Impact Of Dialysis-Dependent Renal Failure At Time Of Myeloma Diagnosis On Overall Survival - a 15-Year Single Centre Analysis

Abstract In myeloma, the use of autologous stem cell transplantation in younger patients as well as the introduction of thalidomide, lenalidomide and bortezomib has resulted in improvement in long-term survival of both younger and older patients. Bortezomid and high dose dexamethasone is currently recommended to treat newly diagnosed myeloma patients presenting with renal impairment and may lead to varying degrees of improvement in renal function. We have assessed not only survival trends for all patients diagnosed at our centre over the past 18 years but also the survival of the subset of patients with severe renal impairment who required dialysis at diagnosis. All patients diagnosed with myeloma at our centre between January 1995 and December 2012 were included. We constructed Kaplan-Meier curves and used the Breslow generalised Wilcoxon test to evaluate overall survival (OS) patterns (diagnosed in three calendar periods: 1995-2000; 2001-2006; 2007-2012) for our total patient population as well as the subset of patients who required dialysis within 4 weeks of diagnostic bone marrow test. 262 patients (60.3% males) were diagnosed between 1995 and 2012. For all patients, median OS significantly increased from 13.2 months in period 1995-2000 to 27 months in period 2001-2006 with median OS not yet reached in period 2007-2012 (p=0.0001). In patients 70 years old or less, median OS significantly increased from 25.4 months in period 1995-2000 to 46.7 months in period 2001-2006 with median OS not yet reached in period 2007-2012 (p=0.0482). Improved median OS was also seen in patients > 70 years old: 4.4 months in period 1995-2000, 17.4 months in period 2001-2006 and 25.1 months in period 2007-2012 (p<0.0001). In contrast, patients requiring dialysis at diagnosis (n = 44) had much worse outcomes: median OS in the period 1995-2000 was 2.8 months and although there was a slight improvement in median OS in the period 2001-2006 (p=0.0318), there has been no further improvement in median OS in the period 2007-2012. In our overall myeloma patient population, median OS has continued to increase over the time periods 1995-2000, 2001-2006 and 2007-2012, both for younger patients 70 years old or less and older patients >70 years old. Patients requiring dialysis at diagnosis, however, continue to have much poorer median OS, despite the use of bortezomib and dexamethasone containing regimens in recent years. The possible benefit of improved supportive measures and the early use of other emerging novel agents in this poor prognostic subgroup should be explored in the clinical trial setting. Disclosures: No relevant conflicts of interest to declare.

Download Full-text

Hodgkin's Lymphoma in the Elderly Patient: Impact of Age and Co-Morbidities On Outcomes.

Blood ◽

10.1182/blood.v114.22.4529.4529 ◽

2009 ◽

Vol 114 (22) ◽

pp. 4529-4529

Author(s):

Samer Nakkar ◽

Toni Pacioles ◽

Gabriela Ballester ◽

Maria Tirona ◽

Oscar F Ballester

Keyword(s):

Overall Survival ◽

Clinical Trials ◽

Older Patients ◽

Hodgkin’S Lymphoma ◽

Conflicts Of Interest ◽

Prognostic Score ◽

Hodgkin's Lymphoma ◽

Younger Patients ◽

Morbidity Score ◽

Co Morbidity

Abstract Abstract 4529 Introduction Age older than 45 years is a recognized independent prognostic factor for patients with Hodgkin's Lymphoma (HL), and it is part of the International Prognostic Score (IPS) system. This score system was based on data derived from selected patients included in clinical trials. It is unclear from these studies if age affects primarily disease biology or the ability of older patients to tolerate therapy. Patients and Methods We retrospectively reviewed all consecutive patients with newly diagnosed HL at our institution. Data collected included their IPS and a co-morbidity score (CoM) which includes assessment of co-existing cardiac, hepatic, pulmonary, renal and other morbidities. Results Forty five patients were identified. Twenty nine patients (64%) were younger than 45 years and 16 (35%) were 45 years or older. Patients were treated wit ABVD (adriamycin, bleomycin, vinblastine and DTIC) chemotherapy, with or without radiotherapy, except for 4 patients who were accrued to clinical trials. An IPS of 2 or more was documented in 17% of younger patients as compared to 71% of those older. There was a significant association between age and IPS score (p= 0.001). Similarly, there was a significant association between age and CoM score (p= 0.01). A CoM score of 4 or higher was seen in only 7.6% of the younger population but in 46.6% of the older patients. With a median follow up of 62 months, overall survival is 86 % for the entire population. Overall survival for the younger patients is 93% and for the older 71% (p= 0.01). Five of the six documented deaths occurred in patients 45 years or older, and 4 of these 5 were seen in patients over 60 years of age. Crude death rates for patients <45 (n= 29), 45 to 59 (n= 9) and 60 or older (n= 7) are: 3.4%, 11% and 57% respectively. Conclusions Older patients are more likely to present with high IPS and CoM scores which explain at least in part their poor outcomes. A high mortality rate in patients >60 years underscores the need to explore new therapeutic approaches in the older population. Disclosures: No relevant conflicts of interest to declare.

Download Full-text

Therapeutic Manipulation of Cancer Cell Metabolism with the Mitochondrial Metabolism Inhibitor Cpi-613 in Addition to Chemotherapy Abrogates the Adverse Prognostic Effect of Age in Relapsed and Refractory AML

Blood ◽

10.1182/blood-2018-99-118991 ◽

2018 ◽

Vol 132 (Supplement 1) ◽

pp. 1355-1355 ◽

Cited By ~ 2

Author(s):

Timothy Pardee ◽

Scott Isom ◽

Leslie Renee Ellis ◽

Dianna S. Howard ◽

Rupali Bhave ◽

...

Keyword(s):

Overall Survival ◽

Phase I ◽

Older Patients ◽

Median Overall Survival ◽

High Dose ◽

Younger Patients ◽

Age Related ◽

High Dose Cytarabine ◽

Refractory Aml ◽

Phase I And Ii

Abstract Background: Acute myeloid leukemia is an aggressive malignancy with poor outcomes especially in patients 60 years of age or older. This thought to be in part from increased resistance to chemotherapy in AML cells arising in an older host. One of the nine recognized biological hallmarks of aging is a decline in mitochondrial quality. The effect of exploiting this age-related metabolic vulnerability in relapsed AML has not been previously established. CPI-613 is a first-in-class agent that inhibits pyruvate dehydrogenase and α-ketoglutarate dehydrogenase, effectively impairing the TCA cycle. We have combined CPI-613 with high dose cytarabine and mitoxantrone in phase I and II clinical trials in over 100 patients with relapsed or refractory AML. Methods: To determine the effect of the addition of CPI-613 in older patients, the phase I and II datasets were combined and outcomes by age were analyzed and compared to age related outcomes in a historical dataset of patients treated with a high dose cytarabine, mitoxantrone and L-asparaginase but without CPI-613. In both trials, patients were given CPI-613 as a 2-hour infusion on days 1 through 5. Cytarabine was dosed at 3,000 mg/m² (if younger than 60) or at 1,500 mg/m² (if 60 years of age or older), given every 12 hours for 5 doses, starting on day 3 following the CPI-613 infusion. The mitoxantrone was dosed at 6 mg/m² and is given once daily following the first, third and fifth cytarabine doses. At day 14, nadir marrow was evaluated, and patients with residual disease could be re-treated as above or with an abbreviated 3-day cycle. Responding patients were eligible to receive up to 2 abbreviated 3-day consolidation cycles. The historical cohort was treated identically without CPI-613, except L-Asparaginase was given at a dose of 6,000 units/m2 following the last dose of cytarabine. Results: Patient characteristics are summarized in Table 1. In the historical dataset younger patients had a highly significant increase in median overall survival when compared to patients ≥60 years of age (figure 1A). In contrast, older and younger patients treated with CPI-613 in addition to the chemotherapy had no significant difference in median survival (figure 1B). Additionally, when outcome by dose of CPI-613 was analyzed, older but not younger patients had a significant improvement in survival when given a dose of 2,000 mg/m2 compared to those given 1,500 mg/m2 (figure 1C+D). Patients 60 years of age or older had a response rate of 55% and a median overall survival of 12.4 months when treated with a dose of CPI-613 of 2,000 mg/m2. Conclusions: Targeting mitochondrial metabolism exploits an age-related metabolic vulnerability in AML arising in older patients. These results have led to a randomized phase III trial of CPI-613 at 2,000 mg/m2 in combination with high dose cytarabine and mitoxantrone compared to high dose cytarabine and mitoxantrone alone in relapsed or refractory AML patients 60 years of age or older. Disclosures Pardee: Amgen: Speakers Bureau; Karyopharm: Research Funding; Celgene: Speakers Bureau; Rafael Pharmaceuticals: Employment; Novartis: Speakers Bureau. Ellis:Alexion: Speakers Bureau. Powell:Rafael Pharmaceuticals: Membership on an entity's Board of Directors or advisory committees.

Download Full-text

Autologous Stem Cell Transplantation for Multiple Myeloma in Patients over 70 Years: A Matched Comparison with Patients under 65 Years.

Blood ◽

10.1182/blood.v106.11.1173.1173 ◽

2005 ◽

Vol 106 (11) ◽

pp. 1173-1173

Author(s):

Shaji Kumar ◽

Martha Lacy ◽

Angela Dispenzieri ◽

Suzzane Hayman ◽

William Hogan ◽

...

Keyword(s):

Multiple Myeloma ◽

Overall Survival ◽

Stem Cell ◽

Stem Cell Transplantation ◽

Older Patients ◽

Control Group ◽

High Dose ◽

High Dose Therapy ◽

Younger Patients ◽

Dose Therapy

Abstract Background: High dose therapy with autologous stem cell rescue has been shown to prolong survival in patients with multiple myeloma in randomized controlled trials. However, most of the prospective studies have included younger patients, usually 65 or less. It is important to have a better understanding of the outcome of transplantation in the older patients given the median age of onset of myeloma of 65 years. We retrospectively reviewed our institutions experience with high dose therapy for patients over 70 years. Methods: We identified 35 patients with multiple myeloma, from the transplant database, who were at or over the age of 70 at the time of their high dose therapy. We matched these patients to 70 patients (two matches for each patient), based on stage at transplant (primary refractory, plateau phase, relapse off therapy, or relapse on therapy), Durie Salmon stage, high or low labeling index, conventional cytogenetics (abnormal vs normal), presence or absence of circulating plasma cells at time of transplant, and whether cyclophosphamide was used as part of mobilization in that order of priority. Results: The median age of the two groups were 55.3 (Range 37.3–64.8) and 71.7 (Range 70–75.8) years at the time of transplant. The median time to transplant from diagnosis was similar (6.4 for the older patients compared to 6.9 months for the other, P = NS). Ten of the 35 older patients received reduced dose melphalan (140 mg/2)) compared to 3 patients in the control group; P < 0.01. The median follow up from transplant was 10.1 months for the older patients compared to 18 months for the control group. The overall response rate was similar for the two groups (97.1% for the older patients compared to 95.5 for the control group). Eleven (31%) of the older patients and 17 (24%) of the control patients achieved a CR (P = NS). The post transplant progression free survival estimate at 1 year post transplant was 65.3% for the older patients compared to 66% for the control group (P = 0.3)The two year estimated overall survival from transplant was similar in the two groups; 58% for the older patients compared to 67% for the control group. The overall survival from diagnosis was similar for the two groups (P = 0.6). The median number of days hospitalized was 9 days for the older population compared to 5 days for the control group (P = 0.37). Four patients died within the first one hundred days, one (3%) among the older patient group and 3 (4.3%) in the control group. Conclusions: High dose therapy and autologous stem cell transplantation is feasible in selected patients with multiple myeloma over 70 years. It is likely that these older patients were selected based on their overall performance status, a factor that is difficult to analyze in this retrospective review. Nearly 70% of the elderly patients received full dose melphalan for conditioning (200 mg/m2). The toxicity of transplant as well as the outcome appears to be very similar to the younger patients. Patients with multiple myeloma should not be excluded from high dose therapy solely on the basis of their chronological age.

Download Full-text

Elderly Multiple Myeloma (MM) Patients (≥70 years) Can Safely Undergo Autologous Stem Cell Transplantation (ASCT) but Have Shorter Overall Survival Than Younger Patients (<70 years).

Blood ◽

10.1182/blood.v114.22.3409.3409 ◽

2009 ◽

Vol 114 (22) ◽

pp. 3409-3409

Author(s):

Carla Borgono ◽

Young Trieu ◽

Wei Xu ◽

Donna E. Reece ◽

Suzanne Trudel ◽

...

Keyword(s):

Overall Survival ◽

Stem Cell ◽

Renal Disease ◽

Older Patients ◽

Elevated Serum ◽

Progression Free Survival ◽

The Elderly ◽

High Dose ◽

Younger Patients ◽

Disease Characteristics

Abstract Abstract 3409 Poster Board III-297 Introduction: MM is a disease of the elderly with a median age at diagnosis of 65 years. For younger patients (<65 years), melphalan-based ASCT is standard therapy. However, limited data are available on the efficacy of ASCT in elderly patients (pts) over age 70, with concerns of excess toxicity and transplant-related mortality (TRM). Methods: From October 2000-August 2006, 548 MM pts were transplanted at our institution, 33 of whom (6%) were ≥70 years in age. Baseline demographics, disease characteristics, transplant and survival outcomes, including toxicities were collected retrospectively on all 548 patients and differences between the older patients (≥70 years) vs the younger pts (<70 years) were analyzed. Patients receiving a second salvage or tandem transplant were excluded. As per institutional transplant standard, all patients received 3-6 cycles of high-dose dexamethasone (DEX)-based induction therapy, underwent peripheral blood stem cell mobilization with cyclophosphamide 2.5g/m2 and GCSF 10mg/kg/day, and received melphalan 200mg/m2 for conditioning (no routine dose reductions for age). Ciprofloxacin prophylaxis and GCSF use (from day 7) were used routinely during the transplant process. Results: A total of 548 MM pts were studied: 33 pts ≥70 yrs of age (median 71 yrs; range 70-74); 515 pts <70 years of age (median 59 yrs; range 29-69). Patient and disease characteristics: MM subtypes for all pts included: IgG (59%), IgA (19%), biphenotypic (2%), IgD and IgM (<1%), light chain only (5%), other (10%) (no differences between the 2 groups). For the ≥70 yrs pts at baseline: median Hb was 98g/L (range 73-141), 22% of pts were hypercalcemic at diagnosis (median 2.38 mmol/L; range 2.09-4.24), 48% had significant renal dysfunction with serum creatinine >177 umol/L at diagnosis (median creatinine 94 umol/L; range 60-450), and 79% had elevated serum beta-2 microglobulin at diagnosis (median 269 nmol/L, range 5.8-505). No differences in baseline lab values were noted between the elderly and younger groups. Comorbid disorders in the elderly pts were common: 36% cardiac conditions (hypertension, coronary artery disease, heart failure, arrthythmias), 18% prior or pre-existing malignancy (solid tumours, lymphoma, leukemia), 12% diabetes, 12% gastrointestinal (ulcers, diverticular disease, colitis), 21% prior major infection (sepsis, pneumonia, TB), 6% renal disease (chronic renal failure, cystic disease), 6% CNS (stroke, seizures). Both renal disease and prior major infections were more common in the ≥70 group (renal 6 vs 1%, p=0.04 and infections 21 vs 5%, p=0.0003. Transplant outcomes: Although a standard stem cell mobilizing procedure was utilized for all pts, fewer stem cells (CD34+ cells) were collected in the ≥70 age group in comparison to the younger pts (median 12.3 vs. 9.1 × 106/kg; p=0.004). This did not, however, translate into significant differences in days to neutrophil or platelet engraftment, nor in days of hospitalization. For the ≥70 group, 76% achieved a PR (9% VGPR/CR) as assessed 3 months post-transplant, similar to the <70 group (p=0.08). Median progression-free survival from transplant was similar between groups (23.7 vs 21.8 mos, p=0.65) but median overall survival of the elderly pts was significantly shorter than that of younger patients (46.3 vs 80.4 mos, p = 0.03). Causes of death are unknown. Toxicities: Older patients exhibited cardiac toxicities (primarily arrhythmias) more frequently than younger patients during the transplant period (grade 1/2 - 3% vs 6%, grade 3/4 – 0 vs. 2%; p<0.0001). Treatment-related deaths, however, were uncommon in both groups [none in ≥70 pts vs 1.3% in <70 pts (p=0.27)]. Conclusions: Disclosures: Reece: Ortho Biotech: Honoraria, Research Funding.

Download Full-text

Bioinformatics Analysis of The Expression of ATP Binding Cassette Transporters and The Screening of Regulatory Genes in PTEN/PI3K/Akt/mTOR Signaling Pathway in The Hepatocellular Carcinoma

10.21203/rs.3.rs-674099/v1 ◽

2021 ◽

Author(s):

Tingdan Zheng ◽

Wuqi Song ◽

Aiying Yang

Keyword(s):

Gene Expression ◽

Hepatocellular Carcinoma ◽

Overall Survival ◽

Bioinformatics Analysis ◽

Wilcoxon Test ◽

Rank Test ◽

Short Term ◽

Term Survival ◽

Log Rank Test ◽

Short Term Survival

Abstract Objective Here we performed the Bioinformatics analysis on the data from The Cancer Genome Atlas (TCGA), in order to find the correlation between the expression of ATP Binding Cassette (ABC) Transporters’ genes and hepatocellular carcinoma (HCC) prognosis; Methods Transcriptome profiles and clinical data of HCC were obtained from TCGA database. Package edgeR was used to analyze differential gene expression. Patients were divided into low-ABC expression and high-ABC expression groups based on the median expression level of ABC genes in cancer. The overall survival and short-term survival (n= 341) of the two groups was analyzed using the log-rank test and Wilcoxon test; Results We found that ABC gene expression was correlated with the expression of PIK3C2B (p<0.001, ABCC1: r=0.27; ABCC10: r=0.57; ABCC4: r=0.20; ABCC5: r=0.28; ABCB9: r=0.17; ABCD1: r=0.21). All patients with low-ABC expression showed significantly increased overall survival. Significantly decreased overall survival (Log-rank test: p<0.05, Wilcoxon test: p<0.05) was found in patients with high expression of ABCC1 (HR=1.58), ABCD1 (HR=1.45), ABCC4 (HR=1.56), and ABCC5 (HR=1.64), while decreased short-term survival (Log-rank test: p>0.05, Wilcoxon test: p<0.05) was correlated with the increased expression of ABCC10 (HR=1.29), PIK3C2B (HR=1.29) and ABCB9 (HR=1.23); Conclusions Our findings indicate that the specific ABC gene expression correlates with the prognosis of HCC. Therefore, ABC expression profile could be a potential indicator for HCC patients.

Download Full-text

Abstract 14178: Characteristics and Outcomes of Young ST Segment Elevation Myocardial Infarction Patients Undergoing Primary Percutaneous Intervention

Circulation ◽

10.1161/circ.142.suppl_3.14178 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Benjamin W Tung ◽

Zhe Yan Ng ◽

William Kristanto ◽

Kalyar W Saw ◽

winnie C sia ◽

...

Keyword(s):

Myocardial Infarction ◽

Older Patients ◽

Young Patients ◽

Percutaneous Intervention ◽

Old Patients ◽

Younger Patients ◽

St Segment Elevation ◽

Segment Elevation Myocardial Infarction ◽

St Segment ◽

Primary Percutaneous Intervention

Introduction: ST-segment elevation myocardial infarction (STEMI) is associated with significant morbidity and mortality leading to loss of productivity and productive life years, especially in younger patients. Understanding the characteristics of younger patients with STEMI and their outcomes could help focus public health efforts in STEMI prevention within a population. Aim: This study aims to compare the characteristics and outcomes of younger versus older patients with STEMI undergoing primary percutaneous intervention (PPCI). Methods: Data from the Coronary Care Unit database of the National University Hospital between July 2015 to June 2019 was reviewed. Patients were divided into Young (<50 years old) or Old (≥50 years old) groups. Results: Of the 1818 consecutive patients with STEMI and underwent PPCI, 465 (25.6%) were Young patients with mean age 43±4.9 years old as compared to Old patients with mean age 63.2±9.4 years old. Young patients were more likely to be male (94% vs. 85%, p<0.0001), current smokers (61.1% vs. 42.6%, p<0.0001), of Indian ethnicity (32% vs. 16.3%, p<0.0001), and had family history of myocardial infarction (MI) (18.1% vs. 9.5%, p<0.0001). Compared to Old patients, Young patients had better post-MI left ventricular ejection fraction (49.5±10.7 vs. 47.8±11.6, p=0.007) with fewer of them suffered from cardiogenic shock (7.1% vs. 13.2%, p<0.0001), and had lower mortality at one year (3.4% vs. 10.4%, p<0.0001). Although diabetes, hypertension and hyperlipidemia was less common among the Young patients when compared to the Old, the prevalence was high in the range of 28 to 38% (Table 1). Conclusions: A sizable proportion of STEMI patients are younger than 50 years old. The risk profile of these younger patients can be attributed to constitutional factors and smoking but other cardiovascular risk factors are also prevalent among them. Although mortality is lower among the younger than the older patients, it is not negligible.

Download Full-text

How I treat elderly patients with myeloma

Blood ◽

10.1182/blood-2009-10-163329 ◽

2010 ◽

Vol 116 (13) ◽

pp. 2215-2223 ◽

Cited By ~ 25

Author(s):

Jayesh Mehta ◽

Michele Cavo ◽

Seema Singhal

Keyword(s):

Adverse Effects ◽

Older Patients ◽

Supportive Therapy ◽

The Elderly ◽

High Dose Chemotherapy ◽

Cytotoxic Agents ◽

High Dose ◽

Clinical Approach ◽

Younger Patients ◽

Best Response

Abstract The clinical approach to older patients with myeloma has to be modified to take into account comorbidities and the likelihood of higher treatment-related toxicity. Individualization of management and adequate supportive therapy are important to obtain the best response while minimizing adverse effects. Corticosteroids, novel agents, conventional cytotoxic agents, and high-dose chemotherapy with autotransplantation (modalities used in younger patients) are also used in older patients, although the elderly undergo transplantation less frequently. The sequential use of active agents singly and in different combinations has improved response rates and survival of all patients with myeloma, including the elderly.

Download Full-text

PS01.162: IS THERE A DIFFERENCE IN SURVIVAL BETWEEN YOUNGER AND OLDER GASTRIC CANCER (INCLUDING AEG II AND AEG III) PATIENTS AFTER GASTRECTOMY?

Diseases of the Esophagus ◽

10.1093/dote/doy089.ps01.162 ◽

2018 ◽

Vol 31 (Supplement_1) ◽

pp. 95-95

Author(s):

Benjamin Babic ◽

Florian Matthias Corvinus ◽

Edin Hadjijusufovic ◽

Evangelos Tagkalos ◽

Hauke Lang ◽

...

Keyword(s):

Gastric Cancer ◽

Survival Rate ◽

Elderly Patients ◽

Conflicts Of Interest ◽

Subtotal Gastrectomy ◽

Young Patients ◽

Western World ◽

Old Patients ◽

Younger Patients ◽

Significant Difference

Abstract Background The incidence of gastric cancer decreases in the western world, however, it remains one of the most common diseases (1). There is just little data from Europe comparing the outcome of young and elderly gastric cancer patients. This study compares, depending on the age of 266 patients, the outcome of 266 consecutive gastrectomy cases due to gastric cancer Methods 266 consecutive patients with gastric cancer received a gastrectomy between 2008–2016 at our comprehensive cancer centre. The mean age of the patients in this study was 64 years old (21- 93 years). All patients were followed up regarding survival. The patients were separated in 6 different groups, depending on the age at the time of operation. The different groups were re-analysed and compared to each other regarding median and 5-year survival. Results In this collective the 5-year survival rate for all patients was 43%. There were more diffuse type adenocarcinomas in Patients < 40 years. In younger patients the tumour was staged in an advanced stadium compared to the elderly patients group. There is a significantly higher 5-year survival rate for younger patients after gastrectomy. There is no significant difference, when separating patient groups in to decades of age. Conclusion Young patients have a higher 5-year survival rate after gastrectomy compared to old patients. However, comparing patients from chronologic age in decades, the significance is not reproducible. Therefore gastrectomy or subtotal gastrectomy is the determining therapeutic approach for gastric cancer with an acceptable outcome in both young and elderly patients. Older patients might have an lower 5 year survival rate not only due to the cancer or the surgical therapy itself, it is related to comorbidities and a lower rate in neoadjuvant therapy as well Disclosure All authors have declared no conflicts of interest.

Download Full-text

Compound Sarcopenia in Hospitalized Patients with Cirrhosis Worsens Outcomes with Increasing Age

Nutrients ◽

10.3390/nu13020659 ◽

2021 ◽

Vol 13 (2) ◽

pp. 659

Author(s):

Nicole Welch ◽

Amy Attaway ◽

Annette Bellar ◽

Hayder Alkhafaji ◽

Adil Vural ◽

...

Keyword(s):

Chronic Diseases ◽

Older Patients ◽

Hospitalized Patients ◽

Muscle Loss ◽

Term Care ◽

Old Patients ◽

Younger Patients ◽

Age Related ◽

Number Of Patients ◽

The Impact

Background: There are limited data on outcomes of older patients with chronic diseases. Skeletal muscle loss of aging (primary sarcopenia) has been extensively studied but the impact of secondary sarcopenia of chronic disease is not as well evaluated. Older patients with chronic diseases have both primary and secondary sarcopenia that we term compound sarcopenia. We evaluated the clinical impact of compound sarcopenia in hospitalized patients with cirrhosis given the increasing number of patients and high prevalence of sarcopenia in these patients. Design: The Nationwide Inpatients Sample (NIS) database (years 2010–2014) was analyzed to study older patients with cirrhosis. Since there is no universal hospital diagnosis code for “muscle loss”, we used a comprehensive array of codes for “muscle loss phenotype” in the international classification of diseases-9 (ICD-9). A randomly selected 2% sample of hospitalized general medical population (GMP) and inpatients with cirrhosis were stratified into 3 age groups based on age-related changes in muscle mass. In-hospital mortality, length of stay (LoS), cost of hospitalization (CoH), comorbidities and discharge disposition were analyzed. Results. Of 517,605 hospitalizations for GMP and 106,835 hospitalizations for treatment of cirrhosis or a cirrhosis-related complication, 207,266 (40.4%) GMP and 29,018 (27.7%) patients with cirrhosis were >65 years old, respectively. Muscle loss phenotype in both GMP and inpatients with cirrhosis 51–65 years old and >65 years old was significantly (p < 0.001 for all) associated with higher mortality, LoS, and CoH compared to those ≤50 years old. Patients >65 years old with cirrhosis and muscle loss phenotype had higher mortality (adjusted OR: 1.06, 95% CI [1.04, 1.08] and CoH (adjusted odds ratio (OR): 1.10, 95% confidence interval (CI) [1.04, 1.08])) when compared to >65 years old GMP with muscle loss phenotype. Muscle loss in younger patients with cirrhosis (≤50 years old) was associated with worse outcomes compared to GMP >65 years old. Non-home discharges (nursing, skilled, long-term care) were more frequent with increasing age to a greater extent in patients with cirrhosis with muscle loss phenotype for each age stratum. Conclusion: Muscle loss is more frequent in older patients with cirrhosis than younger patients with cirrhosis and older GMP. Younger patients with cirrhosis had clinical outcomes similar to those of older GMP, suggesting an accelerated senescence in cirrhosis. Compound sarcopenia in older patients with cirrhosis is associated with higher inpatient mortality, increased LoS, and CoH compared to GMP with sarcopenia.

Download Full-text

Newly Diagnosed Myeloma Pateints Are at Risk of Venous Thrombotic Events - High Risk Patients Need To Be Identified and Recieve Thromboprophylaxis: The MRC Experience.

Blood ◽

10.1182/blood.v104.11.2395.2395 ◽

2004 ◽

Vol 104 (11) ◽

pp. 2395-2395

Author(s):

Faith E. Davies ◽

J. Anthony Child ◽

Kim Hawkins ◽

Susan Bell ◽

Julia Brown ◽

...

Keyword(s):

High Risk ◽

Older Patients ◽

Autologous Transplantation ◽

High Dose ◽

Central Venous ◽

Thrombotic Risk ◽

Younger Patients ◽

High Risk Patients ◽

Increased Risk ◽

Risk Patients

Abstract Standard treatment for younger patients with presenting myeloma is VAD followed by high-dose melphalan with stem cell support. However this regimen requires a central venous catheter with risks of recurrent line infections and central venous thrombus. A number of oral alternatives have been used including dexamethasone (Dex), thalidomide (Thal) or combinations (Thal/Dex), although to date no randomized control trial has compared an intravenous with oral induction therapy. In older patients melphalan/prednisolone (MP) remains the standard approach. Thal combinations (MPT, CTD, DVdT) improve response rates and providing side effects can be managed effectively may also be appropriate for an elderly population. Patients with myeloma have an increased risk of venous thrombotic events (VTEs), and presenting patients receiving Thal may be at increased risk due to bulk disease. Combination with anthracyclines may also exacerbate this risk. The MRC Myeloma IX trial has been designed to address some of these issues. Younger patients are randomized to receive intravenous CVAD or an oral Thal containing regimen, CTD prior to autologous transplantation; older patients are randomized to MP or the Thal containing regimen, CTDa. At trial initiation (May 2003) physicians were advised that patients should start low-dose Thal (100mg od in the intensive and 50mg od in the non-intensive arm) and slowly dose escalate to 200mg. Patients at high risk of VTE should be considered for full anticoagulation with either warfarin or LMWH. As of Aug 2004 420 patients (239 intensive, 181 non-intensive) have been randomized and a total of 30 VTEs in 28 patients have been reported (22 intensive, 6 non-intensive). In the intensive arm there were 8 DVT, 9 PE and 7 line-related thromboses. In the non-intensive arm there were 4 DVT and 2 PE. CVAD CTD CTDa MP DVT 4.2% 2.5% 4.4% 0% PE 1.7% 5.8% 2.2% 0% Line related 5.0% 0.8% NA NA Total 10.9% 9.1% 6.6% 0% The median time from randomization to DVT/PE was 54.5 days (range 15–113). 4 patients were identified who had additional risk factors (2 immobility, 1 recent operation, 1 renal failure). Only 1 patient was receiving prophylaxis having previously suffered a DVT. There was one PE-related death. Importantly 2 PE and 5 DVT occurred in patients not receiving Thal therapy. All central thrombosis occurred in relation to the central line. In the non-intensive arm the addition of Thal increased VTE risk compared to MP. In conclusion myeloma patients have an increased incidence of VTE (5.9%–8.3%) although in this study so far patients on MP appear to have no excess thrombotic risk. Patients receiving infusional regimes are also at increased risk of line-related events (additional 5.0%). Using the combination of a slowly increasing Thal dose and thromboprophylaxis based on identification of high risk patients the addition of Thal marginally increased DVT/PE risk over and above the risk seen in patients with infusional regimens, but even in a large study such as this the number of events are too small to make firm recommendations. Currently our advice remains unchanged and ALL high risk patients should receive thromboprophylaxis.

Download Full-text