Poor risk assessment in the elderly receiving cloretazine induction for AML or MDS

2006 ◽  
Vol 24 (18_suppl) ◽  
pp. 18562-18562
Author(s):  
R. Geller ◽  
D. Rizzieri ◽  
N. Vey ◽  
S. O’Brien ◽  
B. Johnson ◽  
...  
Keyword(s):  
The Elderly ◽  
Myelogenous Leukemia ◽  
Common Disease ◽  
Cell Transplant ◽  
Significant Activity ◽  
Related Factors ◽  
Related Data ◽  
Poor Risk ◽  
Comorbidity Index ◽  
Weighted Values

18562 Background: Elderly patients (pts) ≥60 years with acute myelogenous leukemia (AML) have lower response rates, and higher morbidity and mortality than younger pts when treated with cytotoxic induction therapy. Common disease-related factors that predict poor response in the elderly are adverse cytogenetics and secondary leukemia (following antecedent hematologic disorder or exposure to chemotherapy). Pt-related factors such as ECOG performance status (PS) and organ dysfunction affect treatment decisions due to poor tolerability and early death. Cloretazine, a novel alkylating agent has significant activity in AML and MDS with a favorable safety profile. A Phase II study of monotherapy induction was conducted in elderly pts with AML or high risk MDS (N = 105, median age 72, range 60–88), with a 31% complete response rate and minimal non-hematologic toxicity. To describe the pts in this study considered “unfit” for 7+3 induction, disease-related and pt-related information was obtained. The Hematopoietic Cell Transplantation Comorbidity Index (Sorrer et al, 2005) (HCT-CI) is a modification of the Charlson Comorbidity Index (Charlson et al.1987), for pts considered for stem cell transplant. Seventeen medical conditions are included with weighted values predicting non-relapse mortality (NRM). Methods: Baseline demographic and pt-related data was obtained from case report forms. In addition to disease-related prognostic indicators, pt-related data was scored by the HCT-CI. Pts were grouped in risk categories for NRM by HCT-CI scores (low = 0, intermediate = 1 or 2; high ≥3). Results: Either or both disease-related poor risk factors were present in 68 pts (65%): 42 pts (40%) had unfavorable cytogenetics and 45 pts (43%) had secondary AML. No pt had favorable cytogenetics. Ninety-four (89%) pts had at least one HCT-CI comorbidity. The most common were cardiac (46%), psychiatric (28%); hepatic (25%) and controlled infection (24%). By HCT-CI, the risk for NRM was low in 10%, intermediate in 32%, and high in 57% of pts. Conclusions: The majority of these elderly pts were poor-risk by disease-related criteria or comorbidities measured by the HCT-CI. This index warrants further testing for determining NRM risk of induction regimens for elderly pts with AML. [Table: see text]

Treating the Elderly Patient with Acute Myelogenous Leukemia

Hematology ◽  
2010 ◽  
Vol 2010 (1) ◽  
pp. 62-69 ◽  
Author(s):  
Selina M. Luger
Keyword(s):  
Elderly Patient ◽  
Acute Myelogenous Leukemia ◽  
Intensive Therapy ◽  
Age Groups ◽  
The Elderly ◽  
Population Based ◽  
Myelogenous Leukemia ◽  
Best Interest ◽  
Related Factors ◽  
Acute Myelogenous

Abstract Decisions regarding the optimal treatment of acute myelogenous leukemia in the elderly patient requires the consideration of multiple factors. Population-based studies have demonstrated that, for all age groups, aggressive therapy results in improved survival and quality of life when compared with palliative care. The optimal induction and postremission regimen for older patients has yet to be determined. Furthermore, not all patients are candidates for such therapy. Consideration of patient and disease-related factors can help to determine the appropriateness of intensive therapy in a given patient. For those patients for whom aggressive induction therapy does not seem to be in their best interest, novel agents are being investigated that will hopefully address the issues of induction death and early relapse associated with these patient populations.

Comorbidity Indices Predict Survival Among Elderly Patients with Acute Myelogenous Leukemia but Do Not Aid in Selecting Between Traditional Induction Chemotherapy and 5-Azacytidine Treatment.

Blood ◽  
2009 ◽  
Vol 114 (22) ◽  
pp. 1040-1040
Author(s):  
Stuart L. Goldberg ◽  
Aisha Masood ◽  
Jayshree Shah ◽  
Jack W. Hsu ◽  
Neelesh Rastogi ◽  
...  
Keyword(s):  
Overall Survival ◽  
Elderly Patients ◽  
Induction Chemotherapy ◽  
Median Survival ◽  
Acute Myelogenous Leukemia ◽  
Myelogenous Leukemia ◽  
Poor Risk ◽  
Acute Myelogenous ◽  
Comorbidity Index ◽  
Better Than

Abstract Abstract 1040 Poster Board I-62 Treatment of the elderly patient with acute myelogenous leukemia remains problematic as many have poor performance status precluding aggressive therapy and others have high risk features including abnormal cytogenetics. The success of 5-azacitidine among patients with advanced myelodysplastic syndromes in controlling blast cells and prolonging survival has led to its use in AML. However choosing between potentially curative hospital-based induction chemotherapy and palliative outpatient hypomethylating treatments is difficult. The availability of predictive comorbidity scores may aid in guiding patients in this decision. Methods: Patients with a new diagnosis of AML, ages 60 and older, were offered traditional in-patient induction therapy (7 days cytarabine 100 mg/m2 CI with 3 days idarubicin 12mg/m2) or out-patient therapy (5-azacitidine 75 mg/m2 IV 5 days per month). We report a retrospective review of clinical outcomes among patients treated between June 2003 and August 1, 2009. A review of presenting clinical features, placing patients into prognostic groupings by the Charlson Comorbidity Index (J Chronic Dis 1987; 40:373), Hematopoietic Cell Transplantation – Specific Comorbidity Index (Blood 2007; 110:4606), and the Myelodysplastic Syndrome – Specific Comorbidity Index (Blood 2008; 112: abstr 2677) was performed. Points for a diagnosis of leukemia were excluded from the indices. Results: 99 patients with AML were treated at our center, all with leukemic blasts >20% (median 48%). 75 chose traditional 7+3 and 24 chose 5-aza. The median age was younger for those choosing 7+3 (67 vs 77 years, p<0.001). The median survival for all patients was 340 days (95% CI 258, 422). The median survival was longer with 7+3 at 367 days (95% CI 306,428) compared to a median survival with 5-aza of 186 days (95% CI 122, 250) (p=0.07). Only one patient age <65 chose 5-aza. The median survival for pts with 7+3 was similar by age groups: <65 yrs (n=34) 367 days, 65-69 yrs (n=19) 340 days, and ≥70 yrs (n=22) 467 days (log-rank p=0.31). Cytogenetic features (SWOG criteria) at baseline correlated with survival: good risk (n=3) 186 days, intermediate risk (n=54) 604 days, and poor risk (n=28) 241 days. (p=0.03). Similarly, cytogenetic risk continued to remain significant regardless of treatment choice: 7+3: intermediate/poor risk karyotype 664 days vs 340 days, and 5-aza: intermediate/poor risk 604 days vs 67 days (p=0.03). All 3 examined comorbidity indices were able to predict overall survival for the entire cohort (n=99). Using the CCI, better scores led to improved outcome (log-rank p=0.007): Score 0 (n=41): 475 days; score 1 (n=23): 213 days; score 2 (n=25): 196 days; score 3 (n=8): 186 days; score 4 (n=2) 1404 days. Similar results were obtained using the HCTS-CI (log-rank p=0.01): Score 0 (n=33): 475 days; score 1 (n=24): 353 days; score 2 (n=13): 146 days; score 3 (n=17): 196 days; score 4 (n=5) 1113 days; score 5 (n=5) 337 days; score 8 (n=1) 1404 days. And using the MDS-CI (log-rank p=0.02) better scores predicted improved survival: Score 0 (n=64): 375 days; score 1 (n=18): 241 days; score 2 (n=13): 186 days; score 3 (n=3): 69 days; score 4 (n=1) 1404 days. In addition, patients who scored well on the CCI did better (p=0.005) than patients with poor scores by type of treatment (ie, a low score patient treated with 7+3 did better than a high score patient treated with 7+3, and a low score patient treated with 5-aza did better than a high score patient treated with 5-aza). Similar relationships were noted between scores on the HCTS-CI and MDS-CI and treatment choice. However, in all CCI score categories, 7+3 treatment was superior to 5-aza (score 0: 839 vs 298 days; score 1: 276 vs 69 days; score 2: 279 vs 106 days; score 3: 435 vs 90 days) (p=0.08). Similarly 7+3 treatment appeared superior to 5-aza by HCTS-CI score (p=0.02) and MDS-CI (p=0.05). Conclusions: Elderly patients with AML can achieve survivals approaching one year with current treatment options. 5-azacytidine is a reasonable option for patients declining aggressive hospital based treatments especially if cytogenetic features are favorable, however overall survival may be inferior to standard induction chemotherapy. Although comorbidity indices are able to stratify potential outcomes among elderly patients with AML choosing a particular treatment, in our series we could not identify a comorbidity score that would dissuade aggressive treatment in favor of less intensive therapy. Disclosures: Goldberg: Celgene: Speakers Bureau. Off Label Use: 5-azacytidine use in AML. Masood:Celegene: Speakers Bureau.

Phase 2 Study of Decitabine in Combination with Tretinoin in Myelodysplastic Syndromes and Acute Myelogenous Leukemia: Interim Results

Blood ◽  
2012 ◽  
Vol 120 (21) ◽  
pp. 3815-3815 ◽  
Author(s):  
Virginia M. Klimek ◽  
Emily K Dolezal ◽  
Joseph G. Jurcic ◽  
Sean Devlin ◽  
Kevin Zikaras ◽  
...  
Keyword(s):  
High Risk ◽  
Median Time ◽  
Myelodysplastic Syndromes ◽  
Acute Myelogenous Leukemia ◽  
Myelogenous Leukemia ◽  
Cell Transplant ◽  
Phase 2 ◽  
Poor Risk ◽  
Best Response ◽  
Acute Myelogenous

Abstract Abstract 3815 Background: The activity of DNA methyltransferase inhibitor (DNMTI) monotherapy is suboptimal for most patients (pts) with myelodysplastic syndromes (MDS) and acute myelogenous leukemia (AML). DNMTI combinations studied to date have not convincingly produced higher response rates compared to DNMTI monotherapy, although time to response appears to be improved in some studies. We combined decitabine (DAC) with tretinoin (ATRA), an RAR ligand which can recruit histone acetyltransferases to gene regulatory regions, as a means to upregulate gene expression, and to induce apoptosis or differentiation, as is seen in in vitro studies of non-M3 AML. Our previous phase 1 study established 65 mg/m2/day of ATRA as the MTD (headache was DLT at 85 mg/m2/d) when given on days 10–19 following standard dose decitabine (20 mg/m2/d), given on days 1–5 of a 28-day cycle (Klimek VM, et al. Leuk Res, 2011;35:S70-S). Materials and Methods: MDS pts with any FAB or WHO subtype were enrolled if they had an IPSS score ≥ 0.5, were ineligible for allogeneic stem cell transplant (AlloSCT) at study entry, and had adequate hepatic and renal function. Prior DAC or 5-azacytidine (5-aza) responders who then progressed off treatment, and pts whose MDS progressed on 5-aza were eligible. Pts received up to 10 cycles of DAC (given on days 1–5) and tretinoin (65 mg/m2/d on days 10–19 of a 28-day cycle), allowing for delays due to infection or to allow count recovery as deemed necessary by the treating physician. Those with an ongoing response after 10 cycles continued DAC alone off-study. The primary endpoint is efficacy, assessed after even-numbered cycles using the 2006 Modified International Working Group MDS response criteria. Kaplan-Meier methodology was used to estimate duration of best response due to the censoring for patients undergoing AlloSCT. Results: 36 eligible pts (27M, 9F; median age 66, range 45–84 yrs) were enrolled in the phase 2 cohort as of 6/2012. FAB/WHO subtypes included: RA/RCMD, n=3 (8%); RARS/RCMD-RARS, n=1 (3%); RAEB/RAEB-1 & 2, n= 24 (67%); RAEBt/AML, n= 6 (17%); CMML/CMML-1, n=2 (6%). IPSS risk categories included: Int-1, n=5 (14%); Int-2, n=16 (44%); High Risk, n=11 (31%), and pts with ≥ Int-1 (n=3) or ≥ Int-2 (n=1) risk disease who could not be definitively classified using the IPSS. Most pts (n=20) had IPSS poor risk cytogenetics (CG), 11 had IPSS good risk CG (all with normal karyotype), 3 had intermediate risk CG, and CG results were unknown in 2 pts. 15/36 (42%) had therapy-related disease (t-MDS/AML), all with IPSS poor risk CG and either IPSS Int-2 (n=9) or High Risk (n=6) disease. Marrow blasts were ≥ 5% in 26/36 pts: (5–10%, n=13; 11–20%, n=13; 21–30%, n=6). Prior MDS therapy included lenalidomide (n=2), thalidomide (n=1), 5-aza (n=3), DAC (n=1), and lintuzumab (n=1). Pts received a median of 4 cycles of therapy (range, 1–10), and started therapy 0.6–180 months (median, 1.42 months) from the time of diagnosis. Two pts were classified as treatment failures since they died during the first cycle of therapy. One pt with CMML-1 at baseline progressed to AML during the screening period, and was deemed ineligible. Two pts on study have not yet had a full response assessment. Best responses in the evaluable intent to treat cohort (n=33) include: CR, n=7 (21%); PR, n=1 (3%); mCR, n=3 (9%); mCR+HI, n=3 (9 %); HI alone, n=3 (9 %); Stable disease, n=10 (30%); Disease progression, n= 3 (9%). The composite CR rate (CR+mCR±HI) was 39% (13/33), and the overall response rate (CR+PR+mCR±HI+HI) is 51% (17/33). Median time from diagnosis to start of therapy for responders was 1.7 months (range, 0.8–180). The ORR for the 13 t-MDS/AML pts was 46% (6/13), including 5 pts with monosomy 17 and/or p53 loss by FISH. The median time to initial response and best response is 1.1 months and 2.3 months, respectively. The median response duration is 7.8 months, incorporating the 7 pts censored at the time they came off study to undergo AlloSCT. Conclusions: DAC/ATRA is active in IPSS Int-2 and High Risk MDS and in t-MDS/AML, which is characterized by poor risk cytogenetics and an increased frequency of p53 or chromosome 17p loss. Although our interim ORR appears similar to DAC and 5-aza monotherapy trials, our results were achieved in a higher risk cohort, and the CR rate is equal to or greater than some earlier monotherapy studies with a shorter median time to response. Ongoing and planned correlative studies may define pre-treatment biomarkers for response. Disclosures: Off Label Use: Tretinoin.

High Dose Cytarabine, Mitoxantrone and L-Asparaginase (HAMA) Salvage For Relapsed Or Refractory Acute Myeloid Leukemia (AML) In The Elderly

Blood ◽  
2013 ◽  
Vol 122 (21) ◽  
pp. 2700-2700 ◽  
Author(s):  
Tamjeed Ahmed ◽  
Scott Holwerda ◽  
Timothy Pardee ◽  
Scott Isom ◽  
Susan Lyerly ◽  
...  
Keyword(s):  
Complete Remission ◽  
Median Survival ◽  
Older Patients ◽  
The Elderly ◽  
High Dose ◽  
Cell Transplant ◽  
Hematopoietic Stem ◽  
Poor Risk ◽  
Elderly Aml ◽  
High Dose Cytarabine

Abstract AML is a disease of older adults with the median age at diagnosis of 68. Elderly AML, generally defined as patients ≥60 years of age, is a clinically distinct disease highlighted by worse overall survival (OS), lower complete remission (CR) rates, and higher treatment related toxicity. Most elderly AML patients who achieve a CR will eventually relapse and require further chemotherapy. Despite the central role of relapsed disease in elderly patients few studies have reported on outcomes using salvage chemotherapy in patients over 60 years of age and no standard regimen has been established. We retrospectively examined data for 108 consecutive relapsed or refractory AML patients treated with the HAMA regimen at Wake Forest between May, 1999 and December, 2010. This regimen consists of high dose cytarabine (3gm/m2 in patients <60, 1 to 3gm/m2 in patients ≥60) given Q12 hours for 5 doses, mitoxantrone at 6mg/m2 once daily for 3 days immediately following the cytarabine and a single dose of L-asparaginase at 6000 units/m2 following the last dose of mitoxantrone. We collected data on age, gender, race, comorbidities, baseline lab values, cytogenetics at relapse, length of first remission (CR1), attainment of second complete remission (CR2), further therapy received and survival. Statistical analysis was performed using Kaplan-Meier estimates and Cox proportional hazards models. Of the 108 patients analyzed, 75 were ≥60 years old and 33 were younger than 60 at the time of HAMA treatment. The median age for the younger cohort was 51 (range 20-59) and for the elderly cohort was 68 (range 60-84). Older patients were more likely to have refractory disease (25% vs 6%), one or more comorbidities (47% vs 12%) and poor risk cytogenetics (23% vs 16%). Early all cause mortality (30 and 60 day) was 13% and 22% respectively for all patients and 17% and 28% for those ≥60. The percentage of patients that died during hospitalization or were discharged to hospice was 25% for all patients (12% <60, 31% ≥60). CR2 was achieved in 41% of patients (49% <60, 37% ≥60). Median OS was 7 (2.1-14.3), 13.6 (4.9-68) and 5.8 (1.3-11.9) months for all patients, <60 and ≥60 cohorts respectively. For those patients ≥60 who achieved a CR median OS was 11.9 months. At 12 months 56% of patients <60 were alive compared with 24% for patients ≥60. By 24 months these numbers fell to 40% and 3% respectively. In the <60 cohort 27% (9/33) went on to allogeneic hematopoietic stem cell transplant (HCT) compared to 12% (9/75) in the ≥60 cohort. The only significant predictors for OS were cytogenetic risk score (p=0.0050) and length of first CR >1 year (p=0.0005). Of the 16 patients in the cytogenetic poor risk group only 12% (2/16) achieved CR2 and none were alive more than 14 months from relapse. Median survival for patients with CR1 >1 year was 13.6 (5.9-19.7) months compared to 5.8 (3.3-7.2) months for patients with CR1 <1 year. In conclusion, the HAMA salvage regimen when given to older patients results in a 37% complete remission rate with a median survival of almost one year in this subgroup, however only 12% went on to allogeneic HCT and only 3% were alive 24 months after relapse. Patients with poor risk cytogenetics regardless of age were not effectively salvaged with this regimen and should be offered experimental therapy when possible. Disclosures: No relevant conflicts of interest to declare.

scholarly journals Supply and Demand-Related Decisive Factors in the Utilization of Non-Medical Community Healthcare Services among Elderly Chinese

2020 ◽  
Vol 18 (1) ◽  
pp. 228
Author(s):  
Zhao Yu ◽  
Lijian Wang ◽  
Tolulope Ariyo
Keyword(s):  
Supply And Demand ◽  
The Elderly ◽  
Healthcare Services ◽  
Medical Community ◽  
Quality Service ◽  
Related Factors ◽  
Community Healthcare ◽  
Elderly Chinese ◽  
Service Need ◽  
Community Healthcare Services

There is little research on the utilization of non-medical community healthcare services among the elderly, compared with that of medical community healthcare services. From the perspective of both supply and demand, based on the survey data from Shaanxi province, this study examined supply-related factors (including service supply, service quality, service charge and service accessibility) and demand-related factors (including service need, individual financial status, family care support and knowledge of service) affecting the utilization of non-medical community healthcare services among the elderly in China by using Poisson regression. The findings show that service supply, service quality, service need and knowledge of service are positively associated with the utilization of non-medical community healthcare services among elderly Chinese, but the other factors identified in previous studies are not significant predictors for the utilization of the services among the elderly in the context of China. To our knowledge, this is the first study to examine both supply-related factors and demand-related factors affecting the utilization of non-medical community healthcare services among elderly Chinese.

scholarly journals FRI0322 INSULIN RESISTANCE IN NON-DIABETES PATIENTS WITH SPONDYLOARTHRITIS

2020 ◽  
Vol 79 (Suppl 1) ◽  
pp. 752.2-753
Author(s):  
J. C. Quevedo-Abeledo ◽  
F. Genre ◽  
J. Rueda-Gotor ◽  
A. Corrales ◽  
V. Hernández-Hernández ◽  
...  
Keyword(s):  
Cell Function ◽  
Inflammatory Diseases ◽  
Univariate Analysis ◽  
Serum Levels ◽  
Β Cell ◽  
Related Factors ◽  
C Peptide ◽  
Related Data ◽  
Β Cell Function ◽  
Beta Coefficient

Background:Insulin resistance (IR) is a state in which a given concentration of insulin is associated with a subnormal glucose response. IR constitutes a major underlying abnormality driving cardiovascular disease in the general population and has been linked to inflammatory diseases. In this sense, several reports have confirmed that inflammation worsens IR and impairs pancreatic β-cell function in inflammatory diseases such as rheumatoid arthritis and systemic lupus erythematosus.Objectives:In this study we aimed to determine the prevalence of IR in patients with spondyloarthritis (SpA) compared to controls, and whether IR can be explained by disease-related features in SpA patients.Methods:Study of 577 subjects, 306 patients diagnosed with SpA according to ASAS criteria and 271 controls. Insulin and C-peptide serum levels, IR and β-cell function (%B) indexes by homeostatic model assessment (HOMA2), and lipid profiles were assessed in patients and controls. A multivariate regression analysis was performed to evaluate the differences in IR indexes between patients and controls and to determine how IR is associated with disease-related characteristics.Results:SpA patients showed higher serum levels of insulin (8.7 [4.8-15.9] vs. 8.0 [5.7-11.2] uU/ml, p=0.001) and C peptide (1.4 [0.7-2.5] vs. 1.2 [0.7-1.7] ng/ml, p=0.000) than controls in the univariate analysis. Similarly, HOMA2-B% and IR were all significantly higher in SpA patients. These differences were still evident when the comparisons were made after the multivariate analysis had been adjusted for traditional IR-related factors (sex, age, BMI, hypertension, dyslipidemia, smoking and, cholesterol), glucocorticoids intake, insulin and C-peptide. Moreover, HOMA2-B% and HOMA2-IR scores, both calculated with insulin or C-peptide, yielded statistically higher significant values in SpA patients than controls.Classic IR-related factors (age, BMI, waist circumference, hypertension, obesity, dyslipidemia, atherogenic index, and triglycerides), as well as CRP serum levels, were all related, to a greater or lesser degree, with IR and β-cell function. Regarding disease-related data, ASDAS-CRP, BASFI and BASMI scores were positively associated with IR; and BASMI and BASDAI scores were positively related to HOMA2-%B-C peptide. Moreover, the use of NSAID and prednisone were, respectively, positive and negatively related to β-cell function. However, only some of the associations of the univariate analysis were maintained after adjusting for confounders. In this sense, disease duration (beta coefficient 2 [95% CI 1-3], p=0.001) and positivity for HLA-B27 (beta coefficient 30 [95% CI 12-49], p=0.002) were associated with higher β-cell functionality after the multivariate analysis.Conclusion:Patients with SpA have an increased IR compared to controls. SpA disease-related data like disease duration and HLA-B27 are independently associated with β-cell dysfunction.Disclosure of Interests:Juan Carlos Quevedo-Abeledo Speakers bureau: Abbvie, Fernanda Genre: None declared, Javier Rueda-Gotor: None declared, Alfonso Corrales Speakers bureau: Abbvie, Vanessa Hernández-Hernández Speakers bureau: Pfizer, Abbvie, MSD, Natalia Fañanas-Rodríguez: None declared, Bernardo Lavín-Gómez: None declared, delgado frias esmeralda Speakers bureau: Pfizer, Abbvie, MSD, Antonia de Vera-González: None declared, Alejandra Delgado-González: None declared, Laura de Armas-Rillo: None declared, Maria Teresa García-Unzueta: None declared, Miguel A González-Gay Grant/research support from: Pfizer, Abbvie, MSD, Speakers bureau: Pfizer, Abbvie, MSD, Iván Ferraz-Amaro Grant/research support from: Pfizer, Abbvie, Speakers bureau: Pfizer, Abbvie, MSD.

scholarly journals 1153. Characterization of Invasive Mold Infections in Acute Leukemia and Hematopoietic Stem Cell Transplant Recipient Patients and Risk Factors for Mortality - a Single Center Experience

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S603-S604
Author(s):  
Ryan Kubat ◽  
Praveen Subramanian ◽  
Yanming Li ◽  
Kassem Hammoud ◽  
Albert Eid ◽  
...  
Keyword(s):  
Risk Factors ◽  
Stem Cell ◽  
Acute Leukemia ◽  
Regression Model ◽  
Hematopoietic Stem Cell ◽  
Cox Model ◽  
Myelogenous Leukemia ◽  
Cell Transplant ◽  
Hematopoietic Stem ◽  
Invasive Mold Infections

Abstract Background Invasive mold infections (IMIs) remain a significant cause of morbidity and mortality in patients with acute leukemia (AL) and those undergoing hematopoietic stem cell transplantation (HSCT). We describe the epidemiology of IMIs, the incidence of IMI in patients with acute myelogenous Leukemia (AML) post HSCT, and risk factors for mortality. Methods Patients were identified using ICD9 and ICD10 codes using a University of Kansas internal database from 2009-2019, microbiology records, and an AML HSCT database and were followed through May 1st, 2020. Patients’ electronic medical records were reviewed for inclusion. IMI was defined as proven or probable using the 2009 National Institute of Allergy and Infectious Diseases Mycoses Study Group (MSG) guidelines. Incidence was calculated as IMI cases/100-person-years. Risk factors for overall mortality were evaluated using a Cox regression model. Results We included 138 patients: 79 developed IMI after HSCT (8 autologous, 71 allogeneic) and 59 developed IMI after AL diagnosis. Seventeen of the AL patients underwent HSCT after IMI diagnosis (12 within 100 days of IMI). Proven IMI occurred in 45 (32.6%) and probable IMI occurred in 93 (67.4%) patients. The most common prophylactic agent prior to IMI diagnosis was fluconazole (31.2%), with 21.0% receiving none. Aspergillus was the most commonly identified mold with 91 (65.9%) cases. The average treatment duration was 101 (range 0 - 799) days. The incidence of IMI in patients with AML who underwent HSCT was 2.35 cases/100 person-years. All-cause mortality among patients with AL or HSCT who developed IMI was 23.1% at 6 weeks, 34.1% at 12 weeks, and 61.2% at 1 year. On univariate Cox model, Karnofsky performance status &gt; 70 was associated with lower mortality (hazard ratio (HR) 0.317, 95% confidence interval (CI) [0.110, 0.914]) among HSCT recipients. ICU admission within 7 days prior to IMI diagnosis (HR 6.469, 95% CI [1.779, 23.530]) and each one point increase in BMI (HR 1.051, CI [1.001, 1.103]) were associated with increased mortality in the AL group. Figure 1 - Invasive mold infections by pathogen in HSCT-recipients and acute leukemia patients from 2009-2019. Figure 2 - Antifungal prophylactic agents prescribed for at least one week at time of IMI diagnosis Table 1 - Univariate survival analysis calculated using a Cox proportional-hazards regression model among patients who developed IMI after HSCT and patients who developed IMI after acute leukemia diagnosis Conclusion IMIs are associated with significant mortality in HSCT recipients and AL patients; patients at higher risk for mortality include those with lower baseline Karnofsky scores, recent ICU admissions, and higher BMI at time of IMI diagnosis. Disclosures Wissam El Atrouni, MD, ViiV (Advisor or Review Panel member)

HYPERTENSION IN ELDERLY:OUR CURRENT TRENDS

2021 ◽  
pp. 56-57
Author(s):  
Rohit Arora ◽  
D.K Sharma
Keyword(s):  
Blood Pressure ◽  
Elderly Patients ◽  
The Elderly ◽  
Common Disease ◽  
Old Patients ◽  
Current Trends ◽  
Increased Risk ◽  
Individualized Approach ◽  
Risk Of Falls ◽  
Optimal Target

Hypertension is a common disease in the elderly associated with signicant morbidity and mortality. Due to the complexity of this population, the optimal target of blood pressure (BP) control is still controversial. In this article, we conduct a literature review of trials published in English in the last 10 years which were specically designed to study the efcacy and safety of various BP targets in patients who are 70 years or older. Using these criteria, we found that the benets in the positive studies were demonstrated even with a minimal BPcontrol (systolic BP[SBP] <150 mmHg) and continued to be reported for a SBP<120 mmHg. On the other hand, keeping SBP<140 mmHg seemed to be safely achieved in elderly patients. Although the safety of lowering SBP to <120 mmHg is debated, Systolic Blood Pressure Intervention Trial study has shown no increased risk of falls, fractures, or kidney failure in elderly patients with SBP lower than this threshold. While the recent guidelines recommended to keep BP <130/80 mmHg in the elderly, more individualized approach should be considered to achieve this goal in order to avoid undesirable complications. Furthermore, further studies are required to evaluate BPtarget in very old patients or those with multiple comorbidities.

A Review of Noninfectious Diseases Masquerading as Acute Mastoiditis

2021 ◽  
pp. 019459982110641
Author(s):  
Kevin Wong ◽  
Annie E. Arrighi-Allisan ◽  
Caleb J. Fan ◽  
George B. Wanna ◽  
Maura K. Cosetti ◽  
...  
Keyword(s):  
Langerhans Cell Histiocytosis ◽  
Inflammatory Diseases ◽  
Case Series ◽  
Diagnostic Algorithm ◽  
Langerhans Cell ◽  
Myelogenous Leukemia ◽  
Common Disease ◽  
Acute Mastoiditis ◽  
Significant Group ◽  
Presenting Symptoms

Objective Acute mastoiditis is commonly attributed to infection. Rarely do clinicians encounter cases that do not respond to traditional antibiotics or surgical management. The goal of this study was to systematically review the literature to characterize diseases masquerading as acute infectious mastoiditis. Data Sources PubMed, Embase, and Scopus. Review Methods A systematic review was performed to identify all publications that reported on diseases with presentations mimicking acute mastoiditis, defined as postauricular redness, swelling, and tenderness. We included clinical prospective studies, retrospective studies, and case series/reports. Exclusion criteria included non-English articles, letters/commentaries, abstracts, and review articles. Results Out of 3339 results, 35 studies met final inclusion criteria. In children, 11 diseases were reported to mimic mastoiditis, including solid tumors, hematologic diseases, and autoimmune/inflammatory diseases. The most common disease in children was Langerhans cell histiocytosis, followed by rhabdomyosarcoma and acute myelogenous leukemia. In adults, 8 additional diseases were reported. The most common disease in adults was squamous cell carcinoma, followed by nasopharyngeal carcinoma and Langerhans cell histiocytosis. Presenting symptoms are reviewed, as well as characteristic radiographic, laboratory, and intraoperative features that may assist with diagnosis. A diagnostic algorithm for atypical cases of acute mastoiditis is proposed. Conclusion A small but significant group of diseases in children and adults can mimic acute mastoiditis. In such cases, history and examination alone may be insufficient to reach a diagnosis, and further investigation may be necessary. Otolaryngologists should always be mindful of the possibility that noninfectious pathologies may present with a constellation of symptoms similar to mastoiditis.

scholarly journals The Hematopoietic Cell Transplant Comorbidity Index predicts survival after allogeneic transplant for nonmalignant diseases

Blood ◽  
2019 ◽  
Vol 133 (7) ◽  
pp. 754-762 ◽  
Author(s):  
Monica S. Thakar ◽  
Larisa Broglie ◽  
Brent Logan ◽  
Andrew Artz ◽  
Nancy Bunin ◽  
...  
Keyword(s):  
Hematopoietic Cell Transplantation ◽  
Cox Regression ◽  
Bone Marrow Failure ◽  
Hematopoietic Cell ◽  
Cell Transplant ◽  
Research Database ◽  
Hematopoietic Cell Transplant ◽  
Risk Of Death ◽  
Increased Risk ◽  
Comorbidity Index

Abstract Despite improvements, mortality after allogeneic hematopoietic cell transplantation (HCT) for nonmalignant diseases remains a significant problem. We evaluated whether pre-HCT conditions defined by the HCT Comorbidity Index (HCT-CI) predict probability of posttransplant survival. Using the Center for International Blood and Marrow Transplant Research database, we identified 4083 patients with nonmalignant diseases transplanted between 2007 and 2014. Primary outcome was overall survival (OS) using the Kaplan-Meier method. Hazard ratios (HRs) were estimated by multivariable Cox regression models. Increasing HCT-CI scores translated to decreased 2-year OS of 82.7%, 80.3%, 74%, and 55.8% for patients with HCT-CI scores of 0, 1 to 2, 3 to 4, and ≥5, respectively, regardless of conditioning intensity. HCT-CI scores of 1 to 2 did not differ relative to scores of 0 (HR, 1.12 [95% CI, 0.93-1.34]), but HCT-CI of 3 to 4 and ≥5 posed significantly greater risks of mortality (HR, 1.33 [95% CI, 1.09-1.63]; and HR, 2.31 [95% CI, 1.79-2.96], respectively). The effect of HCT-CI differed by disease indication. Patients with acquired aplastic anemia, primary immune deficiencies, and congenital bone marrow failure syndromes with scores ≥3 had increased risk of death after HCT. However, higher HCT-CI scores among hemoglobinopathy patients did not increase mortality risk. In conclusion, this is the largest study to date reporting on patients with nonmalignant diseases demonstrating HCT-CI scores ≥3 that had inferior survival after HCT, except for patients with hemoglobinopathies. Our findings suggest that using the HCT-CI score, in addition to disease-specific factors, could be useful when developing treatment plans for nonmalignant diseases.

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