Citations

Background— Communicating prognosis to enable shared decision-making is strongly endorsed by heart failure (HF) guidelines. Patients are concerned with both their quantity and quality of life (QoL). To facilitate the recognition of patients at high risk for unfavorable future QoL or death, we created a simple prognostic tool to estimate this combined outcome. Methods and Results— We identified factors associated with 6-month mortality or persistently unfavorable QoL, defined by Kansas City Cardiomyopathy Questionnaire (KCCQ) scores <45 at 1 and 24 weeks after hospital discharge, among 1458 patients from the Efficacy of Vasopressin Antagonism in HF Outcome Study with Tolvaptan (EVEREST). Within 24 weeks of discharge, 478 (32.8%) patients had died and 192 (13.2%) patients had serial KCCQ scores <45. After adjusting for 23 predischarge covariates, independent predictors of the combined end point included low admission KCCQ score, high B-type natriuretic peptide, hyponatremia, tachycardia, hypotension, absence of β-blocker therapy, and history of diabetes mellitus and arrhythmia. A simplified predischarge HF score for subsequent death or unfavorable QoL had moderate discrimination ( c -statistic 0.72). Predischarge clinical covariates were substantially different in predicting the QoL end point as compared with traditional death or rehospitalization end points. Conclusions— At the time of hospital discharge, readily available clinical characteristics are associated with HF patients at high risk for persistently unfavorable QoL or death over the next 6 months. Such information can target patients for whom aggressive treatment options (eg, devices or transplantation) and/or end-of-life discussions should be strongly considered before hospital discharge. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT00071331.

Abstract Allogeneic hematopoietic cell transplantation in multiple myeloma is limited by prior reports of high treatment-related mortality. We analyzed outcomes after allogeneic hematopoietic cell transplantation for multiple myeloma in 1207 recipients in 3 cohorts based on the year of transplantation: 1989-1994 (n = 343), 1995-2000 (n = 376), and 2001-2005 (n = 488). The most recent cohort was significantly older (53% > 50 years) and had more recipients after prior autotransplantation. Use of unrelated donors, reduced-intensity conditioning and the blood cell grafts increased over time. Rates of acute graft-versus-host (GVHD) were similar, but chronic GVHD rates were highest in the most recent cohort. Overall survival (OS) at 1-year increased over time, reflecting a decrease in treatment-related mortality, but 5-year relapse rates increased from 39% (95% confidence interval [CI], 33%-44%) in 1989-1994 to 58% (95% CI, 51%-64%; P < .001) in the 2001-2005 cohort. Projected 5-year progression-free survival and OS are 14% (95% CI, 9%-20%) and 29% (95% CI, 23%-35%), respectively, in the latest cohort. Increasing age, longer interval from diagnosis to transplantation, and unrelated donor grafts adversely affected OS in multivariate analysis. Survival at 5 years for subjects with none, 1, 2, or 3 of these risk factors were 41% (range, 36%-47%), 32% (range, 27%-37%), 25% (range, 19%-31%), and 3% (range, 0%-11%), respectively (P < .0001).

Rehabilitation offers means by which persons disabled after a stroke can be returned to patterns of daily living as close to normal as possible. Often simple and readily available restorative techniques suffice, but sophisticated methods and facilities may be needed in many cases. Certain complex problems require specialized attention by persons with detailed knowledge and specific training. Among these are rehabilitation of language and the management of incontinence, sensory loss, pain, spasticity, and psychosocial problems. High-quality rehabilitation is best delivered by a closely cooperating team, including the family physician, medical specialists, nurses, allied health professionals (physical therapist, occupational therapist, social worker, dietitian, rehabilitation counselor, speech therapist, psychologist), the patient's family, and also the patient. To accomplish these ends, hospitals, rehabilitation centers, extended care facilities, and nursing homes should give specific attention to the special needs of stroke patients. Careful discharge planning and follow-up are necessary in all cases. The home environment and the family attitudes may require considerable revision to meet the patient's individual needs. The family physician can offer many rehabilitation services in his office, and additional education in medical school and on a postgraduate level will belp him to reach his full potential in aiding both the acutely ill and the chronically disabled stroke patient.

Purpose Preoperative aromatase inhibitor (AI) treatment promotes breast-conserving surgery (BCS) for estrogen receptor (ER) –positive breast cancer. To study this treatment option, responses to three AIs were compared in a randomized phase II neoadjuvant trial designed to select agents for phase III investigations. Patients and Methods Three hundred seventy-seven postmenopausal women with clinical stage II to III ER-positive (Allred score 6-8) breast cancer were randomly assigned to receive neoadjuvant exemestane, letrozole, or anastrozole. The primary end point was clinical response. Secondary end points included BCS, Ki67 proliferation marker changes, the Preoperative Endocrine Prognostic Index (PEPI), and PAM50-based intrinsic subtype analysis. Results On the basis of clinical response rates, letrozole and anastrozole were selected for further investigation; however, no other differences in surgical outcome, PEPI score, or Ki67 suppression were detected. The BCS rate for mastectomy-only patients at presentation was 51%. PAM50 analysis identified AI-unresponsive nonluminal subtypes (human epidermal growth factor receptor 2 enriched or basal-like) in 3.3% of patients. Clinical response and surgical outcomes were similar in luminal A (LumA) versus luminal B tumors; however, a PEPI of 0 (best prognostic group) was highest in the LumA subset (27.1% v 10.7%; P = .004). Conclusion Neoadjuvant AI treatment markedly improved surgical outcomes. Ki67 and PEPI data demonstrated that the three agents tested are biologically equivalent and therefore likely to have similar adjuvant activities. LumA tumors were more likely to have favorable biomarker characteristics after treatment; however, occasional paradoxical increases in Ki67 (12% of tumors with > 5% increase after therapy) suggest treatment-resistant cells, present in some LumA tumors, can be detected by post-treatment profiling.

Abstract Background: Neoadjuvant endocrine therapy (NET) trials serve to inform design and selection of agents for larger adjuvant endocrine trials. The neoadjuvant aromatase inhibitor (AI) trial ACOSOG Z1031 randomized the treatment of postmenopausal women with ER rich (Allred 6-8) clinical stage 2/3 breast cancer to either EXE, ANA and LET. The results are therefore of interest in the context of new data that compares these AIs in the adjuvant setting. The opportunity to develop predictive biomarker tests for NET sensitivity was also a key study objective in order guide future selection of patients for inclusion in studies that compare NET versus neoadjuvant chemotherapy (NCT). The value of a baseline PAM50 intrinsic subtype test for NET patient selection was therefore an embedded objective of the study. Methods: Of the 374 women who began study treatment on Z1031, pretreatment biopsy specimen for central IHC testing for ER and Ki67 was available on 304 patients. The PAM50 intrinsic subtype test (PMCID: 2667820) could be conducted on 170 baseline samples. The Preoperative Endocrine Prognostic Index (PEPI) an approach to predicting long term outcomes based on pathological stage and surgical specimen ER and Ki67 status was also conducted because patients with a PEPI of zero (T1/2 N0, ER+, Ki67&lt;=2.7%) have been found to have an excellent long term prognosis and therefore unlikely to benefit from chemotherapy (PMCID: 255670). Results: The degree of Ki67 suppression, the absolute level of Ki67 in the surgical specimen and the PEPI results were not significantly different by treatment arm (Kruskal-Wallis tests p &gt;0.05). Thirty Percent (95%CI: 19.6-42.9%) of women with pre-AI LumA subtype and 12% (95%CI: 6.4-20.0%) of women with pre-AI LumB subtype had a PEPI of zero predicting excellent prognosis. Multivariate logistic modeling found that the likelihood of a PEPI score of zero is 3.2 fold higher (95%CI: 1.43 7.12) among 66 women with a pre-AI LumA subtype compared to 100 women with a pre-AI LumB subtype. Additional baseline variables (clinical T and N stage, HER2 status, pre-AI Ki-67 level (&lt; = 10% vs. &gt;10%) were not found to modify the chance of a PEPI of zero. Baseline PAM50 Subtype versus PEPI Conclusion: The results of Z1031 show no differences in clinical or biologic response between LET, EXE, and ANA in the neoadjuvant setting; predicting that no difference in efficacy will be seen between these agents in adjuvant studies. Pre-AI LumA versus LumB status, defined by the PAM50 subtype, identifies patients who are more likely to be in the most favorable PEPI score following neoadjuvant AI therapy. Patients with pretreatment LumA status may, therefore, not be suitable for a randomized trial of NET versus NCT since approximately one third of these patients may be able to avoid chemotherapy altogether. Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr S1-2.

The National Institute on Aging and the Alzheimer's Association charged a workgroup with the task of developing criteria for the symptomatic predementia phase of Alzheimer's disease (AD), referred to in this article as mild cognitive impairment due to AD. The workgroup developed the following two sets of criteria: (1) core clinical criteria that could be used by healthcare providers without access to advanced imaging techniques or cerebrospinal fluid analysis, and (2) research criteria that could be used in clinical research settings, including clinical trials. The second set of criteria incorporate the use of biomarkers based on imaging and cerebrospinal fluid measures. The final set of criteria for mild cognitive impairment due to AD has four levels of certainty, depending on the presence and nature of the biomarker findings. Considerable work is needed to validate the criteria that use biomarkers and to standardize biomarker analysis for use in community settings.