Real-world use and clinical impact of an electronic patient-reported outcome tool in patients with solid tumors treated with immuno-oncology therapy

BACKGROUND

Utilization of electronic patient-reported outcome (ePRO) tools to monitor symptoms in patients undergoing cancer treatment has shown clinical benefits. Tennessee Oncology (TO) implemented an ePRO platform in 2019, allowing patients to report their health status online. We conducted a real-world, multicenter, observational, non-interventional cohort study to evaluate utilization of this platform in adults with solid tumors who initiated immuno-oncology (IO) therapy as monotherapy or in combination at TO clinics.

METHODS

Patients initiating IO therapy prior to platform implementation were included in a historical control (HC) cohort; those initiating treatment after implementation were included in the ePRO cohort, which was further divided into ePRO users (platform enrollment ≤ 45 days from IO initiation) and non-users. Data were extracted from electronic medical records; patients were followed for up to 6 months (no minimum follow up). Outcomes included patient characteristics, treatment patterns, duration of therapy (DoT), and overall survival (OS).

RESULTS

Data were collected for 538 patients in the HC and 1014 in the ePRO cohort; 319 in the ePRO cohort were ePRO users (uptake rate 31%). Baseline age was higher, more patients had stage IV disease at diagnosis, and more received monotherapy (82 vs 52%, respectively) in the HC vs the ePRO cohort. Median follow-up was 181.0 days (range 0.0-182.6) in the HC and 175.0 (0.0-184.0) in the ePRO cohort. Median DoT of index IO regimen was 5.1 months (95% confidence interval [CI], 4.4-NE) in the HC cohort vs not estimable (NE) in the ePRO cohort. Multivariable regression adjusting for baseline differences confirmed lower risk of treatment discontinuation in the ePRO vs HC cohort: hazard ratio (HR) 0.83 (95% CI, 0.71-0.97); p < 0.05. The estimated 6-month OS rate was 65.5% in the HC vs 72.4% in the ePRO cohort (p < 0 .01). Within the ePRO cohort, DoT of index IO regimen and OS did not differ between users and non-users. In ePRO users, patient platform use was durable over 6 months.

CONCLUSION

Improvements in DoT and OS were seen after ePRO platform implementation. Conclusions are limited by challenges in separating the impact of platform implementation from other changes affecting outcomes.

Achievement of Target Gain Larger than Unity in an Inertial Fusion Experiment

On December 5, 2022, an indirect drive fusion implosion on the National Ignition Facility (NIF) achieved a target gain G_{target} of 1.5. This is the first laboratory demonstration of exceeding "scientific breakeven" (or G_{target}>1) where 2.05 MJ of 351 nm laser light produced 3.1 MJ of total fusion yield, a result which significantly exceeds the Lawson criterion for fusion ignition as reported in a previous NIF implosion [H. Abu-Shawareb et al. (Indirect Drive ICF Collaboration), Phys. Rev. Lett. 129, 075001 (2022)PRLTAO0031-900710.1103/PhysRevLett.129.075001]. This achievement is the culmination of more than five decades of research and gives proof that laboratory fusion, based on fundamental physics principles, is possible. This Letter reports on the target, laser, design, and experimental advancements that led to this result.

Density measurements for the National Ignition Facility (NIF) opacity platform

The Opacity Platform on the National Ignition Facility (NIF) has been developed to measure opacities at varying densities and temperatures relevant to the solar interior and thermal cooling rates in white dwarf stars. The typical temperatures reached at NIF range between 150 and 210 eV, which allow these measurements to be performed experimentally. The captured opacities are crucial to validating radiation-hydrodynamic models that are used in astrophysics. The NIF opacity platform has a unique new capability that allows in situ measurement of the sample expansion. The sample expansion data are used to better understand the plasma conditions in our experiments by inferring the sample density throughout the duration of the laser drive. We present the details of the density measurement technique, data analysis, and recent results for Fe and MgO.

2nd and 3rd order spectral energy corrections with penumbral de-blurring methodology for opacity platform used on the National Ignition Facility

The Opacity Spectrometer (OpSpec) used in the National Ignition Facility's opacity experiments measures x-ray spectra from 0.9 to 2.1 keV from the different experimental regions: the backlight source, emission source, and the absorption region with the transmission calculated from these regions. The OpSpec designs have gone through several iterations to help improve the signal-to-noise ratio, remove alternate crystal plane reflections, and improve spectral resolution, which helps to increase the validity of the opacity measurements. However, the source spans well outside the current working spectral range, and higher-order reflections are intrinsic to the crystal, which increases the overall signal seen in the data regions. The recorded data are the convolution of 1st order transmission, higher-order reflections, and the penumbra blurring. This work represents the details for deconvolving the 2nd and 3rd order spectral energy corrections with a penumbral de-blurring to correct the relative measurement of x-ray intensity of different spectral energies and further analysis of datasets relevant to the opacity experiments.

Real-world use and clinical impact of electronic patient-reported outcomes (ePROs) in patients with solid tumors treated with immuno-oncology (IO) therapy

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Background: Patients with cancer can experience disease- and treatment-related symptoms that are underreported and underestimated by physicians. This observational, non-interventional study evaluated the use of ePROs and their impact on duration of treatment (DoT) in patients with solid tumors receiving IO therapy in community practice. Methods: Patients initiating index IO therapy immediately prior to (Jan-2017 to Dec-2018) and after (Sep-2019 to Dec-2020) implementation of Noona, the ePRO platform at Tennessee Oncology clinics, were included in a retrospective historical control (HC) and ePRO cohort, respectively, and followed for up to 6 months. The ePRO cohort was further divided into ePRO users (platform enrollment ≤45 days from index) and non-users. ePRO questionnaires, based on Common Terminology Criteria for Adverse Events (CTCAE), were sent within a week after each IO infusion and could be completed using an internet browser or smartphone app. Patient characteristics and DoT were described and compared between the HC and ePRO cohorts and between the HC cohort and ePRO users subgroup. Use of ePROs was evaluated within the ePRO cohort. Differences in baseline characteristics between cohorts were adjusted using Cox proportional hazards models. Results: Data were collected for 538 HC and 1014 ePRO patients (319 ePRO users and 695 non-users). Patient characteristics were generally similar between cohorts, but more HC patients were diagnosed with Stage IV disease (54% vs 47%; p < 0.01) and initiated IO as monotherapy (82% vs 52%), while more ePRO patients initiated IO as combination therapy (48% vs 18%). ePRO users were more likely than non-users to be female, white, married, living with a spouse, and have higher education (college or graduate degree) (all p < 0.05). Use of ePROs was durable over follow-up, with a consistent number of questionnaires sent over Months 1-3 and Months 4-6 (median: 6 questionnaires in each period) and a slight decrease in the number answered (median: 4 vs 3 questionnaires). ePRO patients had a longer DoT than HC patients (median time to end of first IO regimen: not estimable vs 5.1 months). Significantly more ePRO than HC patients remained on their first IO regimen at 6 months (54% vs 46%; p < 0.05). Multivariate Cox regression showed the risk of ending first IO therapy was lower for ePRO versus HC patients (p < 0.05). Conclusions: The increased DoT observed in the ePRO versus HC cohort in this study suggests that use of ePROs may facilitate improved care coordination and enable patients to remain on IO therapy longer. However, ePRO uptake was only 31% in the ePRO cohort, with several social determinants appearing to influence use. Overcoming barriers in ePRO uptake is an area for future study.

Sub-keV design for the National Ignition Facility's soft x-ray Opacity Spectrometer (OpSpec) and expansion plans for time-resolved measurements

When compared with the National Ignition Facility's (NIF) original soft x-ray opacity spectrometer, which used a convex cylindrical design, an elliptically shaped design has helped to increase the signal-to-noise ratio and eliminated nearly all reflections from alternate crystal planes. The success of the elliptical geometry in the opacity experiments has driven a new elliptical geometry crystal with a spectral range covering 520-1100 eV. When coupled with the primary elliptical geometry, which spans 1000-2100 eV, the new sub-keV elliptical geometry helps to cover the full iron L-shell and major oxygen transitions important to solar opacity experimentation. The new design has been built and tested by using a Henke x-ray source and shows the desired spectral coverage. Additional plans are underway to expand these opacity measurements into a mode of time-resolved detection, ∼1 ns gated, but considerations for the detector size and photometrics mean a crystal geometry redesign. The new low-energy geometry, including preliminary results from the NIF opacity experiments, is presented along with the expansion plans into a time-resolved platform.

Lawson Criterion for Ignition Exceeded in an Inertial Fusion Experiment

For more than half a century, researchers around the world have been engaged in attempts to achieve fusion ignition as a proof of principle of various fusion concepts. Following the Lawson criterion, an ignited plasma is one where the fusion heating power is high enough to overcome all the physical processes that cool the fusion plasma, creating a positive thermodynamic feedback loop with rapidly increasing temperature. In inertially confined fusion, ignition is a state where the fusion plasma can begin "burn propagation" into surrounding cold fuel, enabling the possibility of high energy gain. While "scientific breakeven" (i.e., unity target gain) has not yet been achieved (here target gain is 0.72, 1.37 MJ of fusion for 1.92 MJ of laser energy), this Letter reports the first controlled fusion experiment, using laser indirect drive, on the National Ignition Facility to produce capsule gain (here 5.8) and reach ignition by nine different formulations of the Lawson criterion.

Impact of clinical pathways on treatment patterns and outcomes for patients with non-small-cell lung cancer: real-world evidence from a community oncology practice

Introduction: The evolving treatment landscape for non-small-cell lung cancer (NSCLC) and complexities of regulations and reimbursement present challenges to community oncologists. Clinical pathways are tools to optimize care, but information on their value in the real world is limited. This retrospective study assessed treatment patterns and clinical outcomes in patients with Stage I-III NSCLC pre- and post-pathways implementation at Tennessee Oncology, a large, community-based oncology practice in the USA. Methods & Materials: Chart data were abstracted for adults diagnosed with Stage I-III NSCLC who received systemic treatment. Patients were divided into pre-pathways (treatment initiation 2014-2015) and post-pathways (treatment initiation 2016-2018) cohorts. Patient characteristics, treatment patterns and outcomes were summarized descriptively. Kaplan-Meier curves were used to assess time-dependent outcomes, and log-rank test was used to compare the cohorts. Results: 291 patients were included (Stage I-II: 38 pre-pathways, 55 post-pathways; Stage III: 105 pre-pathways, 93 post-pathways). Duration on first-line (1L) therapy was similar for Stage I-II patients pre- and post-pathways (median 1.9 months vs 2.1 months; p = 0.75), but increased for Stage III patients post-pathways (2.1 months vs 1.4 months pre-pathways; p < 0.01). Achievement of a complete or partial response with 1L therapy was similar post-pathways among Stage I-Stage -IIII patients (60.0% vs 55.2% pre-pathways), but increased for Stage III patients (56.0% vs 35.2% pre-pathways). Conclusion: Given that improvements in rates of treatment response post-pathways occurred only for patients diagnosed with Stage III NSCLC, among whom immunotherapy uptake increased post-pathways, such improvements may be attributable to evolving practices in cancer care, including advances in treatment and care delivery, rather than clinical pathways implementation. Further research is warranted to assess the impact of clinical pathways in the current treatment era, given that immunotherapy has now become the standard of care in NSCLC.

Characterization of Agfa Structurix series D4 and D3sc x-ray films in the 0.7-4.6 keV energy range

X-ray films remain a key asset for high-resolution x-ray spectral imaging in high-energy-density experiments conducted at the National Ignition Facility (NIF). The soft x-ray Opacity Spectrometer (OpSpec) fielded at the NIF has an elliptically shaped crystal design that measures x rays in the 900-2100 eV range and currently uses an image plate as the detecting medium. However, Agfa D4 and D3sc x-ray films' higher spatial resolution provides increased spectral resolution to the data over the IP-TR image plates, driving the desire for regular use of x-ray film as a detecting medium. The calibration of Agfa D4 x-ray film for use in the OpSpec is communicated here. These calibration efforts are vital to the accuracy of the NIF opacity measurements and are conducted in a previously un-studied x-ray energy range under a new film development protocol required by NIF. The absolute response of Agfa D4 x-ray film from 705 to 4620 eV has been measured using the Nevada National Security Site Manson x-ray source. A broader range of energies was selected to compare results with previously published data. The measurements were taken using selected anodes, filters, and applied voltages to produce well-defined energy lines.

Clinical pathways implementation in a community-based oncology practice: Real-world outcomes in patients with non-small cell lung cancer segmented by disease stage at diagnosis

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Background: Clinical pathways have been introduced as tools to optimize cancer care delivery, but evidence of their value in the real world is limited. This retrospective study was performed to assess treatment patterns and clinical outcomes in patients with non-small cell lung cancer (NSCLC) before and after pathway implementation at Tennessee Oncology (TO). Methods: Chart data were abstracted for patients (≥18 years) diagnosed with Stage I-IV NSCLC who initiated first-line (1L) systemic treatment at a TO clinic and had follow-up for ³6 months or until death. Patients were divided into two cohorts: pre-pathways (treatment initiation 2014–2015) and post-pathways (treatment initiation 2016–2018). Patient characteristics, treatment patterns, and outcomes were described and compared across cohorts. An exploratory study endpoint was the evaluation of outcomes based on disease stage at diagnosis. Results: Among 501 patients (251 pre-pathways and 250 post-pathways), most had advanced or metastatic NSCLC at diagnosis (Stage III: 40%; Stage IV: 42%). Chemotherapy comprised almost all 1L systemic therapy used pre-pathways (Stage I/II: 100%; Stage III: 96%; Stage IV: 83%). Post-pathways, chemotherapy remained the most common 1L therapy in patients with Stage I/II (89%) and Stage III (72%) disease, but among patients with Stage IV disease, use of chemotherapy decreased (47%) and immuno-oncology (IO) therapy alone or in combination became common (45%). Median duration of 1L therapy was longer post-pathways in patients with Stage III (2.1 months vs 1.4 months pre-pathways; P < 0.01) and Stage IV disease (3.3 months vs 2.3 months pre-pathways; P < 0.01) but did not differ among Stage I/II patients. Median progression-free survival was significantly longer post-pathways in patients with Stage IV disease (7.0 months vs 4.2 months pre-pathways; P < 0.05), but not in other disease-stage subgroups. Median overall survival increased non-significantly post-pathways for all disease stage subgroups (Stage I/II: 26 months vs 20 months pre-pathways; Stage III: 26 months vs 20 months; Stage IV: 10 months vs 9 months). For each disease stage, rates of severe adverse events were similar between cohorts. Conclusions: While outcomes for patients diagnosed with Stage III/IV NSCLC were generally improved following the implementation of clinical pathways, this change coincided with a dramatic shift in available treatment options. Improvements post-pathways were mainly observed in patients diagnosed with advanced disease. Thus, differences in outcomes between pre-pathways and post-pathways cohorts in our study are more likely attributable to other evolving practices in cancer care, particularly the availability of newer, more effective treatments such as IO therapy as part of standard practice, than implementation of the clinical pathways.

DANTE as a primary temperature diagnostic for the NIF iron opacity campaign

The Opacity Platform on the National Ignition Facility (NIF) has been developed to measure iron opacities at varying densities and temperatures relevant to the solar interior and to verify recent experimental results obtained at the Sandia Z-machine, that diverge from theory. The first set of NIF experiments collected iron opacity data at ∼150 eV to 160 eV and an electron density of ∼7 × 10²¹ cm^-3, with a goal to study temperatures up to ∼210 eV, with electron densities of up to ∼3 × 10²² cm^-3. Among several techniques used to infer the temperature of the heated Fe sample, the absolutely calibrated DANTE-2 filtered diode array routinely provides measurements of the hohlraum conditions near the sample. However, the DANTE-2 temperatures are consistently low compared to pre-shot LASNEX simulations for a range of laser drive energies. We have re-evaluated the estimated uncertainty in the reported DANTE-2 temperatures and also the error generated by varying channel participation in the data analysis. An uncertainty of ±5% or better can be achieved with appropriate spectral coverage, channel participation, and metrology of the viewing slot.

Use of computer vision for analysis of image datasets from high temperature plasma experiments

Great strides have been made in improving the quality of x-ray radiographs in high energy density plasma experiments, enabled in part by innovations in engineering and manufacturing of integrated circuits and materials. As a consequence, the radiographs of today are filled with a great deal of detail, but few of these features are extracted in a systematic way. Analysis techniques familiar to plasma physicists tend toward brittle 1D lineout or Fourier transform type analyses. The techniques applied to process our data have not kept pace with improvements in the quality of our data. Fortunately, the field of computer vision has a wealth of tools to offer, which have been widely used in industrial imaging and, more recently, adopted in biological imaging. We demonstrate the application of computer vision techniques to the analysis of x-ray radiographs from high energy density plasma experiments, as well as give a brief tutorial on the computer vision techniques themselves. These tools robustly extract 2D contours of shocks, boundaries of inhomogeneities, and secondary flows, thereby allowing for increased automation of analysis, as well as direct and quantitative comparisons with simulations.

Upgrades and redesign of the National Ignition Facility's soft x-ray opacity spectrometer (OpSpec)

The soft x-ray Opacity Spectrometer (OpSpec) used on the National Ignition Facility (NIF) has recently incorporated an elliptically shaped crystal. The original OpSpec used two convex cylindrical crystals for time-integrated measurements of point-projection spectra from 540 to 2100 eV. However, with the convex geometry, the low-energy portion of the spectrum suffered from high backgrounds due to scattered x-rays as well as reflections from alternate crystal planes. An elliptically shaped crystal allows an acceptance aperture at the crossover focus between the crystal and the detector, which reduces background and eliminates nearly all reflections from alternate crystal planes. The current elliptical design is an improvement from the convex cylindrical design but has a usable energy range from 900 to 2100 eV. In addition, OpSpec is currently used on 18 NIF shots/year, in which both crystals are typically damaged beyond reuse, so efficient production of 36 crystals/year is required. Design efforts to improve the existing system focus on mounting reliability, reducing crystal strain to increase survivability between mounting and shot time, and extending the energy range of the instrument down to 520 eV. The elliptical design, results, and future options are presented.

Electronic patient-reported outcomes (ePRO) platform engagement in cancer patients during COVID-19

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Background: Tennessee Oncology partnered with an ePRO platform solution to support patients during their cancer care journey. This cloud-based ePRO platform is designed to assist in improving the management of symptoms. Providing two core pieces of functionality allow both the patient and care teams to retrieve information quickly and communicate effectively. The patient portal is patient input driven and allows the patient to communicate with their care team, track symptoms, and access their health records via website or mobile app. The clinician portal provides multiple care teams the ability to manage and prioritize patient needs as well as communicate directly with patients. In March 2020, due to the pandemic, patients needed a convenient and remote way to communicate with the care team. Our communication plan had to be nimble and provide immediate updates to our large patient population. We leveraged our ePRO platform to meet this need. Methods: We focused efforts on increasing patient engagement by educating them on the benefits of this communication platform. We utilized secure messaging to send appointment details and for Telehealth visits a link to the visit was sent. We were able to provide weekly updates outlining our latest information regarding our safety protocols. Results: We noted an increase in the activation of patient accounts and patient-initiated messages in our ePRO platform. We saw an average of 1,000 new patient accounts activated each month during March, April and May. We saw that patient-initiated messages through the platform showed a 15% increase from February to March. The response rate for patients completing post-treatment questionnaires increased 8% from February to May. Conclusions: By providing patients with a single communication platform to contact their care teams outside of their office visits, patients become an active part of their care journey. As an organization, we continue to identify ways to connect our patients to their care team in a meaningful way through technology. Whether during normal business hours or after-hours, patients need a simple, reliable and consistent way to engage with their care team.

Safety of antiemetic prophylaxis with HTX-019 as a 30-min infusion in patients with cancer: a retrospective study

Aim: The NK-1 receptor antagonist HTX-019 (CINVANTI^® [aprepitant injectable emulsion]) was approved for preventing chemotherapy-induced nausea and vomiting based on bioequivalence studies in healthy volunteers. The objective of this study was to evaluate HTX-019 safety in cancer patients. Patients & methods: This retrospective analysis evaluated the safety of HTX-019 130 mg 30-min intravenous infusion, as part of a three-drug antiemetic regimen. Results: No treatment-emergent adverse events (TEAEs) were deemed related to HTX-019. During treatment cycles, three of 100 patients developed five reversible TEAEs: dyspnea, hot flash, pain, nausea and visual disturbance. Between cycles, six patients had TEAEs of dizziness (three patients), infusion-site events (two patients) and headache (two patients). Conclusion: HTX-019 is safe in cancer patients receiving chemotherapy.

Implementation of a 1-2 keV point-projection x-ray spectrometer on the National Ignition Facility

A point-projection soft X-ray Opacity Spectrometer (OpSpec) has been implemented to measure X-ray spectra from ∼1 to 2 keV on the National Ignition Facility (NIF). Measurement of such soft X-rays with open-aperture point-projection detectors is challenging because only very thin filters may be used to shield the detector from the hostile environment. OpSpec diffracts X-rays from 540 to 2100 eV off a potassium (or rubidium) acid phthalate (KAP or RbAP) crystal onto either image plates or, most recently, X-ray films. A "sacrificial front filter" strategy is used to prevent crystal damage, while 2 or 3 rear filters protect the data. Since May 2017, OpSpec has been recording X-ray transmission data for iron-magnesium plasmas on the NIF, at "Anchor 1" plasma conditions (temperature ∼150 eV, density ∼7 × 10²¹ e ^-/cm³). Upgrades improved OpSpec's performance on 6 NIF shots in August and December 2017, with reduced backgrounds and 100% data return using filter stacks as thin as 2.9 μm (total). Photometric noise is beginning to meet requirements, and further work will reduce systematic errors.

Capsule implosions for continuum x-ray backlighting of opacity samples at the National Ignition Facility

Direct drive implosions of plastic capsules have been performed at the National Ignition Facility to provide a broad-spectrum (500-2000 eV) X-ray continuum source for X-ray transmission spectroscopy. The source was developed for the high-temperature plasma opacity experimental platform. Initial experiments using 2.0 mm diameter polyalpha-methyl styrene capsules with ∼20 μm thickness have been performed. X-ray yields of up to ∼1 kJ/sr have been measured using the Dante multichannel diode array. The backlighter source size was measured to be ∼100 μm FWHM, with ∼350 ps pulse duration during the peak emission stage. Results are used to simulate transmission spectra for a hypothetical iron opacity sample at 150 eV, enabling the derivation of photometrics requirements for future opacity experiments.

Late-Time Mixing Sensitivity to Initial Broadband Surface Roughness in High-Energy-Density Shear Layers

Using a large volume high-energy-density fluid shear experiment (8.5  cm^{3}) at the National Ignition Facility, we have demonstrated for the first time the ability to significantly alter the evolution of a supersonic sheared mixing layer by controlling the initial conditions of that layer. By altering the initial surface roughness of the tracer foil, we demonstrate the ability to transition the shear mixing layer from a highly ordered system of coherent structures to a randomly ordered system with a faster growing mix layer, indicative of strong mixing in the layer at a temperature of several tens of electron volts and at near solid density. Simulations using a turbulent-mix model show good agreement with the experimental results and poor agreement without turbulent mix.

Design of the opacity spectrometer for opacity measurements at the National Ignition Facility

Recent experiments at the Sandia National Laboratory Z facility have called into question models used in calculating opacity, of importance for modeling stellar interiors. An effort is being made to reproduce these results at the National Ignition Facility (NIF). These experiments require a new X-ray opacity spectrometer (OpSpec) spanning 540 eV-2100 eV with a resolving power E/ΔE > 700. The design of the OpSpec is presented. Photometric calculations based on expected opacity data are also presented. First use on NIF is expected in September 2016.

Atomic physics modeling of transmission spectra of Sc-doped aerogel foams to support OMEGA experiments

We present synthetic transmission spectra generated with PrismSPECT utilizing both the ATBASE model and the Los Alamos opacity library (OPLIB) to evaluate whether an alternative choice in atomic data will impact modeling of experimental data from radiation transport experiments using Sc-doped aerogel foams (ScSi₆O₁₂ at 75 mg/cm³ density). We have determined that in the 50-200 eV T_e range there is a significant difference in the 1s-3p spectra, especially below 100 eV, and for T_e = 200 eV above 5000 eV in photon energy. Examining synthetic spectra generated using OPLIB with 300 resolving power reveals spectral sensitivity to T_e changes of ∼3 eV.

Development of a Big Area BackLighter for high energy density experiments

A very large area (7.5 mm(2)) laser-driven x-ray backlighter, termed the Big Area BackLighter (BABL) has been developed for the National Ignition Facility (NIF) to support high energy density experiments. The BABL provides an alternative to Pinhole-Apertured point-projection Backlighting (PABL) for a large field of view. This bypasses the challenges for PABL in the equatorial plane of the NIF target chamber where space is limited because of the unconverted laser light that threatens the diagnostic aperture, the backlighter foil, and the pinhole substrate. A transmission experiment using 132 kJ of NIF laser energy at a maximum intensity of 8.52 × 10(14) W/cm(2) illuminating the BABL demonstrated good conversion efficiency of >3.5% into K-shell emission producing ~4.6 kJ of high energy x rays, while yielding high contrast images with a highly uniform background that agree well with 2D simulated spectra and spatial profiles.

Antiemetic guideline consistency and incidence of chemotherapy-induced nausea and vomiting (CINV) in U.S. community oncology practice: INSPIRE study

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Background: Electronic Health Records (EHRs) are a valuable source to evaluate the quality of oncology care, particularly when combined with patient outcomes data. Our objective was to evaluate the impact of guideline consistent/inconsistent chemotherapy prophylaxis (GCCP, GICP) on the incidence of no CINV after cycle 1 of highly or moderately emetogenic chemotherapy (HEC or MEC). Methods: INSPIRE (Impact of NCCN Antiemesis Guideline Usage on Patient Reported Emesis) was a prospective observational, multicenter study that enrolled chemotherapy-naive adults initiating single-day HEC or MEC. Results from the MASCC Antiemesis Tool, administered 5 to 8 days after HEC/MEC, were merged with EHR data. The primary endpoint, no CINV (no emesis and no clinically significant nausea), was compared between groups using logistic regression. Results: 1,295 patients (mean age=59.3, 30.0% male, 35.5% HEC) were enrolled from Georgia Cancer Specialists (53.0%), Tennessee Oncology (38.1%), Florida Cancer Specialists (5.7%), and Cancer Specialists of N. Florida (3.2%). The prevalence of GCCP was 57.3% (28.7% HEC; 73.1% MEC). If corticosteroids were prescribed to all HEC patients on days 2-4, GCCP for HEC would increase from 28.7% to 89.8%. If NK1-receptor antagonists (NK1-RA) were prescribed to all MEC patients, GCCP for MEC would increase from 73.1% to 97.8%. GCCP and GICP-treated patients differed by age, (p=0.010), HEC/MEC (p<0.0001), primary cancer site (p<0.0001), practice site (p<0.0001). The percent with no CINV, no emesis, and no clinically significant nausea was significantly higher for GCCP patients. Conclusions: Increased GCCP could significantly reduce CINV after HEC or MEC. The main reasons for guideline inconsisteny were lack of corticosteroids in the delayed phase for HEC and lack of NK1-RA for MEC. There remains room for improvement in nausea control. [Table: see text]

Observation of a hydrodynamically driven, radiative-precursor shock

Observations of a radiative-precursor shock that evolves from a purely hydrodynamic system are presented. The radiative precursor is observed in low-density SiO2 aerogel foam using x-ray absorption spectroscopy. A plastic slab, shocked and accelerated by high-intensity laser irradiation, drives the shock which then produces the radiative precursor. The length and temperature profile of the radiative precursor are examined as the intensity of the laser is varied.

Experimental investigation of the three-dimensional interaction of a strong shock with a spherical density inhomogeneity

Laser-driven experiments are described which probe the interaction of a very strong shock with a spherical density inhomogeneity. The interaction is viewed from two orthogonal directions enabling visualization of both the initial distortion of the sphere into a double vortex ring structure as well as the onset of an azimuthal instability that ultimately results in the three-dimensional breakup of the ring. The experimental results are compared with 3D numerical simulations and are shown to be in remarkable agreement with the incompressible theory of Widnall et al. [J. Fluid Mech. 66, 35 (1974)].

Commingling and segregation analysis of serum uric acid in five North American populations: the Lipid Research Clinics family study

The role of major genes in the expression of serum uric acid (UA) levels was investigated in data collected from five clinics of the Lipid Research Clinics (LRC) family study. Over 2,000 randomly ascertained individuals were analyzed. The UA distributions were homogeneous among the five LRC clinics and between the parental and offspring generations. This result suggested that the data could be pooled across clinics, thereby increasing the statistical power associated with larger sample sizes for testing various null hypotheses. Additionally, a mixture of three normal distributions best characterized the combined-clinics data. Segregation patterns were examined in the untransformed data, as well as in a more conservative (and biologically meaningful) log transformation. Prior to log transformation, both major and multifactorial effects were detected. The major effect was not transmissible, i.e., was not compatible with Mendelian transmission, and accounted for 39% of the variance in UA levels. However, after the log transform was applied to the data and the segregation analysis was repeated, support for the major effect disappeared altogether and only the multifactorial component remained, accounting for 50% of the variation in offspring and 19% in patients.

Familial aggregation of lipids and lipoproteins in families ascertained through random and nonrandom probands in the Minnesota Lipid Research Clinic Family Study

The familial aggregation of lipids [total cholesterol (CH) and triglyceride (TG)] and lipoproteins [high-density lipoprotein cholesterol (HDL) and low-density lipoprotein cholesterol (LDL)] was investigated in families ascertained through both random and nonrandom probands in the Minnesota Lipid Research Clinic Family Study. Nonrandom proband ascertainment was based on single selection through truncation for hyperlipidemia at an earlier screening. A path model was used to investigate the nature of familial resemblance using appropriate adjustments for ascertainment and to determine whether random and hyperlipidemic samples are heterogeneous with regard to the multifactorial model. The results suggest that parameter estimates are consistent with those from previous studies in which only random families were used and that random and nonrandom samples are homogeneous with regard to the path model for CH and LDL. However, for TG and HDL the random and hyperlipidemic samples are significantly heterogeneous. This heterogeneity would be observed if familial hypertriglyceridemia and/or familial hypoalphalipoproteinemia segregates predominantly in the hyperlipidemic rather than in the random sample, as on might expect.

Familial aggregation of lipids and lipoproteins in families ascertained through random and nonrandom probands in the Stanford Lipid Research Clinics Family Study

We examined the familial aggregation of lipids [total cholesterol (CH) and triglyceride (TG)] and lipoproteins [high-density lipoprotein cholesterol (HDL) and low-density lipoprotein cholesterol (LDL)] in families ascertained through random and nonrandom probands in the Stanford Lipid Research Clinics Family Study. Nonrandom probands were selected because their lipid levels at a prior screening visit exceeded a certain prespecified threshold. The statistical method is based on selection through indirect truncation on a correlated trait (in which the likelihood function is conditioned on the actual event that the proband's value is beyond the threshold). This method allows for estimation of the path model parameters in randomly and nonrandomly ascertained families jointly and separately, thus enabling tests of heterogeneity between the two types of samples. The results suggest that the multifactorial transmission is homogeneous in the random and hyperlipidemic samples for CH. However, the evidence for heterogeneity is moderate for LDL, marked HDL, and mixed for TG. The general pattern of observed results is for somewhat higher genetic heritabilities in the random than nonrandom samples, which is compatible with a higher prevalence in the random sample of certain dyslipoproteinemias associated with nonelevated lipids. Substantial genetic heritability is found for CH, HDL, and LDL, with somewhat lower estimates for TG. Cultural heritability is low but significant for all four traits. Little or no spouse resemblance or nontransmitted shared sibship effects are seen. In contrast to the findings from previous studies, little or no parental cultural transmission is seen.

Familial aggregation of lipids and lipoproteins in families ascertained through random and nonrandom probands in the Iowa Lipid Research Clinics family study

The aggregation of lipids [total cholesterol (CH) and triglyceride (TG)] and lipoproteins [high-density lipoprotein cholesterol (HDL) and low-density lipoprotein cholesterol (LDL)] in families ascertained through random and nonrandom probands in the Iowa Lipid Research Clinics family study was examined. Nonrandom probands were selected because their lipid levels (at a prior screening visit) exceeded a certain pre-specified threshold. The statistical method conditions the likelihood function on the actual event that the proband's value is beyond the threshold. This method allows for estimation of the path model parameters in randomly and nonrandomly ascertained families jointly and separately, thus enabling tests of heterogeneity between the two types of samples. Marked heterogeneity between the random and the hyperlipidemic samples is detected in the multifactorial transmission for TG and HDL, and moderate heterogeneity is detected for CH and LDL, with a pattern of higher genetic heritability estimates in the random than nonrandom samples. The observed pattern of heterogeneity is compatible with a higher prevalence in the random sample of certain dyslipoproteinemias that are associated with nonelevated lipids. For the random samples, genetic heritabilities are higher for CH and HDL (about 60%) than for TG and LDL (about 50%). For the nonrandom samples those estimates are about 45, 40, 35 and 30% for HDL, CH, LDL and TG, respectively. Little to no cultural (familial environmental) heritability is evident for CH and LDL, although 10-20% of the phenotypic variance is due to cultural factors for TG and HDL. These results suggest that the etiologies for lipids and lipoproteins may be quite different in random versus hyperlipidemic samples.

Heterogeneity in the familial aggregation of fasting serum uric acid level in five North American populations: the Lipid Research Clinics Family Study

This study represents the first formal examination for heterogeneity in the familial aggregation of fasting serum uric acid (UA) levels. Data from 5 clinics (Cincinnati, Stanford, Iowa, Minnesota, and Oklahoma) participating in the Lipid Research Clinics (LRC) family study, which included a total of 685 nuclear families (N = 2,146), were analyzed. Heterogeneity among the clinics in familial resemblance was detected. However, this heterogeneity could not be attributed to differences in distributional properties (such as means and variances) or to path model parameters representing latent genetic or cultural (environmental) components associated with UA levels. Intergenerational differences in genetic heritabilities were found, with higher offspring (h2 = 43%) than parent (h2z2 = 16%) estimates, but no generational differences were detected for cultural heritability (c2 = 0.09). Equal maternal and paternal cultural transmission was found, and effects due to extra sibling environments and to marital resemblance were both significant. These results show no clear indication as to the source of the heterogeneity observed for familial resemblance of UA levels in randomly selected data. This question should be further investigated, especially in clinical samples such as dyslipoproteinemic families.

Heterogeneity in the familial aggregation of fasting plasma glucose in five North American populations: the Lipid Research Clinics Family Study

Heterogeneity in the familial aggregation of plasma glucose in five samples of the Lipid Research Clinics Family Study (LRC) was investigated using path analysis. This study was deemed appropriate since recent investigations reported a wide range of estimates for genetic and cultural factors. The path model incorporated a measured index of the familial environment in order to separate the effects of genes and environments in the nuclear family design, genetic and environmental heritabilities, spouse resemblance, sibling environmental effects, and parental cultural transmission. The methodology was completely general in allowing sample-specific, as well as pooled-sample, estimation of all or any subset of the model parameters. Genetic heritability estimates were heterogeneous, ranging from zero to 33% across the clinics. Environmental heritability (7%), spouse resemblance, non-transmitted sibling environmental effects, and parental cultural transmission were homogeneous across samples. No support was found for specific maternal effects, nor for intergenerational differences in cultural or genetic heritability. We conclude that the genetic and environmental heritabilities for plasma glucose in the LRC are consistent with the diverse reports by earlier investigators. In addition, we were able to exclude methodological differences as a cause of this heterogeneity. Furthermore, formal hypothesis tests suggest that the aetiology of this heterogeneity is genetic (and not cultural), taking the form of two distinct homogeneous patterns (one for no genetic effect, and one for a moderate genetic effect). Only formal heterogeneity tests of the type described here can detect these effects, and allow pooling of separate studies in order to obtain more precise estimates of the parameters of interest.

Heterogeneity in the biological and cultural determinants of high-density lipoprotein cholesterol in five North American populations: the Lipid Research Clinics Family Study

Heterogeneity in the source of familial resemblance for high-density lipoprotein (HDL) cholesterol in 5 different Lipid Research Clinics (Cincinnati, Iowa, Minnesota, Oklahoma and Stanford) was assessed using a general linear model for cultural and biological inheritance. No evidence of heterogeneity was found in any of the parameters of the model. Under the most parsimonious hypothesis, using data pooled over all clinics, genetic and cultural heritability were both significant and were estimated to be 0.52 +/- 0.04 and 0.09 +/- 0.02, respectively; there was cultural transmission but no maternal effects; marital and nontransmitted sibship environmental resemblance were significant.