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Processing multimode binding situations in simulation-based prediction of ligand-macromolecule affinities.

The linear response (LR) approximation and similar approaches belong to practical methods for estimation of ligand-receptor binding affinities. The approaches correlate experimental binding affinities with the changes upon binding of the ligand electrostatic and van der Waals energies and of solvation characteristics. These attributes are expressed as ensemble averages that are obtained by conformational sampling of the protein-ligand complex and of the free ligand by molecular dynamics or Monte Carlo simulations. We observed that outliers in the LR correlations occasionally exhibit major conformational changes of the complex during sampling. We treated the situation as a multimode binding case, for which the observed association constant is the sum of the partial association constants of individual states/modes. The resulting nonlinear expression for the binding affinities contains all the LR variables for individual modes that are scaled by the same two to four adjustable parameters as in the one-mode LR equation. The multimode method was applied to inhibitors of a matrix metalloproteinase, where this treatment improved the explained variance in experimental activity from 75% for the unimode case to about 85%. The predictive ability scaled accordingly, as verified by extensive cross-validations.

Computer Simulation↗

Family processes and treatment outcome in the MTA: negative/ineffective parenting practices in relation to multimodal treatment.

To elucidate processes underlying therapeutic change in a large-scale randomized clinical trial, we examined whether alterations in self-reported parenting practices were associated with the effects of behavioral, medication, or combination treatments on teacher-reported outcomes (disruptive behavior, social skills, internalizing symptoms) in children with attention-deficit hyperactivity disorder (ADHD). Participants were 579 children with Combined-type ADHD, aged 7-9.9 years, in the Multimodal Treatment Study of Children with ADHD (MTA). We uncovered 2 second-order factors of parenting practices, entitled Positive Involvement and Negative/Ineffective Discipline. Although Positive Involvement was not associated with amelioration of the school-based outcome measures, reductions in Negative/Ineffective Discipline mediated improvement in children's social skills at school. For families showing the greatest reductions in Negative/Ineffective Discipline, effects of combined medication plus behavioral treatment were pronounced in relation to regular community care. Furthermore, only in combination treatment (and not in behavioral treatment alone) was decreased Negative/Ineffective Discipline associated with reduction in children's disruptive behavior at school. Here, children in families receiving combination treatment who showed the greatest reductions in Negative/Ineffective Discipline had teacher-reported disruptive behavior that was essentially normalized. Overall, the success of combination treatment for important school-related outcomes appears related to reductions in negative and ineffective parenting practices at home; we discuss problems in interpreting the temporal sequencing of such process-outcome linkages and the means by which multimodal treatment may be mediated by psychosocial processes related to parenting.

Adult↗

Insufficient processing resources in Parkinson's disease: evaluation using multimodal event-related potentials paradigm.

The purpose of our study was to demonstrate impaired allocation of processing resources in non-demented patients with early-stage mild Parkinson's disease (PD) using a multimodal event-related potential (ERP) paradigm. The multimodal ERP paradigm was performed in 18 non-demented medicated patients with early-stage PD (Mini-Mental State Examination Score >26) and 16 matched normal controls, the Global Field Power (GFP) was employed for ERP components analysis, and the new modified Wisconsin Card Sorting Test (WCST) was used to evaluate frontal lobe function. Patients with PD did not exhibit novelty P3s, and P3 latency to non-target novel stimuli in visual and auditory modalities was significantly longer in PD patients than in controls. P3 amplitude for the target stimuli (P3b) was higher in PD in both auditory and visual modalities; however, P3b latency was not different between the two groups. Patients with PD showed a significantly lower score of achieved categories and made more perseverative errors in WCST as compared to controls. Our results showed that there were no natural novelty P3s in patients with PD; this finding suggests that non-demented patients with mild PD do not have sufficient mental resources to allocate to the central executive, due to dysfunction of the frontal lobe.

Acoustic Stimulation↗

Evaluation of multimodal treatment program for fibromyalgia.

A quasi-experimental design was used to assess a multimodal pain treatment program for female patients with fibromyalgia to ascertain immediate and long-term effects. Laboratory and self-report pain measures together with psychological measures were obtained from patients who were tested up to 6 months after treatment. Comparison data were also obtained from fibromyalgia patients who failed to qualify for the treatment program because of insurance coverage. Immediate and long-term treatment effects were evident with the psychological measures and the subjective pain measures but not with the laboratory pain measures. Participants who attended the month-long multimodal program achieved significant and positive changes on most of the outcome measures. However, relapse prevention must be addressed.

Activities of Daily Living↗

Surgery, radio- and chemotherapy for multimodal treatment of rectal cancer.

The possibilities and results of multimodal treatment in rectal cancer were reviewed with respect to the results of surgical treatment only. Based on the results of 4 studies, reducing local relapse rates and increasing long term survival rates significantly, postoperative radiochemotherapy (RCT) + chemotherapy (CT) should remain the recommended standard for R0 resected UICC II and III rectal cancers. The addition of RT to adjuvant CT reduces local relapses without significant impact on survival (NSABP R-02). Vice versa, the addition of CT to RT or an improved CT in the RCT-concept prolongs survival. Preoperative neoadjuvant radiotherapy (RT) reduced local relapse rates in 9 studies, and extended survival in one study that evaluated all eligible patients. Preoperative RT reduced local relapse rates in addition to total mesorectal excision (TME) but did not extend survival. The preoperative RCT + CT downstages resectable and nonresectable tumors and induces a higher sphincter preservation rate. Phase III data justifying its routine use in all UICC II + III stages are not yet available. This treatment may be routinely applied in nonresectable primary tumors or local relapses. Preoperative RCT (or RT) may evolve as standard, if the patient selection is improved and postoperative morbidity and long term toxicity reduced. Intraoperative RT could be added to this concept or be used together with preoperative/postoperative RT at the same indications. Postoperative adjuvant RT reduced local relapses significantly in a single trial, and no impact on survival time is reported. Since postoperative RT is inferior to preoperative RT, this treatment cannot be recommended, if RT is chosen as a single treatment modality in adjunction to surgery. The results of local tumor excisions may be improved with pre- or postoperative RCT + CT. In the future, multimodal treatment of rectal cancer might be more effective, if individualized according to prognostic factors.

Chemotherapy, Adjuvant↗

Multimodal intervention raises smoking cessation rate during pregnancy.

BACKGROUND: The aim was to study the effect of a multimodal smoking cessation intervention regimen on a number of pregnant smokers. METHODS: A prospective intervention study was designed where participants were allocated to intervention or control based on their birth date. The study included 647 pregnant smokers. The intervention group (n = 327) received initial individual smoking cessation counseling supplemented by an invitation to join, individually or in a group, a smoking cessation program with nicotine replacement therapy as a voluntary option. Intervention was designed as an integral part of the midwives' prenatal care. All pregnant smokers in the usual care group (n = 320) received standard counseling from a midwife. Outcome was self-reported smoking cessation in the 37th week of pregnancy and the reported cessation was validated by cotinine saliva concentration. RESULTS: Self-reported cessation rates during pregnancy were significantly higher in the intervention group (14%) than in the group receiving usual care (5.0%) (p < 0.0001) (Fisher's exact test). Cotinine-validated cessation rates during pregnancy were significantly higher among the former (7%) than the latter (2%) (p = 0.003). The adjusted odds ratio (OR) for smoking cessation was 4.20 (95% CI 2.13-8.03). Logistic regression analysis showed a significant positive association of smoking cessation with low caffeine consumption in pregnancy, many years in school, no exposure to passive smoking outside the home, and previous attempts to stop smoking. CONCLUSIONS: A multimodal intervention regimen with initial individual counseling supplemented by an invitation to join a smoking cessation program with nicotine replacement therapy as a voluntary option markedly increased cessation rates during pregnancy.

Adult↗

A multimodal cortical network for the detection of changes in the sensory environment.

Sensory stimuli undergoing sudden changes draw attention and preferentially enter our awareness. We used event-related functional magnetic-resonance imaging (fMRI) to identify brain regions responsive to changes in visual, auditory and tactile stimuli. Unimodally responsive areas included visual, auditory and somatosensory association cortex. Multimodally responsive areas comprised a right-lateralized network including the temporoparietal junction, inferior frontal gyrus, insula and left cingulate and supplementary motor areas. These results reveal a distributed, multimodal network for involuntary attention to events in the sensory environment. This network contains areas thought to underlie the P300 event-related potential and closely corresponds to the set of cortical regions damaged in patients with hemineglect syndromes.

Adolescent↗

PASTA: versatile tyramide-oligonucleotide amplification for multimodal spatial biology.

Spatial proteomics is limited by detection sensitivity, multiplexing and multimodal integration, leaving a gap between discovery and clinical assays. Here we present protein and nucleic acid serial tyramide amplification (PASTA), using horseradish peroxidase-mediated oligonucleotide deposition and cyclical imaging for high-plex, multimodal spatial profiling. Compatible with conjugated antibodies and in situ hybridization, PASTA enables simultaneous protein and RNA codetection from formalin-fixed, paraffin-embedded samples, providing a cost-effective bridge from discovery to clinical validation.

Tyramine↗

The prognostic significance of genetic polymorphisms (Methylenetetrahydrofolate Reductase C677T, Methionine Synthase A2756G, Thymidilate Synthase tandem repeat polymorphism) in multimodally treated oesophageal squamous cell carcinoma.

The present study retrospectively examined the correlation between the outcome of patients with locally advanced oesophageal squamous cell carcinoma (cT3-4 cN0-1 cM0) after multimodal treatment (radiochemotherapy+/-surgical resection), and the presence of genetic polymorphisms in genes involved in folate metabolism. In total, 68 patients who took part in a prospective multicentric trial received 5-fluorouracil (FU)-based radiochemotherapy, optionally followed by surgery. DNA was extracted from pretherapeutic tumour biopsies and was subsequently genotyped for common genetic polymorphisms of three genes (MTHFR C677T, MTR A2756G, TS tandem repeat polymorphism) involved in folate metabolism and potentially in sensitivity to 5-FU-based chemotherapy. The genotypes were correlated with tumour response to polychemotherapy, radiochemotherapy and with overall survival. Tumours with the MTR wild-type genotype (2756AA) showed a median survival time of 16 months, whereas tumours with an MTR variant genotype (2756AG/2756GG) showed a median survival time of 42 months (P=0.0463). No prognostic impact could be verified for the genotypes of the MTHFR genes and the TS gene. Among tumours treated with radiochemotherapy and subsequent resection, MTR variant genotype showed higher histopathological response rate than tumours with MTR wild-type genotype (P=0.0442). In contrast, no significant relationship between clinically determined tumour regression after polychemotherapy and polymorphisms of the three genes under analysis was observed. In conclusion, pretherapeutic determination of the MTR A2756G polymorphism may predict survival of multimodally treated oesophageal squamous cell carcinomas. Determination of MTHFR C677T and TS tandem repeat polymorphism has no predictive value.

5-Methyltetrahydrofolate-Homocysteine S-Methyltran↗

Prognostically orientated multimodality treatment including surgery for selected patients of small-cell lung cancer patients stages IB to IIIB: long-term results of a phase II trial.

Following mediastinoscopy, a prognostically orientated multimodality approach was chosen in selected small-cell lung cancer (SCLC) patients with hyperfractionated accelerated chemoradiotherapy (Hf-RTx) and definitive surgery (S). Stage IB/IIA patients had four cycles of cisplatin/etoposide (PE) and surgery. Stage IIB/IIIA patients had three cycles PE followed by one cycle concurrent chemoradiation including Hf-RTx and surgery. Most stage IIIB patients were not planned for surgery and had CTx followed by sequential RTx or one cycle concurrent CTx/RTx. Of 46 consecutive patients (stage IB six, IIA two, IIB/IIIA 22, IIIB 16) 43 (94%) showed an objective response. Twenty-three of patients (72%) planned for inclusion of S were completely resected (R0) (IB 6/6, IIA 2/2, IIB/IIIA 13/22, IIIB 2/2). Overall toxicity was acceptable--one patient died of septicaemia, no perioperative deaths occurred. Median follow-up of patients alive (n = 21) is 52 months (30+ - 75+). Median survival and 5-year survival rate of all patients are 36 months and 46%, in R0 patients 68 months and 63% (R0-IIB/IIIA/IIIB: not yet reached and 67%). This multimodality treatment including surgery proved highly effective with 100% local control and remarkable long-term survival after complete resection, even in locally advanced SCLC stages IIB/IIIA patients.

Adolescent↗

Benefit of aggressive multimodality therapy with autologous stem cell support for intra-abdominal desmoplastic small round cell tumor.

A case is described of a 19-year-old man with poor prognosis intra-abdominal desmoplastic small round cell tumor, who achieved a durable complete remission after aggressive multimodality treatment. He was diagnosed with a large peri-rectal mass and bulky metastases to the peritoneum, omentum and liver. He achieved a partial response to six courses of chemotherapy with VAC (vincristine, adriamycin, actinomycin, cyclophosphamide) and VIP (VP-16, ifosfamide, cisplatin). This was followed by resection of the omentum and cryotherapy to six of the liver lesions. He then achieved a complete response following high-dose busulfan 16 mg/kg and melphalan 140 mg/m2 with autologous stem cell support. Finally, pelvic radiotherapy was given to consolidate the remission. Twenty-six months following his diagnosis, and 19 months after the transplant, he remains well with no clinical or radiologic evidence of recurrent disease. This case report suggests a role for autologous stem cell transplantation as part of multimodality therapy for this unusual and aggressive malignancy.

Abdominal Neoplasms↗

Implications for Australia of the multimodal treatment study of children with attention-deficit/hyperactivity disorder.

OBJECTIVES: This paper reviews the implications of the large-scale USA Multimodal Treatment Study of Children with Attention-Deficit/Hyperactivity Disorder (MTA) by the MTA Cooperative group for planning of clinical services for children with attention deficit hyperactivity disorder in Australia. METHOD: The MTA study findings of no significant difference between active medication treatment alone, and combined medication combined with behaviour therapy treatments, on core symptom outcomes, are examined. Service traditions, workforce issues, diagnostic and ethical and philosophical considerations are discussed in relation to their impact on service planning in Australia. Implications of pharmacogenomic research are examined. Ethical and philosophical questions are raised in relation to the use of stimulant medications for subthreshold symptoms and for socialization of children. RESULTS: A critical evaluation of results reveals that combined treatments allow the use of lower medication doses, and that multimodal treatments are effective for comorbid symptoms. Completion of the Human Genome Project promises increasing technological advances. Arguments for and against a technological approach to child rearing are posited. CONCLUSIONS: The MTA study raises not just service planning questions, but also important ethical and philosophical considerations about optimal degree of medicalization of services in an increasingly technological society. Child psychiatrists will be required to have an understanding of technological developments if they wish to contribute to future debates.

Attention Deficit Disorder with Hyperactivity↗

Stepwise multimodal approach in the treatment of Kasabach-Merritt syndrome.

BACKGROUND: The purpose of the present study was to evalutate the various treatment modalities for Kasabach-Merritt syndrome (KMS) and to identify the most reliable treatment modalities. METHODS: A retrospective analysis was performed on 37 KMS patients who were admitted to Seoul National University Hospital between January 1979 and June 1999. Age, sex, locations of the hemangiomas, clinical symptoms and hematologic data were analyzed by multivariate logistical regression analysis to determine the response to various treatment modalities. RESULTS: Twenty-four of 37 patients (20 boys and 17 girls) were diagnosed during infancy. The locations of hemangioma were superficial skin in 31 patients, combined skin and visceral organs in four patients and visceral organs only in two patients. Tumor size was more than 5 cm in diameter in all cases, except for one. The treatment principle of KMS in our center involves a stepwise multimodal approach. Of the 37 cases, surgical resection was performed in two. Steroids were tried initially in 35 patients over a 1 week period, with an initial response rate of 11.4% (4/35). Combined steroid/radiation treatment was given in 28 cases, with a response rate of 75.0% (21/28). Four of five patients with additional interferon (IFN)-alpha therapy improved. No significant correlations were found between the prognostic factors, such as age, sex, size and locations of the hemangioma, hematologic data and the treatment modalities. CONCLUSIONS: Based on the experiences in a single center over a period of 20 years, we recommend a stepwise multimodal approach for the treatment of KMS; for example, steroid, radiation therapy and IFN-alpha in this order. However, surgical treatment is helpful if total resection is possible.

Abnormalities, Multiple↗

Multimodality therapy of local regional esophageal cancer.

Recent trials regarding the use of multimodality therapy for patients with cancers of the esophagus and gastroesophageal junction have not conclusively shown benefit. Regimens containing cisplatin and fluorouracil administered preoperatively appear to be tolerable and do not increase operative morbidity or mortality when compared with surgery alone. Yet clinical trials have not clearly shown that such regimens improve outcome as measured by survival. Likewise, trials of postoperative chemoradiation have not reported a significant improvement in median or overall survival. The reasons for the lack of clinical benefit from multimodality therapy are not completely understood, but improvements in systemic therapy will probably be necessary before disease-free or overall survival improves substantially. Some new single agents such as the taxanes (docetaxel or paclitaxel) and the camptothecan analog irinotecan have shown modest activity for palliative therapy.

Adenocarcinoma↗

Multimodal analgesia and intravenous nutrition preserves total body protein following major upper gastrointestinal surgery.

BACKGROUND AND OBJECTIVES: This study examined whether perioperative multimodal analgesia (MMA) improves the effectiveness of intravenous nutrition (IVN) as a means of preventing protein wasting following major upper abdominal surgery (UAS). The MMA regimen utilized combined epidural opioid/local anesthetic and the systemic nonsteroidal anti-inflammatory drug (NSAID) ketorolac for 48 hours. METHODS: In a prospective, randomized, nonblinded study, 47 patients scheduled for major UAS were allocated to receive the following: MMA +/- intravenous lipid-based nutrition (IVN) or patient-controlled analgesia with opioids (PCA) +/- IVN. Pain scores, nitrogen balance, total body protein (TBP), arterial blood gases, and various hormones were measured. RESULTS: Pain control was significantly better in the MMA patients at rest and coughing. Only the MMA + IVN group maintained TBP, mean (+/-95% confidence interval) preoperative day 1, 10.5 (+/-1.0) kg; day 14, 10.7 (+/-1.2) kg, whereas TBP decreased in the other groups (P =.04). Nitrogen balance was significantly greater in patients receiving IVN on day 7 (P =.01), but there was no effect related to the analgetic regimen. Decreased PaO(2) seen on postoperative day 2 was not prevented by MMA. The hormonal response to surgery was not influenced by treatment modality, apart from a return to postprandial insulin levels on postoperative day 7 in those patients receiving IVN (P =.002). CONCLUSIONS: In conclusion, we have shown that the combination of MMA and IVN prevents protein loss and improves pain control after major UAS. Our results suggest that after UAS, MMA significantly reduced pain and, in combination with IVN, preserves total body protein and fat. This is the first direct evidence of such effects associated with a commonly used multimodal regimen.

Adult↗

[Function and responsibility of an interdisciplinary tumor center. Need for a "cancer center" for multimodal therapy concepts].

BACKGROUND AND OBJECTIVE: Cancer will be the leading cause of death in industrialized countries within the next few years. A successful treatment represents a great challenge within the next years and requires multimodality treatment approaches. An multidisciplinary tumour center is essential for coordination and communication between different departments and institutions and is important to maintain standards in diagnostic and therapeutic procedures. METHODS: Two years ago, a cancer center was founded in Marburg. The central facility of its work is a twice weekly tumour conference, where patients requiring multimodality treatment approaches are presented and treatment procedures are fixed and documented. Furthermore, guidelines for diagnosis and treatment of the various cancer diseases will be established and the transfer of clinical and experimental research to the actual patient treatment is intended. RESULTS: A total of 407 patients were discussed within the first year. Leading cancer entities were lung cancer, colorectal cancer and tumours of the upper GI-tract. The tumour conference has improved the communication between all involved disciplines. The process of standardisation of diagnostic and therapeutic procedures is ongoing. The next step will be the documentation of the further follow up of all patients discussed in the tumour conference. CONCLUSIONS: In the communication between all disciplines involved in cancer patient care, success, be it a survival benefit or an improvement in quality of life, is most likely. All the described tasks are best organized within a cancer center.

Adolescent↗

[Remission rate of mediastinal lymph nodes after multimodal therapy of lung cancer--is it a prognostic factor?].

OBJECTIVE: General acceptance in the oncologic community has been gained for combined modality treatment of non-small cell lung (NSCLC) cancer in locally advanced stage IIIA and IIIB disease. However, no optimal regimen has been established. This study (chemotherapy and radiochemotherapy followed by operation) assesses feasibility, response, resectability, and survival in patients with stage IIIA and IIIB lung cancer. Currently, only little data is available about the prognostic significance of tumor clearance of mediastinal nodes. Thus, an important aim of our study was to evaluate the prognostic significance of the extent of tumor reduction in mediastinal nodes by a neoadjuvant multimodality protocol. PATIENTS: In a phase II protocol, 26 patients underwent neoadjuvant radiochemotherapy. Subsequently, a radical lymphadenectomy was performed during surgery. The extent of tumor regression was determined according to the methodology initially described by Salzer-Kuntschik for osteosarcoma: Grade I: no vital tumor cells, grade II: some tumor cells, grade III: less than 10 % vital tumor cells, grade IV: 10-50 % vital tumor cells, grade V: more than 50 % vital tumor cells, grade VI: no effect of chemotherapy. RESULTS: Complete pathologic response was seen in 30.7 % of primary tumors, in 38.5 % of mediastinal lymph nodes, and in 23 % of corresponding specimens simultaneously. Median survival was 34.7 months for those patients with grade I, 12.6 months with grade II, and 8.9 months for patients showing a grade III/IV regression in mediastinal nodes. Response rate to neoadjuvant chemotherapy in mediastinal nodes proved to be the only statistically significant parameter for long-term survival: In cases with no vital tumor cells in the operation specimen, median survival was 34.7 months in comparison to those with vital cells showing a median survival of only 11.4 months (P = 0.01). CONCLUSION: Patients with locally advanced NSCLCs can enjoy long-term survival after multimodal therapy. However, the complications related to therapy are considerably. Especially, clearance of tumor cells from mediastinal lymph nodes is an important independent prognostic factor.

Adult↗

[Multimodal therapy of children with attention deficit/hyperactivity disorder and their parents in in-patient rehabilitation].

BACKGROUND: Attention deficit/hyperactivity disorder (ADHD) is one of the most frequent psychic disorders of childhood, characterized by high persistence and an increased risk for the development of externalising disorders of behavior. Due to ADHD increased problems can be frequently observed at school as well as in the social and emotional context of the child. Concepts for in-patient rehabilitation have not been developed, although effective modifications of the behavior of ADHD patients appeared to be achievable under the conditions found in in-patient rehabilitation. OBJECTIVE: The present pilot study aimed to evaluate whether this newly developed concept has any benefit on psychological problems, coping and quality of life. METHOD: In total, n = 28 boys with ADHD 7 to 12 years old were included into a quasi-experimental pre-post design and completed self-report questionnaires on psychological problems, coping and quality of life. In addition, 26 mothers evaluated the behavior problems, psychological problems and quality of life of their sons at the beginning and the end of in-patient rehabilitation. During a 4-week in-patient rehabilitation all children and their mothers took part in a multimodal training containing components of behavior therapy and cognitive-behavioral therapy (self-instruction, self-management, and stress management), applied in child-, parent-child- and parent-centered interventions. RESULTS: Parents estimated the behavior problems of their children as significantly reduced after in-patient rehabilitation as compared to before. In addition, psychological problems and quality of life improved significantly in self- and parent-proxy reports during the in-patient rehabilitation. CONCLUSION: Our results support the hypothesis that this multimodal therapy concept is an effective tool for the treatment of ADHD patients. However, a replication of our results in a control-group study on a larger population is required.

Adolescent↗