Attitudes towards biosecurity practices relevant to Johne's disease control on beef cattle farms.

The success of control programs can be improved when producers' attitudes towards these programs are positive. Implementation of control programs for chronic diseases are more challenging than those for acute diseases because of the absence of the "cues-to-action" that are associated with acute diseases. Johne's disease (JD) is a chronic diarrheal disease of ruminants, and national voluntary control programs exist in several countries. We used a mailed cross-sectional survey to describe the attitudes of producers towards biosecurity practices and veterinarians' beliefs relevant to the control of JD on beef farms. Another objective was to describe and compare the attitudes of producers and veterinarians towards specific measures recommended by the Texas Voluntary Johne's Disease Program (TVJDP) for cattle. Questionnaires were mailed to 1100 producers and 840 veterinarians in the state of Texas, USA. Two hundred and eighty-five producers (26%) and 153 veterinarians (18%) returned questionnaires for analysis. Fifty-nine percent of producers and 50% of veterinarians agreed that JD is responsible for substantial losses in beef cattle production. Sixty-four percent of veterinarians had educated producers on management strategies for the control or elimination of JD. However, only 36% had participated in the training program and 29% were certified to develop risk assessments and implement testing. Only 20% of producers reported that they were familiar with the TVJDP and 16% had considered participating in this program. There is a need for greater promotion of the control program among veterinarians and producers. Reasons for the apparent difference in opinions need to be understood to increase the likelihood of control measures adoption and to subsequently reduce the impact of JD on beef cattle operations.

Benefits of obtaining test-negative Level 4 classification for beef producers in the Voluntary Bovine Johne's Disease Control Program.

The US Voluntary Bovine Johne's Disease Control Program (VBJDCP) stipulates the national standards for Johne's disease (JD) control, and herds classified as test-negative at Level 4 of the VBJDCP have the greatest likelihood of being non-infected. A questionnaire survey of owners of VBJDCP test-negative Level 4 beef herds was conducted to describe perceived benefits of attaining Level 4 status. Thirty-nine of the 40 producers returned completed or partially completed surveys. Sixty-four percent (23/36) of herds contained 50 or less test eligible cattle. Twenty-seven percent (10/37) of producers reported increased marketing opportunities as a goal for enrollment in the VBJDCP. Classification at test-negative Level 4 status in the VBJDCP led to increased marketing opportunities for more than one-third (13/35) of the producers. Twenty-five percent (9/36) of the producers reported significant and 39% (14/36) marginal benefits (financial and non-financial) as a result of participation in the VBJDCP. The median (range) reported annual benefit was $0 ($0, $10,000), whilst the median (range) annual cost of implementing and sustaining the VBJDCP on ranches was $200 ($0, $5000). It is suggested that greater publicity about the VBJDCP in the beef cattle industry will increase its chances of success by increasing awareness amongst producers concerned about herd health/disease monitoring, and through improved marketing opportunities.

E2A protein degradation by the ubiquitin-proteasome system is stage-dependent during muscle differentiation.

The E2A proteins are basic helix-loop-helix transcription factors that regulate proliferation and differentiation in many cell types. In muscle cells, the E2A proteins form heterodimers with muscle regulatory factors such as MyoD, which then bind to DNA and regulate the transcription of target genes essential for muscle differentiation. We now demonstrate that E2A proteins are primarily localized in the nucleus in both C2C12 myoblasts and myotubes, and are degraded by the ubiquitin proteasome system evidenced by stabilization following treatment with the proteasome inhibitor, MG132. During the differentiation from myoblast to myotube, the cellular abundance of E2A proteins is relatively unaltered, despite significant changes (each approximately 5-fold) in the relative rates of protein synthesis and protein degradation via the ubiquitin-proteasome system. The rate of ubiquitin-proteasome-mediated E2A protein degradation depends on the myogenic differentiation state (t 1/2 approximately 2 h in proliferating myoblasts versus t 1/2 > 10 h in differentiated myotubes), and is also associated with cell cycle in non-muscle cells. Our findings reveal an important role for both translational and post-translational regulatory mechanisms in mediating the complex program of muscle differentiation determined by the E2A proteins.

The putative tumor suppressor LRP1B, a novel member of the low density lipoprotein (LDL) receptor family, exhibits both overlapping and distinct properties with the LDL receptor-related protein.

The low density lipoprotein receptor-related protein-deleted in tumor (LRP1B, initially referred to as LRP-DIT) was cloned and characterized as a candidate tumor suppressor. It is a new member of the low density lipoprotein receptor gene family. Its overall domain structure and large size (approximately 600 kDa) are similar to LRP and suggest that it is a multifunctional cell surface receptor. Herein, we characterize a series of ligands for the receptor using cell lines that stably express it as a domain IV minireceptor (mLRP1B4). Ligands of LRP including receptor-associated protein, urokinase plasminogen activator, tissue-type plasminogen activator, and plasminogen activator inhibitor type-1 each demonstrate binding, internalization, and degradation via mLRP1B4. Interestingly, the kinetics of ligand endocytosis is distinctly different from that of LRP, with LRP1B exhibiting a markedly diminished internalization rate. In addition, tissue expression analysis reveals that the LRP1B gene is expressed in brain, thyroid, and salivary gland. These studies thus extend the physiological roles of members of the LDL receptor family.

The nuclear ubiquitin-proteasome system degrades MyoD.

Many short-lived nuclear proteins are targeted for degradation by the ubiquitin-proteasome pathway. The role of the nucleus in regulating the turnover of these proteins is not well defined, although many components of the ubiquitin-proteasome system are localized in the nucleus. We have used nucleoplasm from highly purified HeLa nuclei to examine the degradation of a physiological substrate of the ubiquitin-proteasome system (MyoD). In vitro studies using inhibitors of the system demonstrate MyoD is degraded via the ubiquitin-proteasome pathway in HeLa nucleoplasm. Purified nucleoplasm in vitro also supports the generation of high molecular mass MyoD-ubiquitin adducts. In addition, in vivo studies, using leptomycin B to inhibit nuclear export, demonstrate that MyoD is degraded in HeLa cells by the nuclear ubiquitin-proteasome system.

Exercise reduces daily fatigue in women with breast cancer receiving chemotherapy.

PURPOSE: Cancer treatment-related fatigue is the most prevalent and distressing symptom of cancer therapy. Interventions to minimize fatigue are needed. The purpose of this study was to examine the relationship between exercise and fatigue over the first three cycles of chemotherapy in women receiving either cyclophosphamide, methotrexate, and fluorouracil (CMF) or doxorubicin and cyclophosphamide (AC) for breast cancer. METHODS: Seventy-two newly diagnosed women with breast cancer were instructed in a home-based moderate-intensity exercise intervention. Measures of functional ability, energy expenditure, and fatigue were obtained at baseline and posttest. Subjects maintained daily records of four types of fatigue, and exercise duration, intensity, and type. RESULTS: Exercise significantly reduced all four levels of fatigue (P < 0.01). As the duration of exercise increased, the intensity of fatigue declined (P < 0.01). There was a significant carry-over effect of exercise on fatigue, but the effect lasted only 1 d. The level of fatigue at study entry was not associated with number of days of exercise or amount of exercise a woman engaged in. CONCLUSIONS: The impact of exercise on fatigue was significant and suggests the effectiveness of a low- to moderate-intensity regular exercise program in maintaining functional ability and reducing fatigue in women with breast cancer receiving chemotherapy.

Mechanisms of ubiquitin-mediated, limited processing of the NF-kappaB1 precursor protein p105.

In most cases, target proteins of the ubiquitin system are completely degraded. In several exceptions, such as the first step in the activation of the transcriptional regulator NF-kappaB, the substrate, the precursor protein p105, is processed in a limited manner to yield the active subunit p50. p50 is derived from the N-terminal domain of p105, whereas the C-terminal domain is degraded. The mechanisms involved in this unique process have remained elusive. We have shown that a Gly-rich region (GRR) at the C-terminal domain of p50 is one important processing signal and that it interferes with processing of the ubiquitinated precursor by the 26S proteasome. Also, amino acid residues 441-454 are important for processing under non-stimulated conditions. Lys 441 and 442 serve as ubiquitination targets, whereas residues 446-454 may serve as a ligase recognition motif. Following IkappaB kinase (IKK)-mediated phosphorylation, the C-terminal domain of p105, residues 918-934, recruits the SCF(beta-TrCP) ubiquitin ligase, and ubiquitination by this complex leads to accelerated processing. The two sites appear to be recognized under different physiological conditions by two different ligases, targeting two distinct recognition motifs. We have shown that ubiquitin conjugation and processing of a series of precursors of p105 that lack the C-terminal IKK phosphorylation/TrCP binding domain, is progressively inhibited with increasing number of ankyrin repeats. Inhibition is due to docking of active NF-kappaB subunits to the ankyrin repeat domain in the C-terminal half of p105 (IkappaBgamma). Inhibition is alleviated by phosphorylation of the C-terminal domain that leads to ubiquitin-mediated degradation of the ankyrin repeat domain and release of the anchored subunits. We propose a model that may explain the requirement for two sites: a) a basal site that may be involved in co-translational processing prior to the synthesis of the ankyrin repeat domain; and b) a signal-induced site that is involved in processing/degradation of the complete molecule following cell activation, with rapid release of stored, transcriptionally active subunits.

Dissection of receptor folding and ligand-binding property with functional minireceptors of LDL receptor-related protein.

The LDL receptor-related protein (LRP) is a large, multifunctional endocytic receptor that binds and endocytoses a variety of structurally and functionally distinct ligands. LRP contains four putative ligand-binding domains. However, only domains II, III and IV, but not domain I, bind the receptor-associated protein (RAP), a molecular chaperone and universal antagonist for LRP. In order to dissect the function of RAP in LRP folding and to examine the ligand-binding properties of LRP, we generated LRP minireceptors that represent each of the four putative ligand-binding domains (termed mLRP1, mLRP2, mLRP3 and mLRP4, respectively). We found that proper folding and trafficking of mLRP2, mLRP3, mLRP4, but not mLRP1, is facilitated by coexpression of RAP. When these mLRPs were stably expressed in Chinese Hamster Ovary cells that lack the endogenous LRP, we found that each of these receptors was processed and traffics through the secretory pathway. Cell surface expression of these minireceptors was quantitatively examined by flow cytometric analyses. Using these minireceptor cell lines to map the ligand-binding domains, we found that although the majority of LRP ligands bind to both domain II and domain IV, Pseudomonas exotoxin A utilizes only domain IV for its binding to LRP. We conclude that while domains II and IV of LRP share many ligand-binding properties, each of the putative ligand-binding domains of LRP is unique in its contribution to ligand binding.

The effects of intense physical exercise on secondary antibody response in young and old mice.

BACKGROUND AND PURPOSE: Based largely on data from young subjects, intense physical exercise is believed to suppress immune function. In addition, immune function, including secondary antibody response, declines with advancing age. Therefore, intense exercise in old subjects may further suppress the secondary antibody response. The purpose of this in vivo study was to investigate the effects of intense physical exercise on secondary antibody response in young (6-8 weeks) and old (22-24 months) C57BL/6 mice. SUBJECTS AND METHODS: Data were obtained from 22 young and 18 old C57BL/6 mice that were immunized to human serum albumin (HSA) and randomly divided into 3 groups. Two groups were exposed to a single bout of intense exercise to exhaustion and immediately boosted with an injection of HSA. The first group did not exercise further, but the second group continued with daily bouts of intense exercise to exhaustion for 9 days. The third group (control group) did not undergo intense exercise, but received the booster injection of HSA at the same time as the other groups. Ten days after the HSA booster injection, when high level of antibodies are produced in secondary antibody response, serum anti-HSA antibodies were measured by enzyme-linked immunosorbent assay. RESULTS: Young mice did not show suppression of secondary antibody response following intense exercise. However, old mice, exposed to a single bout of intense exercise, had an enhanced response similar to the response seen in young control mice. CONCLUSION AND DISCUSSION: The widely accepted hypothesis of immunosuppression resulting from intense exercise may not be true for old mice.

Age-dependent prevalence of mutations at the GLC1A locus in primary open-angle glaucoma.

PURPOSE: To screen a population with primary open-angle glaucoma for mutations in the gene that encodes the trabecular meshwork inducible glucocorticoid response protein (TIGR), also known as myocilin (MYOC). METHODS: Ophthalmologic information was collected for study subjects with primary open-angle glaucoma and their relatives. Mutation screening of 74 primary open-angle glaucoma probands was conducted by sequencing TIGR/MYOC coding sequence and splice sites. RESULTS: In 23 families we detected 13 nonsynonymous sequence changes, nine of which appear to be mutations likely to cause or contribute to primary open-angle glaucoma. Two mutations, Arg272Gly and Ile499Ser, and one nonsynonymous sequence variant, Asn57Asp, are novel. We found mutations in nine of 25 juvenile glaucoma probands (36%) and two of 49 adult-onset glaucoma probands (4%). Age classification of families rather than individual probands revealed mutations in three of nine families with strictly juvenile primary open-angle glaucoma (33%), and no mutations in 39 families with strictly adult-onset primary open-angle glaucoma (0%). In families with mixed-onset primary open-angle glaucoma containing both juvenile primary open-angle glaucoma and adult-onset primary open-angle glaucoma cases, we found mutations in eight of 26 families (31%). CONCLUSIONS: Our data suggest that Gly252Arg, Arg272Gly, Glu323Lys, Gln368STOP, Pro370Leu, Thr377Met, Val426Phe, Ile477Asn, and Ile499Ser are likely to play roles that cause or contribute to the etiology of autosomal dominant primary open-angle glaucoma. Our finding of more TIGR/MYOC mutations in families with mixed-onset primary open-angle glaucoma than in the families with strictly adult-onset primary open-angle glaucoma implies that the presence of relatives with juvenile primary open-angle glaucoma in a family could be used as a basis for identifying a subset of the population with adult-onset primary open-angle glaucoma with higher prevalence of TIGR/MYOC mutations. To address this issue, and to refine estimations of mutation prevalence in these age-defined subpopulations, prospective study of a larger population ascertained entirely through adult-onset primary open-angle glaucoma probands will be needed.

Disease management program improves asthma outcomes.

OBJECTIVE: To show that a disease management program that empowers patients with asthma to participate in the management of their condition can improve quality of life and reduce the use of medical services. STUDY DESIGN: Utilization and quality-of-life data were tracked to identify outcome changes in patients with moderate to severe asthma. Baseline measures were used as a control and were compared with measures taken at 6 and 12 months after enrollment. PATIENTS AND METHODS: Study participants were from a single Medicaid managed care plan in western Pennsylvania. Patients' quality of life during their participation in the program was tracked through an outside pharmacoepidemiologic research firm. Utilization data were updated with every interaction between a patient and case management nurse. RESULTS: Both quality-of-life and utilization data show statistically significant improvements at 6 months. Further, 12-month data show improvement that is statistically significant in all measures with the exception of the adult quality-of-life measure, where a small sample size limited the statistical results. CONCLUSIONS: A collaborative, proactive approach to asthma management improves patients' quality of life and reduces use of costly medical services.

Mutational and spectroscopic studies of the significance of the active site glutamine to metal ion specificity in superoxide dismutase.

We are addressing the puzzling metal ion specificity of Fe- and Mn-containing superoxide dismutases (SODs) [see C.K.Vance, A.-F. Miller. J. Am. Chem. Soc. 120(3) (1998) 461-467]. Here, we test the significance to activity and active site integrity of the Gln side chain at the center of the active site hydrogen bond network. We have generated a mutant of MnSOD with the active site Gln in the location characteristic of Fe-specific SODs. The active site is similar to that of MnSOD when Mn2+, Fe3+ or Fe2+ are bound, based on EPR and NMR spectroscopy. However, the mutant's Fe-supported activity is at least 7% that of FeSOD, in contrast to Fe(Mn)SOD, which has 0% of FeSOD's activity. Thus, moving the active site Gln converts Mn-specific SOD into a cambialistic SOD and the Gln proves to be important but not the sole determinant of metal-ion specificity. Indeed, subtle differences in the spectra of Mn2+, Fe3+ and 1H in the presence of Fe2+ distinguish the G77Q, Q146A mut-(Mn)SOD from WT (Mn)SOD, and may prove to be correlated with metal ion activity. We have directly observed the side chain of the active site Gln in Fe2+ SOD and Fe2+ (Mn)SOD by 15N NMR. The very different chemical shifts indicate that the active site Gln interacts differently with Fe2+ in the two proteins. Since a shorter distance from Gln to Fe and stronger interaction with Fe correlate with a lower Em in Fe(Mn)SOD, Gln has the effect of destabilizing additional electron density on the metal ion. It may do this by stabilizing OH- coordinated to the metal ion.

Psychometric testing of fatigue instruments for use with cancer patients.

BACKGROUND: Cancer treatment-related fatigue (CRF) is a common side effect of cancer treatment. A problem identified in most reviews of CRF is lack of sound approaches to measurement that are congruent with the conceptualization of CRF as a self-perceived state. The diversity of instruments available to measure fatigue and the lack of comprehensive testing of several promising instruments with cancer patients undergoing treatment provided the rationale for this study. The purpose of this article is to report the results of psychometric testing of several fatigue instruments in patients undergoing cancer treatment. OBJECTIVES: The aims of this study were to determine the reliability, validity, and responsiveness of each instrument and to determine the ability of each instrument to capture CRF. METHODS: Existing fatigue instruments with published psychometric information that indicated suitability for further testing were selected and included the Profile of Mood States Short Form fatigue subscale (F_POMS-sf), Multidimensional Assessment of Fatigue (MAF), Lee Fatigue Scale (LFS), and the Multidimensional Fatigue Inventory (MFI). Data were collected at a university-based clinical cancer center and a freestanding comprehensive cancer center. Subjects completed all study instruments, which were presented in random order, at a time when CRF was expected to be high and again when it was expected to be low. A subset of subjects completed the instruments within 48 hours of one of the data collection points when CRF was expected to be relatively unchanged to provide stability data. RESULTS: Reliability estimates using Cronbach's alpha indicated that all instruments examined had good internal consistency. Test-retest correlations showed good stability for total scores on all the instruments, but some subscales of the LFS and MFI had marginal stability. Factor analysis of all instruments indicated that only the LFS and the F_POMS-sf fully supported their construct validity. All of the instruments showed responsiveness to changes in CRF related to treatment. CONCLUSIONS: The results of the study provide researchers and clinicians with detailed comparisons of the performance of established fatigue measures in cancer patients undergoing treatment to use when selecting measures of CRF.

SCF(beta)(-TrCP) ubiquitin ligase-mediated processing of NF-kappaB p105 requires phosphorylation of its C-terminus by IkappaB kinase.

Processing of the p105 precursor to form the active subunit p50 of the NF-kappaB transcription factor is a unique case in which the ubiquitin system is involved in limited processing rather than in complete destruction of the target substrate. A glycine-rich region along with a downstream acidic domain have been demonstrated to be essential for processing. Here we demonstrate that following IkappaB kinase (IkappaK)-mediated phosphorylation, the C-terminal domain of p105 (residues 918-934) serves as a recognition motif for the SCF(beta)(-TrCP) ubiquitin ligase. Expression of IkappaKbeta dramatically increases processing of wild-type p105, but not of p105-Delta918-934. Dominant-negative beta-TrCP inhibits IkappaK-dependent processing. Furthermore, the ligase and wild-type p105 but not p105-Delta918-934 associate physically following phosphorylation. In vitro, SCF(beta)(-TrCP) specifically conjugates and promotes processing of phosphorylated p105. Importantly, the TrCP recognition motif in p105 is different from that described for IkappaBs, beta-catenin and human immunodeficiency virus type 1 Vpu. Since p105-Delta918-934 is also conjugated and processed, it appears that p105 can be recognized under different physiological conditions by two different ligases, targeting two distinct recognition motifs.

Ubiquitin-mediated proteolysis: biological regulation via destruction.

The ubiquitin proteolytic system plays an important role in a broad array of basic cellular processes. Among these are regulation of cell cycle, modulation of the immune and inflammatory responses, control of signal transduction pathways, development and differentiation. These complex processes are controlled via specific degradation of a single or a subset of proteins. Degradation of a protein by the ubiquitin system involves two successive steps, conjugation of multiple moieties of ubiquitin and degradation of the tagged protein by the 26S proteasome. An important question concerns the identity of the mechanisms that underlie the high degree of specificity of the system. Substrate recognition is governed by a large family ubiquitin ligases that recognize the substrates, bind them and catalyze/facilitate their interaction with ubiquitin.

The ubiquitin-mediated proteolytic pathway: mode of action and clinical implications.

Proteolysis via the ubiquitin system plays important roles in a variety of basic cellular processes. Among these are regulation of cell cycle and division, modulation of the immune and inflammatory responses, and development and differentiation. In all cases studied, these complex processes are mediated via degradation or processing of a single or a subset of specific proteins. Ubiquitin-mediated degradation of a protein involves two discrete and successive steps: (1) conjugation of multiple moieties of ubiquitin to the protein, and (2) degradation of the conjugated protein by the 26S proteasome complex with the release of free and reutilizable ubiquitin. In a few cases, it has been reported that ubiquitination targets membrane-anchored proteins to degradation in the lysosome/vacuole. An important yet largely unresolved problem involves the mechanisms that endow the system with the high degree specificity and selectivity toward its many substrates. These are determined by a large family of ubiquitin-protein ligases that recognize different primary and/or secondary/post-translational motifs in the different substrates and by a wide array of modifying enzymes, such as protein kinases, and ancillary proteins, such as molecular chaperones, that render them susceptible for recognition by the ligases via modification or association with protein substrates. With the broad spectrum of protein substrates and the complex enzymatic machinery involved in targeting them, it is not surprising that the system was recently implicated in the pathogenesis of several important diseases. In addition, genetic studies in animals underscore the role of the system in normal development. We briefly review the enzymatic cascade involved in ubiquitin-mediated degradation, describe some of the structural motifs identified by the conjugating machinery, and summarize recent developments in the involvement of the system in the pathogenesis of selected disease states.

Daily fatigue patterns and effect of exercise in women with breast cancer.

OBJECTIVES: Cancer treatment-related fatigue is a common and disruptive side effect of chemotherapy. Exercise is an intervention proposed to reduce fatigue in cancer patients. The purpose of this study was to describe the patterns of daily fatigue in women with breast cancer who did and did not exercise while receiving the first three cycles of adjuvant chemotherapy. MATERIALS AND METHODS: Women received instruction to follow an 8-week home-based exercise program and to maintain daily exercise and fatigue diaries. Functional ability (12-minute walk) was measured pretest and post-test. RESULTS: Several distinct patterns of fatigue emerged. The most common pattern of fatigue after chemotherapy demonstrated a sharp rise in fatigue. However, several women demonstrated a chaotic pattern with erratic and wide swings in their fatigue throughout the entire study period. Women who adopted exercise experienced fewer days of high fatigue levels and more days of low levels of fatigue for both average and worst levels of fatigue. Women who did not exercise experienced more bad days (high fatigue) and fewer good days (low fatigue). CONCLUSIONS: Exercise appears to reduce the levels of average and worst fatigue and may help women recognize their pattern of fatigue. Exercise may reduce the intensity of fatigue by reorganizing women's interpretation of fatigue. Routine clinical assessment and education about fatigue by health professionals can help patients to understand their pattern of fatigue and may help them to manage the symptom.

Recombinant full-length tissue factor pathway inhibitor fails to bind to the cell surface: implications for catabolism in vitro and in vivo.

Tissue factor pathway inhibitor (TFPI) plays a key role in the regulation of tissue factor-initiated blood coagulation secondary to loss of the integrity of the blood vessel wall. TFPI is a naturally occurring Kunitz-type protease inhibitor that inhibits coagulation factor Xa and, in a factor Xa-dependent manner, mediates feedback inhibition of the factor VIIa/tissue factor catalytic complex. In vivo full-length TFPI is thought to be primarily bound to the vascular endothelium and the high affinity binding requires an intact carboxy terminus. Here we describe a full-length TFPI molecule, expressed in mouse C127 cells (TFPI(C127)), which exhibits virtually no cellular binding yet contains the intact carboxy terminus. This TFPI (TFPI(C127)) is neither internalized nor degraded via the TFPI endocytic receptor, LDL-receptor-related protein. Pharmacokinetic studies of TFPI(C127 )in vivo demonstrate a 10-fold prolongation in the plasma half-life, compared with that of bacterial recombinant TFPI. (Blood. 2000;95:1973-1978)

Fatigue patterns observed in patients receiving chemotherapy and radiotherapy.

The purpose of this study was to describe the patterns of cancer-related fatigue (CRF) and vigor in patients receiving chemotherapy or radiation therapy. Five studies that measured fatigue and vigor with the Profile of Mood States were used to describe the pattern of CRF and vigor during and after both types of treatment. Repeated-measures ANOVA was used to determine differences over time in each study. Results demonstrate different patterns of CRF for patients receiving chemotherapy and radiation therapy. Chemotherapy-related CRF peaks in the days after chemotherapy, whereas radiation therapy-related CRF gradually accumulates over the course of treatment. The CRF associated with both forms of treatment gradually declines over time. The prevalence, intensity, and persistence of CRF during treatment and for months after treatment is complete make this symptom one that cannot be ignored.