receptors

The platelet membrane glycoprotein IIb X IIIa heterodimer complex (GPIIb X IIIa) is the platelet receptor for adhesive proteins, containing binding sites for fibrinogen, von Willebrand factor, and fibronectin on activated platelets. GPIIb X IIIa also appears to be a member of a family of membrane adhesive protein receptors that plays a major role in cell-cell and cell-matrix interactions. GPIb is the larger component of this platelet receptor and is composed of two disulfide-linked subunits. In this report we describe the analysis of cDNA clones for human GPIIb that were isolated from a lambda gt11 expression library prepared using RNA from HEL cells. A total of 3.3 kilobases of cDNA was sequence, revealing a continuous open reading frame encoding both GPIIb subunits. The cDNA encodes 1039 amino acids: 137 constituting the smaller subunit, 871 constituting the larger subunit, and 30 constituting an NH2-terminal signal peptide. No homology was found between the larger and smaller subunits. The smaller subunit contains a 26-residue hydrophobic sequence near its COOH terminus that represents a potential transmembrane domain. Four stretches of 12 amino acids present in the larger subunit are homologous to the calcium binding sites of calmodulin and troponin C. Northern blot analysis using HEL cell RNA indicated that the mature mRNA coding for GPIIb is 4.1 kilobases in size. A comparison of the GPIIb coding region with available cDNA sequences of the alpha-chains of the vitronectin and fibronectin receptors revealed 41% DNA homology and 74% and 63% amino acid homology, respectively. Our data establish the amino acid sequence for the human platelet glycoprotein IIb and provide additional evidence for the existence of a family of cellular adhesion protein receptors.

The in vitro synthesis of polypeptides for the platelet membrane glycoproteins IIb and IIIa

The platelet membrane glycoproteins IIb (GpIIb) and GpIIIa form calcium-dependent heterodimers containing binding sites for fibrinogen, von Willebrand factor, and fibronectin. Although GpIIb and GpIIIa are distinct proteins, both GpIIb and GpIIIa are deficient in platelets from individuals with the recessive disorder Glanzmann's thrombasthenia. To gain a better understanding of the genetic basis for GpIIb and GpIIIa synthesis, we studied their synthesis by two human leukemia cell lines, HEL and K562. HEL cells contained complexes of GpIIb and GpIIIa, and K562 cells expressed GpIIIa, but not GpIIb, when stimulated with phorbol-12-myristate-13-acetate (PMA). RNA from HEL cells directed the in vitro synthesis of a 110,000-Mr precursor for GpIIb and a 92,000-Mr precursor for GpIIIa, which indicates that the synthesis of GpIIb and GpIIIa by HEL cells is directed by separate mRNAs. In contrast, RNA from PMA-stimulated K562 cells only directed the synthesis of a 92,000-Mr precursor for GpIIIa. The dissociation of GpIIb and GpIIIa synthesis in K562 cells suggests that GpIIb and GpIIIa may be the products of separate genes.

Factor-analytic support for DSM-III's post-traumatic stress disorder for Vietnam veterans

Found substantial support for DSM-III's criteria for Post-Traumatic Stress using 405 Vietnam combat veterans. The results also suggested that some additional symptoms such as depression and anger be included as major signs, especially when one is dealing with Vietnam veterans. A comparison of symptom intensity was made between Vietnam veterans and non-Vietnam veterans. The results of the second study showed that Vietnam veterans attested to experiencing significantly greater intensities of DSM-III criteria behaviors than did non-Vietnam veterans. However, no significant differences were found for symptoms related to depression.

Experience in Posology

We used an organized problem-solving method to resolve posology problems in integrated curriculum. A thorough assessment of the extent of problems revealed the need for a mathematical foundation (perhaps due to decreased mathematics SAT scores) to achieve a high level of accuracy with posology in preparation for professional nursing practice. Early curriculum intervention allowed for higher learning level achievement and sufficient time for demonstration of acquired skills. The implementation of a self-learning module in conjunction with small group intervention appeared to have an impact on students' level of knowledge as well as the application of knowledge. This was evidenced by an increased mean score from pre- to post-testing on a multiple-choice examination. Ongoing evaluations will measure students' ability to actualize these concepts in their clinical practice. Perhaps now is the time to identify posology within integrated curricula and examine it as a basis for pharmacology to better prepare all students for this vital nursing responsibility.

Loss on serial passage of rhesus monkey kidney cells of proteolytic activity required for Sendai virus activation

Primary and secondary cultures of rhesus monkey kidney cells supported multiple-cycle replication of Sendai virus, but later passages lost this ability, and this was reflected in decreased plaque formation. Multiple-cycle replication also did not occur in LLC-MK2 cells, a continuous line of RMK cells. Failure of replication in serially passed cells was correlated with a decrease in proteolytic cleavage of a viral surface glycoprotein (Fo), and the ability of cells to support multiple-cycle replication and plaque formation could be restored by the addition of trypsin (0.3 microgram/ml) to the overlay medium. The use of wild-type virus, which requires trypsin, and protease activation mutants that require chymotrypsin or elastase for activation has provided evidence that the activating protease supplied by primary or secondary cells has trypsin-like activity. Inactive virus, with uncleaved Fo glycoprotein, absorbed to primary or secondary cells but did not infect them, even though such cells possess the enzyme that is capable of cleaving the Fo glycoprotein of virus synthesized in these cells. The inability of these cells to activate adsorbed virus indicates that the activating protease that they possess is inacessible to adsorbed virus, although it can act on the Fo glycoprotein during virus maturation in these cells. These data provide a biochemical explanation for the failure of later passages of a cell strain or a continuous cell line to support the replication of a paramyxovirus.