Amplification and overexpression of the PSMB5 gene contributes to bortezomib resistance in retreatment of patients with multiple myeloma

e19500

Background: The proteasome inhibitor Bortezomib is a novel anticancer drug that targets primarily the beta5 subunit (PSMB5) of the 26 S proteasome which has also demonstrated efficacy in re-treatment of almost half of relapsed Multiple Myeloma (MM) pts. Recent studies have identified qualitative and quantitative alterations at the level of PSMB5 subunit, which is located at 14q11, and cells that carry these alterations displayed a marked resistance to proteasome inhibition. We investigated the relevance of amplification and PSMB5 overexpression in the clinical outcome of pts with MM during retreatment with bortezomib. Methods: Between January and June 2008 pts with secretory MM on relapse were elegible for bortezomib re-treatment (1.3 or 1.0 mg/mq on days 1,4,8 and 11 of a 21 day cycle) if they had at least a partial remission to a bortezomib based on most recent treatment and a free interval of at least 6 months since the last dose. Bone marrow samples for morphologic analysis, mRNA expression levels of PSMB5, classical cytogenetics, FISH and in situ hybridization using a fluorescein-labeled probe to detect the amplification of PSMB5 gene, were obtained from 26 pts (16 male, 10 female mean age 64 years) before and during re-treatment with Bortezomib. Results: At the time of analyses all pts who received at least two cycles were evaluable. We identified 12 pts refractory to retreatment and five of these pts (3 males, 2 females, mean age 65 years) had a detectable amplification and overexpression of PSMB5 which interestingly appears rapidly following exposure to bortezomib and wanes with time off-therapy, even if it curiously reappeared rapidly after re-exposure to bortezomib. Conclusions: Amplification and overexpression of PSMB5 contributes to bortezomib resistance in clinical practice. These findings do highlight the susceptibility of proteasome units to genetic modifications under constant selective pressure which occur with continued treatment, furthermore, the drug resistance remains dormant but it rapidly revives upon re-exposure to bortezomib.

No significant financial relationships to disclose.

Myelodysplastic syndromes developing after imatinib therapy for GIST

10532

Background: Imatinib mesylate 400 mg a day is the standard treatment for patients (pts.) who have advanced or metastatic gastrointestinal stromal tumor (GIST) even if different kit and PDGFRA mutations have a marked impact on the outcome of pts.; briefly, pts. with exon 9 mutations fared worse than those who had exon 11 mutations and both types of pts. did better than those with wild type genotype. Previously, we had detected clonal chromosomal abnormalities in the bone marrow of GIST pts. who developed a myelodysplastic syndrome during treatment with imatinib, so we performed a systematic study in a series of male and female GIST pts. during treatment with imatinib. Methods: Between January 2007 and December 2008, bone marrow samples for morphologic analysis, FISH and classical cytogenetics were obtained from 49 pts. (30 male; 19 female, mean age 62) with unresectable or metastatic GIST before and during treatment with 400 mg/d of imatinib. For pts. with progressive disease (15 pts.) or exon 9 mutant disease (5 pts.), imatinib 800 mg a day was scheduled. All pathologic material was reviewed to identify pts. with MDS or AML according to the WHO classification. Interphase and metaphase preparations were done according to the standard protocol. Results: At the time of analyses, all pts. were evaluable. Ten patients experienced anemia of grade 3–4 while five pts. developed granulocytopenia of grade 3–4. Eight pts. acquired cytogenetic chromosomal abnormalities in their bone marrow. A trisomy 8 was detectable in seven pts. even if, curiously, in four of these pts. this come and went on repeated sampling without any apparent clinical effect, three pts. developed an MDS (two refractory cytopenias with multilineage dysplasia, and one refractory cytopenia with multilineage dysplasia and ringed sideroblast). One patient developed a RAEB-1 with monosomy 7 which rapidly transformed into AML. Conclusions: During therapy with imatinib some pts. with GIST developed chromosomal abnormalities. Although, these occurrences are rare, the findings highlight the need for close monitoring of pts. with GIST treated with imatinib.

No significant financial relationships to disclose.

Level of circulating endothelial cells as new biomarker in patients with multiple myeloma, treated with bortezomib-pegylated liposomal doxorubicin-dexamethasone combination

17551

Background: Bortezomib is a proteasome inhibitor and has effects on both multiple myeloma (MM) tumor cells and stromal cells. Recent data suggests that relative levels of circulating endothelial cells (CECs) may serve as surrogate markers of myeloma activity. Hence, we assay the number of CECs by cell phenotype, to explore the activity and response to treatment with BMD (Bortezomib, Myocet, Dexametasone) in previously untreated MM patients. Methods: Twelve pts. with newly diagnosed multiple myeloma were enrolled in this study. Panel of monoclonal antibodies and appropriate analysis gates were used to enumerate CECs. Patients received Bortezomib 1.3 mg/m2 on days 1, 4, 8 and 11, pegylated liposomal doxorubicin (30 mg/m2-Myocet) on day 1 and dexamethasone (40 mg/daily for 4days) for four cycles (q21) before Cyclophosphamide (5 g/m2) and G-CSF mobilization, followed by peripheral blood stem cell collection. The pts received high-dose Melphalan (MEL200) with PBSC transplantation. Samples of healthy controls were used to compare CECs levels. Results: After the treatment with BMD 4 patients had a complete remission, 2 nCR, 5 VGPR and 1 PD. All pts. underwent PBSC mobilization and 11 out of 12 were mobilized, with a median of 3.50 × 106 CD34+ cells/Kg collected with a median of 2 (range 1–4) collection procedures. Responding pts. (11) received high-dose Melphalan with stem cell transplantation. The median time to reach neutrophil and platelet regeneration was 13.5 days and 13 days respectively. In healthy controls (N° 18) mean values of CECs were 0.05% (0.1–0.62). Before treatment with BMD mean CECs level in study patients was 0.79% (0.54–1.53). After BMD treatment CECs in responding pts. was 0.07% (0.1–0.70; p < 0.01). Conclusion: BMD combination therapy in newly diagnosed MM pts. has a high response rate, it does not influence on subsequent stem cell collection, is associated with modest toxicity, furthermore, CECs value can serve as new biomarker for myeloma activity.

No significant financial relationships to disclose.

Response to STI571 in chronic myelomonocytic leukemia with platelet derived growth factor beta receptor involvement: a new case report

Based on its ability to inhibit the tyrosine kinase activity of ABL, as well as the c-kit and the Platelet Derived Growth Factor Receptor tyrosine kinases, the spectrum of diseases that may respond to STI571 is increasing. A recently recognized subgroup of myeloproliferative disorders/myelodysplastic syndromes (MPD/MDS) has a t(5;12)(q33;p13) with the activation of the gene for PDGFBR which encodes a receptor tyrosine kinase. Here, we present the case of a patient, with MPD/MDS, and eosinophilia, carrying a translocation t(5;12)(q33;p13) who achieved a complete remission following treatment with STI571, 400 mg daily. At the time of writing he still remains in complete remission with an excellent performance status. There is clearly a need for further studies of STI 571in MPD/MDS with chromosomal translocations involving PDGFBR to confirm this promising initial result.

Comparison between the QOLIE-31 and derived QOLIE-10 in a clinical trial of levetiracetam

PURPOSE

to determine whether the QOLIE-10, an abbreviated quality of life questionnaire, provides results similar to the more detailed QOLIE-31 instrument when the ten items are derived from the QOLIE-31.

METHODS

the QOLIE-31 was completed by 246 patients participating in UCB protocol N132 at baseline and after 18 weeks of treatment with levetiracetam (LEV 1000 or 3000 mg) or placebo added to standard therapy. QOLIE-10 components and total scores were calculated from the QOLIE-31 data.

RESULTS

baseline QOLIE-10 components and total score correlated highly with corresponding QOLIE-31 scores, both at baseline and follow-up (range 0.70-0.95). Changes from baseline to follow-up were significantly different (ANCOVA) among treatment groups for both the QOLIE-10 and QOLIE-31 for the total score (P = 0.02, P = 0.009, respectively), seizure worry (P = 0.005, P = 0.0003) and cognitive functioning (P = 0.01, P = 0.01). One subscale (overall QOL) showed significant change with the QOLIE-31 (P = 0.04), but not with the QOLIE-10 (P = 0.07). Differences in QOLIE-10 scores were found between responders (> or = 50% partial onset seizure reduction) and non-responders for the total score (P = 0.0001) and two components (overall QOL P = 0.002, social function P = 0.0003). In the QOLIE-31, the total score and six subscale scores (all except medication effects) were significantly different. Both instruments were able to detect change over time. Responsiveness assessed by effect sizes (- 0.1 for non-responders, 0.4 for responders, 0.8 for seizure-free patients) and the Guyatt statistic (0.1, 0.6 and 1.0, respectively) was similar for both instruments.

CONCLUSIONS

although the QOLIE-10 was designed as a screening tool, it can be scored and used in research. The total score did discern differences among treatments in a clinical trial. Nonetheless, questionnaires with multiple, multi-item subscales provide more detailed information than abbreviated forms. The QOLIE-31 is preferred where time and resources are available.

Post-basic cancer nursing education in Belgium: an innovative collaboration between a nursing school, a comprehensive cancer centre and the Oncology Nursing Society

Since 1989, the Nursing School attached to the Free University, Brussels, has organized post-basic courses in cancer nursing, with the collaboration of the Belgian Oncology Nursing Society (French speaking) (SIO) and a comprehensive cancer centre, the Jules Bordet Institute. The 1-day-a-week course evolves over 30 weeks and is open to registered nurses. Its structure and its content respect the recommendations of the Core Curriculum for a Post-Basic Course in Cancer Nursing (EONS, 1989). However, there are some differences related to the entry requirements, the clinical experience, and the evaluation of both the course and the students' performance. So far, 72 nurses from different cancer units from the southern part of Belgium have obtained the certificate at the end of this course. In parallel with the 1-day-a-week course, seven modular courses were set up during the first semester of 1992, with the financial support of the 'Europe against Cancer' Programme. Each module tackles a specific theme: Basic Principles in Oncology Nursing; Training the Trainers; Prevention and Early Screening; Rehabilitation--Palliative Care--Psycho-oncology (one short and one long module); Radiotherapy; and Chemotherapy.

Effect of levetiracetam on epilepsy-related quality of life. N132 Study Group

PURPOSE

To evaluate the short-term effect of levetiracetam (LEV; UCB L059) as add-on therapy on health-related quality of life in the treatment of refractory partial-onset seizures.

METHODS

Patients were enrolled in protocol UCB N132 if they had >/=12 partial-onset seizures with or without secondary generalization during the 12-week baseline period with a minimum of two seizures every 4 weeks. Randomization was made to placebo, LEV 1,000 mg, or LEV 3,000 mg, with sample size based on seizure frequency reduction. The 31-item Quality of Life in Epilepsy (QOLIE-31) questionnaire was completed by 246 patients at the end of baseline and at 18-week follow-up, or earlier if withdrawn.

RESULTS

Significant differences were found among the three treatment groups for Seizure Worry (p = 0. 0003), Overall Quality of Life (p = 0.04), and Cognitive Functioning domains (p = 0.01), as well as the Total Score (p = 0.009). Responders (>/=50% partial onset seizure reduction) had significant improvements in all areas, except Medication Effect, compared with nonresponders (all p > 0.006). Clinically noticeable improvement (>/=10% change from baseline to follow-up) was perceived by LEV 3, 000 mg responders in all areas, except Emotional Well-Being, by LEV 1,000 mg responders in 5 of 9 areas, and by placebo responders in 2 of 9 areas.

CONCLUSIONS

Addition of LEV to standard medication seems to have a positive impact on health-related quality of life, particularly among responders in this short-term study. These exploratory analyses require additional studies to evaluate long-term changes in a larger population.

Bone marrow transplantation for childhood hematological disorders: a global pediatric approach in a twelve year single center experience

One hundred and 43 consecutive pediatric patients (June 1985-December 1996) with at least 18 months of follow-up, were considered: most of the patients (111/143, 77.6%) underwent allogeneic BMT. The median follow-up was 5.7 years. Overall survival and 5 years EFS were 48.6% and 46.9%, respectively. For patients who underwent allogeneic BMT from HLA-identical siblings, the 5 years EFS for ALL was 75% in 1st CR, 60.4% in 2nd CR, 22.3% in > 2nd CR and 86.7% for AML in 1st CR. The EFS for Allo-BMT in "good" and "poor" prognosis patients was 68.6% and 21.8%, respectively (p value = 0.001). Early mortality in Allo-BMT patients was 17.7% between 1985-1990 and 10.3% between 1991-1996. Early treatment-related organ complications occurred mostly in patients who underwent BMT from an unrelated or a mismatched family donor. Late toxicity was evaluated in 57 patients (median follow-up of 82 months): none of the patients complained of significant late cardiac or respiratory dysfunction. With regards to growth, 18/57 patients (31.6%) lost more than two height centile channels. Three cases of thyroid neoplasms were observed. Evaluation of psychosocial functioning, studied in 39 patients who had at least 2 years of follow-up in CR, did not reveal any evident quality of life impairment. The possibility of curing childhood hematological malignancies is based on a global pediatric and multidisciplinary approach. A continuous need to improve results in terms of EFS and quality of life suggests that further multicenter prospective studies should be carried out.

Rehabilitation after anterior cruciate ligament reconstruction in the female athlete

OBJECTIVE

To discuss the rehabilitation program after anterior cruciate ligament (ACL) reconstruction in the female athlete. In addition, we will discuss 8 unique characteristics identified in the female athlete and specific training drills to address and correct the potentially deleterious effects of these unique characteristics.

BACKGROUND

The female athlete appears to be more susceptible to noncontact ACL injuries than the male athlete. There seem to be many differences between the female and male athlete that may contribute to the increased injury rate in the female athlete. These variations include anatomical and neuromuscular considerations and differences.

DESCRIPTION

Based on the unique characteristics of the female athlete and the anatomical and neuromuscular dissimilarities, a specially designed rehabilitation program has been established for the female athlete after ACL surgery.

CLINICAL ADVANTAGES

The rehabilitation drills discussed in this article challenge the neuromuscular system through proprioception, kinesthesia, dynamic joint stability, neuromuscular control, and perturbation training activities. Improving the female athlete's neuromuscular system will, we believe, expedite the injured athlete's recovery after ACL injury or surgery. Although the concepts discussed are part of a postoperative rehabilitation program after ACL surgery, these concepts may also be implemented as a preventive program to assist in reducing the incidence of ACL injuries in the female athlete.

The role of thalidomide in the treatment of refractory chronic graft-versus-host disease following bone marrow transplantation in children

Chronic graft-versus-host disease (cGVHD) is a frequent complication of allogeneic bone marrow transplantation (BMT). Thalidomide was found to have immunosuppressive properties and it has been used in a limited number of children with cGVHD. We report our experience with refractory and/or high-risk cGVHD in 14 children. Six children showed complete clinical response to thalidomide in a median time of 2 months. Four children had partial responses and four failed. Side-effects were usually mild (somnolence, constipation) and only two patients developed sensory peripheral neuropathy. An increased incidence of infectious complications attributable to thalidomide was not observed. Nine out of 10 responding patients are alive 49-111 months post-BMT. Thalidomide can be effective particularly in children with prevailing mucocutaneous cGVHD. All patients should be carefully monitored to detect peripheral neuropathy early.

Long-term effects of bone marrow transplantation on dental status in children with leukaemia

Minimal data about oral and dental health in long-term survivors after BMT are available. We studied the dental status of 27 children (19 males, eight females) with leukaemia, followed up with a routine oral examination, panoramic tomogram and, when necessary, an endoral radiograph at a median of 2 years (range 1-10) after BMT. Community periodontal index treatment necessity (CPITN), dental caries, missing or filled permanent teeth (DMFT) and dento-facial alterations according to WHO criteria were registered and evaluated. Median age of the patients at BMT was 9 years (range 1.1-17.9). The mean DMFT score ranged from 1.6 to 12.4 according to age at examination and was slightly higher than that which we previously reported in children who received chemotherapy alone. CPITN showed the presence of soft deposits in 77.7%, serious gingivitis in 59.2% and parodontal involvement in 3.7% of cases. Dento-facial abnormalities were found in 55.5% of patients, while 62.9% of the patients had tooth abnormalities or agenesis. Nine out of 27 patients (33%) had root hypoplasia. A negative impact on DMFT index due to multiple post-BMT factors was found. Age is the crucial factor in determining a developmental defect of enamel and root. The follow-up of long-term survivors after BMT should include regular dental examination.

Febrile complications in the first 100 days after bone marrow transplantation in children: a single center's experience

One hundred fifty-six episodes of fever occurred in 102 children during the first 100 days after bone marrow transplantation (BMT) performed at a single institution: fever of undetermined origin (FUO), 40.3%; septicemia, 7.1%; pneumonia, 19.2%; other infections, 33.4% of cases. The overall incidence of mortality was 22.6% and of mortality due to infections 17.4%. All FUO episodes resolved. Pneumonia was the major cause of death; 60% of recipients who developed pneumonia died, accounting for 90% of deaths attributable to febrile complications. Interstitial pneumonia, occurred rarely, in 3.9% of all febrile episodes. The Cox model showed that the presence of graft-versus-host disease (GVHD) was related to an approximately ninefold increase in the risk of a first episode of FUO (P value .03). The risk of developing pneumonia was fourfold greater in children who received a transplant from a matched unrelated donor or a mismatched family donor (P value .01). Developments in diagnostic tools are needed to diagnose febrile episodes earlier and more precisely with the aim of reducing early mortality after BMT.

An evaluation of the NCI Physician Data Query (PDQ) dissemination in Europe

The Physician Data Query (PDQ) is a computerised medical database aimed at communicating cancer-related information through computer technology. PDQ has been distributed in Europe since 1988 and in the U.S. since 1985. A study aimed at evaluating whether PDQ had reached a wide medical community was conducted among European PDQ distributors in 1992 as part of an evaluation of PDQ use and impact. Results indicate that PDQ promotion was limited and that several countries were underserved. A preference was expressed for on-line systems. It was found that PDQ access was limited by the requirement of special equipment, by subscription costs and by language barriers. Subscribers were found mainly in the countries with the highest number of distributors. Among a total 12,205 reported subscribers, only 20% were physicians. The proportion of physicians subscribing to the system was, therefore, low (range 4-39.7/10,000). Altogether 453 searches (range 0-213) and 84.5 h of connection time (range 0-52.5) were reported per month for Europe. It is obvious that additional investigation is needed to further evaluate the impact of PDQ on clinical practice.

Mechanical and infective central venous catheter-related complications: a prospective non-randomized study using Hickman and Groshong catheters in children with hematological malignancies

The aim of this study was to compare the Hickman and Groshong central venous catheters (CVCs) for incidence and severity of catheter-related complications in children. Seventy-three patients with hematological malignancies were observed, 42 with Groshong CVCs and 31 with Hickman CVCs. The number of infective episodes per 100 CVC-days was not significantly different (0.25 in the Hickman group versus 0.13 in the Groshong group; P = 0.24). The most frequent type of CVC-related infection in both groups was microbiologically documented sepsis; in most cases Gram-positive bacteria were isolated. Neutropenia (P < 0.001 for both CVCs) and hospital CVC management (P = 0.0047 for the Hickman group, P < 0.001 for the Groshong group) emerged as the major risk factors for the outbreak of infections. The rate of mechanical complication episodes per 100 CVC-days was similar in both groups (1.01 in the Hickman group versus 1.1 in the Groshong group: P = 0.58). Some complications (fissures, ruptures, total lumen obstruction by clots) occurred only in the Groshong group. Our study did not demonstrate any statistically significant difference in the incidence of mechanical and infective CVC-related complications between these two types of catheter.

Role of early diagnosis for a noninvasive treatment of pulmonary thromboembolism in leukemic children

Pulmonary thromboembolism (PTE) in leukemic children undergoing intensive chemotherapy should be promptly recognized so that specific therapy can be started. Our experience with the two cases reported here has led us to propose guidelines for the treatment of initial PTE in a pediatric hematology unit. Two children with leukemia developed PTE, the first during the relapse for acute lymphoblastic leukemia and the second at the onset of acute promyelocytic leukemia. In both cases, the diagnosis of PTE was based on clinical assessment of sudden acute respiratory failure with positive pulmonary perfusional scintigraphy in spite of a negative chest X-ray. The subintensive supervision consisted of instrumental monitoring with the assistance of an intensive care anesthetist. The clinical monitoring was based on the serial registration of respiratory rate, cardiac rate, SaO2 and body temperature. The thrombolytic therapy, together with heparin prophylaxis, was successfully administered in the hematology ward without the need for intensive care support (i.e. mechanical ventilation). The success of the treatment was documented by the criterion of a return to the normal cardiorespiratory parameters a few hours after the start of the thrombolytic treatment. Furthermore, a chest CT scan in case 1 and an arteriography in case 2 confirmed the PTE-related hypoperfusion. On the basis of this experience, the authors point out that in the course of acute respiratory failure in leukemic children, the combination of a negative chest X-ray and a positive pulmonary perfusional scintigraphy (compared whenever possible with ventilatory scintigraphy) in the presence of a negative CT scan could be a reliable diagnostic tool for PTE. This pathology should be treated promptly and with specific therapy to avoid progression to a severe, massive PTE.

Expanding the role of the nurse in clinical trials: the nursing summaries

In order to improve the overall quality of clinical trials, the role of the nurse should be expanded. The minimum requirement to facilitate nurses' participation and the optimal implementation of a clinical research protocol is to provide access to the clinical protocol document itself. However, given the high workload in an oncology unit, there is often little time for the staff to read the entire document. In addition, clinical protocols do not often provide detailed practical instructions for delivering treatment, observing patients, managing toxicities, and treating complications. A nursing summary of the medical protocol is a document that provides a short and easy-to-read selection of protocol-relevant information. It enables nurses to safely and more easily implement the research protocol and improve the care of patients in clinical trials. Master nursing summaries can be prepared centrally by the group responsible for the research protocol, while the unit/wards involved in the research can customize or adapt it to local needs. The potential benefit of implementing nursing summaries is overall improvement of the quality of the study by (a) increasing the reliability of nursing care regarding patients' safety, (b) standardizing monitoring and care of patients, (c) standardizing preventive measures, (d) proposing similar management of complications related to experimental treatments. Moreover, discussing nursing summaries may help evaluate workload related to research, allowing for better planning and allocation of resources.

Bone marrow transplantation for refractory Langerhans' cell histiocytosis

Langerhans' cell histiocytosis (LCH) is an uncommon disorder of childhood, formerly referred to histiocytosis X. A significant proportion of children with disseminated disease may undergo progression to a fatal outcome despite chemotherapy with single or multiple agents. Only six cases of LCH treated with BMT have been reported in the literature, including two cases of autologous BMT. Of them, only one was less than 14 years of age. We describe a 4-year-old child whose disseminated, refractory Langerhans' cell histiocytosis was not controlled by front-line monotherapy with etoposide, nor by rescue treatment with combined chemotherapy (vinblastine and etoposide) and immunotherapy (steroids and cyclosporine). Due to the high risk of fatal progressive disease, he underwent bone marrow transplantation from his HLA-identical sister who was heterozigous for beta-thalassemia. On day 24 after transplantation marrow reconstitution was evident, with WBC count 2.3 x 10(9)/L, neutrophil count > 0.5 x 10(9)/L, and platelet count 72 x 10(9)/L. Engraftment was demonstrated by PCR DNA analysis. The patient was discharged on day 25. After transplantation he experienced fever for 11 days and developed signs of grade I cutaneous and intestinal graft-versus-host disease, that was treated with methylprednisolone from days 11 to day 68 (1 mg/kg/day for 18 days, then tapered). He became transfusion independent on day 24; the hemoglobin value was 7.5 g/dL on day 54 and has remained > 10 g/dL since day 200. Features of heterozygous beta-thalassemia have been evident since then. Bone marrow aspirate was normal on days 25 and 94. At the time of this writing he remains in excellent condition, disease and treatment free, 25 months after transplantation. Although limited, current experience suggests that bone marrow transplantation has the potential to cure refractory Langerhans' cell histiocytosis.

Clinical trials and quality of life assessment: the nurses' viewpoint

The rationale for quality of life assessment has been largely developed in the literature. Quality of life is an important concept in the oncology environment because the physical, psychological and social wellbeing of patients are affected both by the disease and the related treatments. The relevance of quality of life assessment to nursing clinical practice has been discussed by several authors. There is a need to use more valid and reliable instruments to plan appropriate nursing care, to evaluate and document the effect of nursing interventions. In clinical trials, quality of life assessment is being used increasingly to predict patients' outcomes and to evaluate medical and nursing interventions. Nurses' viewpoints of potential benefits and pitfalls related to quality of life assessment are discussed. Among the benefits, it is usually considered that therapeutic interventions might be improved. These could be adjusted and individualised and the need for supportive care interventions might be evaluated more accurately. As for the pitfalls, the quality of life evaluation causes an extra burden if its implementation is not properly co-ordinated and if poor or incomplete guidelines are provided to patients and staff. Proposals for implementing effective quality of life assessment in clinical trials are discussed. Basic requirements, such as preliminary instructions, guidelines for administration of the questionnaire and proposals for reducing missing evaluations, are presented.

Morphological, phenotypic and karyotypic characterization of a novel natural-killer-cell target - evidence of involvement of MHC class-I molecules in NK cell recognition

A new cell line from a neoplastic ascites was established. This strain, designated PAT-206, was characterized by plastic adherence and a high proliferative potential without any specific growth factor requirement. Karyotype analysis showed that the line was of human chromosomal constitution and aneuploid. Surface marker analysis showed that CD45, CD33 and CD15 were positive. In addition, the presence of human cytokeratins was detected by cytoplasmic immunofluorescence. Interestingly, the cell line did not express major hystocompatibility complex (MHC) class I and II, and was more sensitive than the 'classic' K562 cell line, to killing mediated by fresh uncultured peripheral blood lymphocytes. Following differentiation with interferon-gamma, the cell line expressed MHC class I antigens and resulted resistant to natural killing mediated lysis. This novel NK cell target seems to be suitable for further studies on NK cell specificities.

The involvement of nurses in clinical trials. Results of the EORTC Oncology Nurses Study Group survey

The Oncology Nurses Study Group (ONSG) of the European Organization for Research and Treatment of Cancer (EORTC) initiated a survey to document the involvement of nurses in clinical trials. An English-language questionnaire was sent to 312 nurses in > 15 European countries. Results indicate that nurses lack training in oncology and in research methods. Nurses' tasks and activities are mainly oriented toward patient care. Nurses are rarely involved in activities related to protocol preparation and review. The circulation of information about clinical studies varies according to the center and the investigator responsible. Proposals to optimize nurse participation in clinical trials that were rated highly included (a) the availability of nursing protocol summaries translated into the local language, (b) contact with colleagues involved in the same trials, and (c) additional training in aspects of clinical trials related to nursing.

Current concepts in the rehabilitation of the athletic shoulder

The rehabilitative process of the overhead athlete represents a significant challenge to the clinician. Overhead athletes (thrower, tennis player, swimmer) repetitively subject their shoulder joints to high microtraumatic stresses that, due to the accumulative effects, may lead to a variety of shoulder injuries. This type of athletic patient exhibits uniquely specific physical characteristics, such as hypermobility of the anterior shoulder capsule, excessive external rotation, hypomobility of the posterior capsule, limited internal rotation, and generalized ligamentous laxity of the glenohumeral joint. However, the overhead athlete must exhibit functional stability for pain-free sports participation. Functional stability is accomplished through the proficient balance of static (passive) and dynamic (active) stabilizers. During the rehabilitation process, various concepts, such as neuromuscular control, proprioception, force couple efficiency, plyometrics, eccentrics, and scapular stability, can enhance dynamic functional stability for the overhead athlete. The evaluation and treatment of the shoulder patient is in perpetual change, and the purpose of this paper is to discuss several current concepts in the rehabilitative treatment of the athletic shoulder patient.

Rehabilitation of the elbow in the throwing athlete

Rehabilitation following an injury to the elbow joint complex is common in physical therapy practice. The unique anatomical considerations of the elbow joint provide a significant challenge to the therapist in rehabilitating elbow injuries. The purpose of this paper is to describe the rehabilitation process for various elbow pathologies and provide a rationale for their treatment. The rehabilitation process for the injured elbow presented in this paper will emphasize phases that are progressive, sequential, and based on clinical and scientific research.

Cooper's technique in the treatment of neuromuscular pes cavovarus

The authors present the technique described by Cooper to correct neuromuscular pes cavovarus and the results of 13 cases of pes cavovarus treated at the Orthopaedic Clinic of "La Sapienza" University in Rome. Cooper's technique seems to be a valid way of correcting pes cavovarus, particularly in growing patients or those with anterior deformities.

Six-year results of a multimodality treatment strategy for locally advanced breast cancer

Between 1976 and 1982, 59 patients with locally advanced breast cancer were treated with preoperative supervoltage radiotherapy, adjuvant preoperative and postoperative hormonochemotherapy, and modified radical mastectomy. Systemic treatment, which was started simultaneously with radiotherapy, consisted of a combination of daily oral tamoxifen and a monthly alternation of Doxorubicin + vincristine and cyclophosphamide + methotrexate + 5-fluorouracil (CMF). One of each cycle was given preoperatively at half dosage and five of each were repeated postoperatively at full dosage. All patients became operable. Results of pathologic examination of the operative specimen, available in 51 patients, showed complete disappearance of tumor tissue in breast areas in eight patients, of which three still had positive axillary nodes. After a median follow-up time of 6 years locoregional failure was observed in 12 patients (20%) but in only three (5%) did it occur before distant failure. The actuarial median survival of the entire patient population is close to 4 years. Seven patients are alive without recurrence at greater than 9 years. This aggressive multidisciplinary treatment approach is associated with a projected 30% long-term survival (10 years), excellent local control, but substantial toxicity.