Sexual Problems in MS: Sex Differences and Their Impact on Quality of Life

BACKGROUND

Low sexual function and satisfaction are common problems among people with multiple sclerosis (PwMS), but the literature on which patient variables are associated with these issues is inconsistent.

OBJECTIVE

To investigate the associations between sexual function and satisfaction in PwMS with clinical, demographic, and patient-reported quality of life (QOL) measures and determine if sex differences exist.

METHODS

This analysis includes PwMS enrolled in the Comprehensive Longitudinal Investigation of Multiple Sclerosis at the Brigham and Women's Hospital (CLIMB), who completed patient-reported outcome measures: Multiple Sclerosis Quality of Life-54 (MSQOL-54), Modified Fatigue Impact Scale (MFIS), and Center for Epidemiologic Studies Depression Scale (CES-D). Regression models were used to analyze associations between patient variables and function and satisfaction. Results were stratified by sex. Cross-sectional and longitudinal data were used.

RESULTS

702 PwMS (526 females,176 males, mean age 42.2 +/-11.1, median EDSS 1.5) were included in the cross-sectional analysis. Data from 341 PwMS were used in the three-year longitudinal analysis. Increasing age, disease duration, and disability were associated with reduced sexual function and satisfaction to the same degree in males and females. However, sex differences existed in the strength of associations with QOL variables. There was no significant longitudinal change in females or males.

CONCLUSIONS

Age and disease duration were associated with reduced sexual function and satisfaction in males and females. In females, function was significantly associated with disability and satisfaction with fatigue. Males had stronger associations with sexual function in domains related to emotional well-being, health perceptions, and overall QOL. Males had stronger associations with satisfaction in emotional and social functioning and physical health domains. These findings can help better understand the multidimensional problems of sexual function and satisfaction in PwMS and better guide patient care.

P3342Prevalence of patients with paroxysmal supraventricular tachycardia (PSVT) in the United States

Background/Introduction

PSVT is a sporadic, sudden and recurring tachycardia that can be difficult to diagnose. Estimates based on an initial healthcare encounter may underestimate PSVT prevalence because patients may have multiple encounters before definitive diagnosis.

Purpose

To estimate the prevalence of PSVT patients in the US using longitudinal data.

Methods

Retrospective study that used demographic, enrollment and claims data from Truven MarketScan® (age <65y) and Medicare Limited Dataset (age≥65y) databases from 2008–2016. All individuals continuously enrolled in their health plans for 5 years were included; PSVT patients were required to have claims with a PSVT diagnosis (ICD-9: 427.0; ICD-10: I47.1) on 2+ outpatient visits, 1+ inpatient admission or 1+ ED visit. The 9-year period prevalence was calculated as the number of PSVT patients /number of individuals observable for 5 continuous years, and the 9-year prevalence from the study population was projected to the U.S. population by sex and age (<18, 18–34, 35–44, 45–54, 55–64, ≥65) using 2010–2016 U.S. census data.

Results

Of 18,057,297 study patients, 86,630 met criteria for PSVT. Projected to the US population, prevalence estimates ranged from 1,749,358 in 2010 to 1,967,532 in 2016. Prevalence rates increased with age, from 0.871/1,000 (<18y) to 5.031/1,000 (45–54y) and 21.881/1,000 (≥65y). Prevalence rates were higher for females in all age groups, except the <18y cohort, but the difference in prevalence between female and male patients decreased with age. Relative rates of PSVT were more than twice as high for females age 18–44y, while prevalence rates were 1.3 to 1.6 times higher in females age 45y and above (Table).

Prevalence of PSVT in the US by Age and Gender, 2010–2016 Age Prevalence/1,000 [Female; Male] US Population (Year) Projected Prevalence (US) <18 0.871 [0.898; 0.845] 323,127,513 (2016) 1,967,532 18–34 2.268 [3.023; 1.440] 320,896,618 (2015) 1,930,746 35–44 3.313 [4,340; 2.147] 318,563,456 (2014) 1,892,923 45–54 5.031 [6.058; 3.845] 316,204,908 (2013) 1,855,256 55–64 7.761 [8.663; 6.727] 313,998,379 (2012) 1,818,690 65+ 21.881 [24.480; 18.329] 311,663,358 (2011) 1,777,397 Total 4.798 [5.823; 3.668] 309,348,193 (2010) 1,749,064

Conclusions

Based on insurance claims data, PSVT affected 1.7–2 million individuals in the U.S. annually between 2010 and 2016. Prevalence rates were higher in older individuals and females, with much higher rates for females ages 18–44y relative to males. Estimates that rely on a single medical encounter may underestimate PSVT prevalence.

Impact of long-term daylight deprivation on retinal light sensitivity, circadian rhythms and sleep during the Antarctic winter

Long-term daylight deprivation such as during the Antarctic winter has been shown to lead to delayed sleep timing and sleep fragmentation. We aimed at testing whether retinal sensitivity, sleep and circadian rest-activity will change during long-term daylight deprivation on two Antarctic bases (Concordia and Halley VI) in a total of 25 healthy crew members (mean age: 34 ± 11y; 7f). The pupil responses to different light stimuli were used to assess retinal sensitivity changes. Rest-activity cycles were continuously monitored by activity watches. Overall, our data showed increased pupil responses under scotopic (mainly rod-dependent), photopic (mainly L-/M-cone dependent) as well as bright-blue light (mainly melanopsin-dependent) conditions during the time without direct sunlight. Circadian rhythm analysis revealed a significant decay of intra-daily stability, indicating more fragmented rest-activity rhythms during the dark period. Sleep and wake times (as assessed from rest-activity recordings) were significantly delayed after the first month without sunlight (p < 0.05). Our results suggest that during long-term daylight deprivation, retinal sensitivity to blue light increases, whereas circadian rhythm stability decreases and sleep-wake timing is delayed.

Impact of removing point-of-sale tobacco displays: data from a New Zealand youth survey

INTRODUCTION

The tobacco industry increasingly invests in point-of-sale (POS) marketing. In July 2012, New Zealand required the removal of POS tobacco displays concurrently with increased enforcement and penalties for selling tobacco to minors, and additional restrictions on tobacco sponsorship. We evaluated the impact of these measures using a before-after study.

METHODS

We analysed data from annual surveys of more than 25 000 year 10 (14-15 years) students from 2007 and 2011 to 2014. Measures included prevalence of smoking-related behaviours and strength of association between visiting tobacco-retailing stores and smoking behaviours.

RESULTS

Between 2011 and 2014, smoking experimentation (had smoked ever but smoked less than monthly currently) decreased from 23% in 2011 to 17% in 2014 (adjusted odds ratio (aOR) 0.73, 95% CI 0.69 to 0.78); current smoking (at least monthly) prevalence from 9% to 7% (aOR 0.71, 0.64 to 0.79) and initiation in the last year from 13% to 11% (aOR 0.91, 0.84 to 0.98). Attempted purchase of cigarettes in the past 30 days among smokers decreased from 30% in 2012 to 26% in 2013 (aOR 0.77, 0.63 to 0.91). Positive associations between frequency of visiting tobacco-retailing stores and smoking-related behaviours weakened post-implementation.

CONCLUSIONS

The introduction of a POS display ban and concurrent measures was followed by significant reductions in initiation, experimental and regular smoking, attempted purchase of cigarettes, and reduced association between visiting tobacco-retailing stores and smoking behaviours. The findings suggest that POS display bans are important components of strategies to reduce smoking initiation among youth and young people.

Standardizing the influenza neuraminidase inhibition assay among United States public health laboratories conducting virological surveillance

BACKGROUND

Monitoring influenza virus susceptibility to neuraminidase (NA) inhibitors (NAIs) is vital for detecting drug-resistant variants, and is primarily assessed using NA inhibition (NI) assays, supplemented by NA sequence analysis. However, differences in NI testing methodologies between surveillance laboratories results in variability of 50% inhibitory concentration (IC50) values, which impacts data sharing, reporting and interpretation. In 2011, the Centers for Disease Control and Prevention (CDC), in collaboration with the Association for Public Health Laboratories (APHL) spearheaded efforts to standardize fluorescence-based NI assay testing in the United States (U.S.), with the goal of achieving consistency of IC50 data.

METHODS

For the standardization process, three participating state public health laboratories (PHLs), designated as National Surveillance Reference Centers for Influenza (NSRC-Is), assessed the NAI susceptibility of the 2011-12 CDC reference virus panel using stepwise procedures, with support from the CDC reference laboratory. Next, the NSRC-Is assessed the NAI susceptibility of season 2011-12 U.S. influenza surveillance isolates (n = 940), with a large subset (n = 742) tested in parallel by CDC. Subsequently, U.S. influenza surveillance isolates (n = 9629) circulating during the next three influenza seasons (2012-15), were independently tested by the three NSRC-Is (n = 7331) and CDC (n = 2298).

RESULTS

The NI assay IC50s generated by respective NSRC-Is using viruses and drugs prepared by CDC were similar to those obtained with viruses and drugs prepared in-house, and were uniform between laboratories. IC50s for U.S. surveillance isolates tested during four consecutive influenza seasons (2011-15) were consistent from season to season, within and between laboratories.

CONCLUSION

These results show that the NI assay is robust enough to be standardized, marking the first time IC50 data have been normalized across multiple laboratories, and used for U.S. national NAI susceptibility surveillance.

Youth Preferences for Roll-Your-Own Versus Factory-Made Cigarettes: Trends and Associations in Repeated National Surveys (2006-2013) and Implications for Policy

INTRODUCTION

We investigated trends in roll-your-own (RYO) and factory-made (FM) cigarette use over time among youth in New Zealand (NZ), a high RYO use country. We also explored factors associated with RYO use.

METHODS

We analyzed data from an annual survey of NZ students (14-15 years old) from 2006-2013. Smokers were asked whether they usually smoked RYO or FM cigarettes, and provided details of their source of supply. We estimated prevalences and developed a binary logistic regression model to explore determinants of RYO use.

RESULTS

Between 6663 (2006) and 3143 (2013) current smokers responded. Each year, around 80% reported usually smoking RYO or FM cigarettes. The proportion reporting usual RYO use was 45% (95% confidence interval [CI] ±3%) in 2006, reducing to 40% (95% CI ±3%) in 2013 (trend test: P < .001). By contrast, the proportions reporting usual FM use increased slightly over time from 36% (95% CI ±3%) in 2006 to 38% (95% CI ±3%) in 2013 (trend test: P < .001). Usual RYO use was more common amongst regular smokers, those who initiated smoking younger, who belonged to low or medium socioeconomic status groups, and whose friends and family both smoked.

CONCLUSIONS

RYO use is very high among NZ youth who smoke. Preference for RYO cigarettes amongst longer-term, regular smokers suggests RYO tobacco supports and maintains youth smoking. There was some initial evidence that a 2010 differential tax increase on RYO tobacco was associated with a shift away from usual RYO use amongst those who sourced tobacco from caregivers or friends. Additional measures such as further differential excise tax increases appear warranted.

Evaluation of a point-of-care blood test for identification of Ebola virus disease at Ebola holding units, Western Area, Sierra Leone, January to February 2015

Current Ebola virus disease (EVD) diagnosis relies on reverse transcription-PCR (RT-PCR) technology, requiring skilled laboratory personnel and technical infrastructure. Lack of laboratory diagnostic capacity has led to diagnostic delays in the current West African EVD outbreak of 2014 and 2015, compromising outbreak control. We evaluated the diagnostic accuracy of the EVD bedside rapid diagnostic antigen test (RDT) developed by the United Kingdom's Defence Science and Technology Laboratory, compared with Ebola virus RT-PCR, in an operational setting for EVD diagnosis of suspected cases admitted to Ebola holding units in the Western Area of Sierra Leone. From 22 January to 16 February 2015, 138 participants were enrolled. EVD prevalence was 11.5%. All EVD cases were identified by a positive RDT with a test line score of 6 or more, giving a sensitivity of 100% (95% confidence interval (CI): 78.2-100). The corresponding specificity was high (96.6%, 95% CI: 91.3-99.1). The positive and negative predictive values for the population prevalence were 79.0% (95% CI: 54.4-93.8) and 100% (95% CI: 96.7-100), respectively. These results, if confirmed in a larger study, suggest that this RDT could be used as a 'rule-out' screening test for EVD to improve rapid case identification and resource allocation.

Posting behaviour patterns in an online smoking cessation social network: implications for intervention design and development

Objectives

Online Cessation Support Networks (OCSNs) are associated with increased quit success rates, but few studies have examined their use over time. We identified usage patterns in New Zealand's largest OCSN over two years and explored implications for OCSN intervention design and evaluation.

Methods

We analysed metadata relating to 133,096 OCSN interactions during 2011 and 2012. Metrics covered aggregate network activity, user posting activity and longevity, and between-user commenting. Binary logistic regression models were estimated to investigate the feasibility of predicting low user engagement using early interaction data.

Results

Repeating periodic peaks and troughs in aggregate activity related not only to seasonality (e.g., New Year), but also to day of the week. Out of 2,062 unique users, 69 Highly Engaged Users (180+ interactions each) contributed 69% of all OCSN interactions in 2012 compared to 1.3% contributed by 864 Minimally Engaged Users (< = 2 items each). The proportion of Highly Engaged Users increased with network growth between 2011 and 2012 (with marginal significance), but the proportion of Minimally Engaged Users did not decline substantively. First week interaction data enabled identification of Minimally Engaged Users with high specificity and sensitivity (AUROC  = 0.94).

Implications

Results suggest future research should develop and test interventions that promote activity, and hence cessation support, amongst specific user groups or at key time points. For example, early usage information could help identify Minimally Engaged Users for tests of targeted messaging designed to improve their integration into, or re-engagement with, the OCSN. Furthermore, although we observed strong growth over time on varied metrics including posts and comments, this change did not coincide with large gains in first-time user persistence. Researchers assessing intervention effects should therefore examine multiple measures when evaluating changes in network dynamics over time.

Youth tobacco access: trends and policy implications

OBJECTIVE

We examined whether the supply routes via which New Zealand adolescents aged 14-15 years accessed tobacco had changed during a period of dynamic policy activity.

SETTING

We analysed data from seven consecutive years (2006-2012) of the New Zealand Action on Smoking and Health (ASH) Year 10 survey, a nationwide cross-sectional annual survey.

PARTICIPANTS

All New Zealand schools teaching Year 10 students are invited to participate in the survey; school-level participation rates have ranged between 44% and 58% and more than 25 000 students have responded to the survey in each year. The results presented draw on the subsample who reported smoking when surveyed (N∼9200). The data were weighted by age, ethnicity and school socioeconomic status (SES) to remove effects of systematic over-response by New Zealand Europeans and under-response by those in lower SES groups from trend analyses.

PRIMARY AND SECONDARY OUTCOME MEASURES

The survey measured adolescents' main reported tobacco supply source.

RESULTS

Smoking prevalence declined significantly (8.1%) over the period examined (linear tend coefficient: -0.74; 95% CI -1.03 to -0.45, significant p<0.01). Friends showed a significant decline in relative importance as a supply source while caregivers and other sources showed a significant increase over the period examined.

CONCLUSIONS

The findings show that social supply, particularly via friends, caregivers and others, such as older siblings, is a key tobacco source for adolescents; commercial supply is much less important. The findings raise questions about the additional measures needed to reduce smoking among youth. Endgame policies that make tobacco more difficult to obtain and less appealing and convenient to gift merit further investigation.

Evaluation of three influenza neuraminidase inhibition assays for use in a public health laboratory setting during the 2011-2012 influenza season

OBJECTIVES

We evaluated the implementation of three commercially available neuraminidase inhibition assays in a public health laboratory (PHL) setting. We also described the drug susceptibility patterns of human influenza A and B circulating in Maryland during the 2011-2012 influenza season.

METHODS

From January to May 2012, 169 influenza virus isolates were tested for phenotypic susceptibility to oseltamivir, zanamivir, and peramivir using NA-Fluor(TM), NA-Star®, and NA-XTD(TM) concurrently. A 50% neuraminidase inhibitory concentration (IC50) value was calculated to determine drug susceptibility. We used the standard deviation based on the median absolute deviation of the median analysis to determine the potential for reduced drug susceptibility. We evaluated each assay for the use of resources in high- and low-volume testing scenarios.

RESULTS

One of the 25 2009 influenza A (H1N1) pandemic isolates tested was resistant to oseltamivir and peramivir, and sensitive to zanamivir, on all three platforms. Eighty-two influenza A (H3N2) and 62 B isolates were sensitive to all three drugs in all three assays. For a low-volume scenario, NA-Star and NA-XTD took 120 minutes to complete, while NA-Fluor required 300 minutes to complete. The lowest relative cost favored NA-Star. In a high-volume scenario, NA-Fluor had the highest throughput. Reagent use was most efficient when maximizing throughput. Cost efficiency from low- to high-volume testing improved the most for NA-Star.

CONCLUSIONS

Our evaluation showed that both chemiluminescent and fluorescent neuraminidase inhibition assays can be successfully implemented in a PHL setting to screen circulating influenza strains for neuraminidase inhibitor resistance. For improved PHL influenza surveillance, it may be essential to develop guidelines for phenotypic drug-resistance testing that take into consideration a PHL's workload and available resources.

Youth exposure to in-vehicle second-hand smoke and their smoking behaviours: trends and associations in repeated national surveys (2006-2012)

OBJECTIVE

To extend the limited international evidence on youth in-vehicle second-hand smoke (SHS) exposure by examining trends in New Zealand, a country with a national smoke-free goal and indoors smoke-free environment legislation.

METHODS

We tracked exposure rates and explored the associations between in-vehicle SHS exposure and smoking behaviours. In-home exposure was also examined for comparative purposes. Data were collected in annual surveys of over 25 000 year 10 school students (14-15-year olds) for a 7-year period (2006-2012). Questions covered smoking behaviour, exposure to smoking and demographics.

RESULTS

Youth SHS exposure rates in-vehicle and in-home trended down slightly over time (p<0.0001 for both) with 23% exposed in-vehicle in the previous week in 2012. However, marked inequalities in exposure between ethnic groups, and by school-based socioeconomic position, persisted. The strongest association with SHS exposure was parental smoking (eg, for both parents versus neither smoking in 2012: in-vehicle SHS exposure adjusted OR: 7.4; 95% CI: 6.5 to 8.4). After adjusting for seven other factors associated with initiation, logistic regression analyses revealed statistically significant associations of in-vehicle SHS exposure with susceptibility to initiation and smoking.

CONCLUSIONS

The slow decline in SHS exposure in vehicles and the lack of progress in reducing relative inequalities is problematic. To accelerate progress, the New Zealand Government could follow the example of other jurisdictions and prohibit smoking in cars carrying children. Other major policy interventions, beside enhanced smoke-free environments, will also likely be required if New Zealand is to achieve its 2025 smoke-free nation goal.

The effectiveness of a hospital diabetes outreach service in supporting care for acutely admitted patients with diabetes

BACKGROUND

Patients with diabetes have increased frequency of hospital admissions and longer lengths of stay compared to patients without diabetes. Our specialist diabetes inpatient service was reconfigured to deliver a proactive diabetes outreach service to improve the overall care of this population.

AIMS

To ascertain the effect of a structured diabetes outreach service to acutely admitted patients with diabetes on avoidable admissions, delayed discharges and appropriate diabetes related follow-up plans.

METHODS

Audits were carried out before and 4 months after the introduction of a diabetes outreach service. The proportion of patients under care of the diabetes team, avoidable admissions, delayed discharges and existence of effective follow-up plans were compared pre- and post-implementation of this outreach service.

RESULTS

The number of inpatients with diabetes fell by 35% (83 on a typical day pre-outreach vs. 53 post-outreach) despite a similar number of total medical admissions in that month (1449 vs.1459). This was due to a reduction in those admitted with diabetes related (13 vs. 5) and general medical (29 vs. 10) problems whilst numbers requiring other specialist care (41 vs. 39) remained unchanged. The proportion of patients under the care of diabetes team rose (23% vs. 73%) while those with avoidable admissions (18% vs. 7%), delayed discharges (17% vs. 2%) and inappropriate discharge plans (65% vs. 11%) all fell.

CONCLUSION

This reformatted service was associated with a marked improvement in a number of parameters relevant to inpatient care.

Concurrent 72-hour continuous infusion of etoposide and cisplatin in metastatic breast cancer

We conducted a multiinstitutional phase II clinical trial to determine the toxicity, response, and survival rate of concurrent 72-h continuous infusion of etoposide and cisplatin in patients with metastatic breast cancer. A total of 26 women were enrolled, 4 of whom received no prior chemotherapy for metastatic disease. All patients were evaluated for toxicity, response, and survival employing the National Cancer Institute (NCI) Common Toxicity Criteria and the Eastern Cooperative Oncology Group (ECOG) response criteria. A total of 84 cycles of therapy were administered, median 3 (range 1 to 6). Severe grade 3 and grade 4 neutropenia occurred in 22 cycles (26%), and there were only 11 episodes (11%) of similar grade thrombocytopenia. Nausea and vomiting were seen in one third of cycles. A single patient (4%) had a complete remission, and seven patients (27%) had partial remissions for an overall objective response rate of 31% (95% confidence interval, 13 to 49%). Three of four patients (75%) without prior therapy for metastatic disease had objective responses. Median survival was 7 months. This combination regimen is active in extensively treated patients with metastatic breast cancer. It is responsible to further investigate the role of etoposide-cisplatin combination chemotherapy as firstline therapy for patients with metastatic breast cancer.

"Eight-drugs-in-one-day" chemotherapy administered before and after radiotherapy to adult patients with malignant gliomas

Thirty-one adult patients with malignant glioma (23 with glioblastoma multiforme, six with anaplastic astrocytoma, and two with brainstem glioma) were treated with up to ten cycles of "eight-drugs-in-one-day" chemotherapy (methylprednisolone 300 mg/m2, vincristine 1.5 mg/m2 [maximum of 2 mg/cycle], CCNU 75 mg/m2, procarbazine 75 mg/m2, hydroxyurea 3000 mg/m2, cisplatin 90 mg/m2, cytosine arabinoside 300 mg/m2, and imidazole carboxamide 150 mg/m2). Chemotherapy was planned as two cycles before and eight cycles after 60 Gy of involved brain irradiation. A total of 117 cycles of chemotherapy was administered. There was one treatment-related death. Myelosuppression was the most frequent toxic effect (leucopenia was less than 1000/mm3 in 9% of cycles and 1000-2500/mm3 in 25%; thrombocytopenia was less than 100,000/mm3 in 33% of cycles). Sixteen patients developed infections requiring treatment, two of which were life-threatening. Five patients suffered ototoxicity. Nausea and vomiting were observed in 35% of patients. A reversible rise in creatinine was observed in five patients. One patient developed a severe motor neuropathy, and three patients developed mild peripheral neuropathies. Three patients had episodes of atrial fibrillation. One new bundle branch block with supraventricular tachycardia was observed in a patient with pulmonary embolus. Five patients developed thrombophlebitis, three of whom had pulmonary emboli. Two patients suffered strokes in areas anatomically separate from their tumor. Eleven patients declined to continue therapy after receiving an average of three cycles. Two had complete, and five had partial responses. The median survival time was 47 weeks. The responses and survival times observed are comparable to less toxic treatment protocols for adults with malignant gliomas.

Eight-drugs-in-one-day chemotherapy in postirradiated adult patients with malignant gliomas

Fifteen patients, 12 with glioblastoma multiforme and 3 with anaplastic astrocytoma, were treated with "eight-drugs-in-one-day" chemotherapy [methylprednisolone 300 mg/m2, vincristine 1.5 mg/m2 (maximum of 2 mg/cycle), CCNU 75 mg/m2, procarbazine 75 mg/m2, hydroxyurea 3,000 mg/m2, cisplatin 90 mg/m2, cytosine arabinoside 300 mg/m2, and imidazole carboxamide 150 mg/m2]. All patients had prior brain irradiation but none had previous chemotherapy. The population included 10 patients with progressive disease after irradiation and 5 who presented within 2 months of completing radiation. Patients received an average of 5 monthly cycles of chemotherapy. Three patients achieved a complete and 2 a partial response (CR + PRrate was 33%). The median survival time was 46 weeks. Myelosuppression was the dose-limiting toxicity. Leucocyte counts between 2.0-4.5 x 10(3)/mm3 were observed in 40% of patients, between 1.0- less than 2.0 x 10(3)/mm3 in 33%, and less than 1.0 x 10(3)/mm3 in 7%. Platelet counts between 50-130 x 10(3)/mm3 were observed in 27% of patients, and less than 50 x 10(3)/mm3 in 33%. Six patients suffered infections, 4 had reversible renal toxicity, 2 developed paresthesias, and one a debilitating myopathy related to treatment with dexamethasone. Ototoxicity was seen in 3 patients. Two patients developed pulmonary emboli. Nine patients had nausea and vomiting, in one case associated with Candida esophagitis. One long-term survivor developed necrosis of the corpus callosum and dementia. Four patients discontinued treatment after an average of 3.5 cycles because of toxicity. Although extremely toxic, this regimen has modest activity in previously irradiated adult patients with malignant glioma.