Management of advanced non-small-cell lung cancer in elderly populations

Elderly patients, defined as those >or= 70 years of age, represent approximately 40% of all patients diagnosed with non-small-cell lung cancer in the United States. Nonetheless, elderly patients have been underrepresented in national cooperative group trials, and many do not receive appropriate treatment. Whereas the benefit of systemic chemotherapy in younger patients is accepted by most clinicians, there remains a great deal of skepticism with respect to older patients, who are often labeled unfit for chemotherapy. More recent studies with a special focus on elderly patients demonstrate that these patients indeed benefit from chemotherapy. The landmark Elderly Lung Cancer Vinorelbine Italian Study Group trial and the Multicentre Italian Lung Cancer in the Elderly Study clarified the role of vinorelbine in the treatment of elderly patients. Retrospective and prospective subgroup analyses from selected North American trials suggested that elderly patients also benefit from platinum-based combinations. Whether elderly patients should be treated with single-agent versus combination chemotherapy is discussed in this review. The available data suggest that patients should be evaluated for chemotherapy based on their performance status and comorbidities rather than age alone. For elderly patients judged fit to receive combination chemotherapy, carboplatin-based regimens are a reasonable option. In elderly patients with less than optimal performance status or significant comorbid conditions, single-agent therapy may be more appropriate.     

Comparison of left ventricular electromechanical mapping and left ventricular angiography: defining practical standards for analysis of NOGA maps

We performed this prospective cohort study to correlate the findings of left ventricular angiography (LVA) and NOGA left ventricular electromechanical mapping (LVEM) in the evaluation of cardiac wall motion and also to establish standards for wall motion assessment by LVEM. Fifty-five patients (35 men; mean age, 60.4 +/- 11.8 years) eligible for elective left cardiac catheterization underwent LVA and LVEM. Wall motion scores, LV ejection fractions (LVEF), and LV volumes derived from LVA versus LVEM data were compared and analyzed statistically. Receiver operating characteristic (ROC) curves were used to assess the accuracy of LVEM in distinguishing between normal, hypokinetic, and akinetic/dyskinetic wall motion. Mean LVEM procedure time was 37 +/- 11 minutes. The LVEM and LVA findings differed for mean LVEF (55% +/- 13% vs 36% +/- 9%), mean end-systolic volume (56 +/- 13 mL vs 36 +/- 10 mL), and mean end-diastolic volume (174 +/- 104 mL vs 123 +/- 65 mL). Mean wall motion scores (+/- SD) for normokinetic, hypokinetic, and akinetic/dyskinetic segments were 13.9% +/- 5.6%, 8.3% +/- 5.2%, and 3.2% +/- 3.1%, respectively. Cutpoints for differentiating between wall motion types were 12% and 6%. The ROC curves showed LVEM to have a 93% accuracy in differentiating between normokinetic and akinetic/dyskinetic segments and a 73% accuracy between normokinetic and hypokinetic segments. These data suggest that LVEM can differentiate between normal and abnormal cardiac wall motion, although it is more accurate at differentiating between normokinetic and akinetic/dyskinetic motion than between normokinetic and hypokinetic motion.     

Role of serum S100B as a predictive marker of fatal outcome following isolated severe head injury or multitrauma in males.

BACKGROUND: Severe traumatic brain injury (TBI) is associated with a 30%-70% mortality rate. S100B has been proposed as a biomarker for indicating outcome after TBI. Nevertheless, controversy has arisen concerning the predictive value of S100B for severe TBI in the context of multitrauma. Therefore, our aim was to determine whether S100B serum levels correlate with primary outcome following isolated severe TBI or multitrauma in males. METHODS: Twenty-three consecutive male patients (age 18-65 years), victims of severe TBI [Glasgow Coma Scale (GCS) 3-8] (10 isolated TBI and 13 multitrauma with TBI) and a control group consisting of eight healthy volunteers were enrolled in this prospective study. Clinical outcome variables of severe TBI comprised: survival, time to intensive care unit (ICU) discharge, and neurological assessment [Glasgow Outcome Scale (GOS) at ICU discharge]. Venous blood samples were taken at admission in the ICU (study entry), 24 h later, and 7 days later. Serum S100B concentration was measured by an immunoluminometric assay. RESULTS: At study entry (mean time 10.9 h after injury), mean S100B concentrations were significantly increased in the patient with TBI (1.448 microg/L) compared with the control group (0.037 microg/L) and patients with fatal outcome had higher mean S100B (2.10 microg/L) concentrations when compared with survivors (0.85 microg/L). In fact, there was a significant correlation between higher initial S100B concentrations and fatal outcome (Spearman's =0.485, p=0.019). However, there was no correlation between higher S100B concentrations and the presence of multitrauma. The specificity of S100B in predicting mortality according to the cut-off of 0.79 microg/L was 73% at study entry. Conclusions: Increased serum S100B levels constitute a valid predictor of unfavourable outcome in severe TBI, regardless of the presence of associated multitrauma.     

Human bedside evaluation versus automatic responsiveness testing in epilepsy (ARTiE)

Evaluation of behavioral impairment during epileptic seizures is critical for medical decision making, including accurate diagnosis, recommendations for driving, and presurgical evaluation. We investigated the quality of behavioral testing during inpatient video–electroencephalography (EEG) monitoring at an established epilepsy center, and introduce a technical innovation that may improve clinical care. We retrospectively reviewed video‐EEG data from 152 seizures in 33 adult or pediatric patients admitted for video‐EEG monitoring. Behavioral testing with questions or commands was performed in only 50% of seizures ictally, 73% of seizures postictally, and 80% with either ictal or postictal testing combined. Furthermore, the questions or commands were highly inconsistent and were performed by nonmedical personnel in about one fourth of cases. In an effort to improve this situation we developed and here introduce Automatic Responsiveness Testing in Epilepsy (ARTiE), a series of video‐recorded behavioral tasks automatically triggered to play in the patient's room by computerized seizure detection. In initial technical testing using prerecorded or live video‐EEG data we found that ARTiE is initiated reliably by automatic seizure detection. With additional clinical testing we hope that ARTiE will succeed in providing comprehensive and reliable behavioral evaluation during seizures for people with epilepsy to greatly improve their clinical care.     

Reversible Kallmann syndrome: report of the first case with a KAL1 mutation and literature review

Kallmann syndrome (KS) describes the association of isolated hypogonadotropic hypogonadism with hypo/anosmia. A few KS patients may reverse hypogonadism after testosterone withdrawal, a variant known as reversible KS. Herein, we describe the first mutation in KAL1 in a patient with reversible KS and review the literature. The proband was first seen at 22 years complaining of anosmia and lack of puberty. His brother had puberty at 30 years and a maternal granduncle had anosmia and delayed puberty. On physical examination, he was P(2)G(1), testes were 3 ml and bone age was 14 years. During 20 years of irregular testosterone replacement, he developed secondary sexual characteristics and testicular enlargement. At the age of 41 years, after stopping testosterone replacement for 5 months, his testes were 15 ml, serum testosterone, LH, and FSH responses to GnRH were normal, and his wife was pregnant. The molecular study revealed a cytosine insertion in exon 2 of KAL1, generating a frameshift at codon 75 and a premature stop at codon 85. The expected gene product is a truncated peptide with 85 of the 680 [corrected] amino acids present in the wild-type protein. Fourteen cases of reversible KS have been described but the genotype was only studied in a single case showing a heterozygous fibroblast growth factor receptor type 1 (FGFR1) mutation. Considering the low prevalence of mutations in KAL1 or FGFR1 in KS, it is possible that these genotypes are more prevalent in reversible KS than in other KS patients, but additional studies are necessary to confirm this hypothesis.     

Endoscopic findings in the excluded stomach after Roux-en-Y gastric bypass surgery

HYPOTHESIS: After gastric bypass surgery performed because of morbid obesity, the excluded stomach can rarely be endoscopically examined. With the advent of a new apparatus and technique, possible mucosal changes can be routinely accessed and monitored, thus preventing potential benign and malignant complications. DESIGN: Prospective observational study in a homogeneous population with nonspecific symptoms. SETTING: Outpatient clinic of a large public academic hospital. PATIENTS: Forty consecutive patients (mean +/- SD age, 44.5 +/- 10.0 y ears; 85.0% women) were seen at a mean +/- SD of 77.3 +/- 19.4 months after Roux-en-Y gastric bypass surgery. INTERVENTION: Elective double-balloon enteroscopy of the excluded stomach was performed. MAIN OUTCOME MEASURES: Rate of successful intubation, endoscopic findings, and complications. RESULTS: The excluded stomach was reached in 35 of 40 patients (87.5%). Mean +/- SD time to enter the organ was 24.9 +/- 14.3 minutes (range, 5-75 minutes). Endoscopic findings were normal in 9 patients (25.7%), whereas in 26 (74.3%), various types of gastritis (erythematous, erosive, hemorrhagic erosive, and atrophic) were identified, primarily in the gastric body and antrum. No cancer was documented in the present series. Tolerance was good, and no complications were recorded during or after the intervention. CONCLUSIONS: The double-balloon method is useful and practical for access to the excluded stomach. Although cancer was not noted, most of the studied population had gastritis, including moderate and severe forms. Surveillance of the excluded stomach is recommended after Roux-en-Y gastric bypass surgery performed because of morbid obesity.     

Validation of a Portable Monitoring System for the Diagnosis of Obstructive Sleep Apnea Syndrome

Study Objective:

To evaluate if a portable monitor could accurately measure the apnea-hypopnea index (AHI) in patients with a suspicion of obstructive sleep apnea (OSA).

Design:

Prospective and randomized.

Setting:

Sleep laboratory.

Participants:

80 participants: 70 patients with clinical OSA suspicion and 10 subjects without suspicion of OSA.

Interventions:

N/A

Measurements and Results:

Three-order randomized evaluations were performed: (1) STD (Stardust II) used at the participants'' home (STD home), (2) STD used simultaneously with PSG in the sleep lab (STD+PSG lab), and (3) PSG performed without the STD (PSG lab). Four AHI values were generated and analyzed: (a) STD home; (b) STD from STD+PSG lab; (c) PSG from STD+PSG (named PSG+STD lab); and (d) PSG lab. Two technicians, blinded to study details, performed the analyses of all evaluations. There was a strong correlation between AHI from the STD and PSG recordings for all 4 AHI values (all correlations above 0.87). Sensitivity, specificity, and positive and negative predictive values at AHI cut-off values of 5, 15, and 30 events/hour were calculated. AHI values from the PSG lab and PSG+STD lab were compared to STD home and STD+PSG lab and showed the best results when STD and PSG were performed simultaneously. In all analyses, the area under ROC curve was at least 0.90. With multiple comparisons, diagnostic agreement was between 91% and 75%. The Bland Altman analyses showed strong agreement between AHI values from the STD and PSG recordings, especially when comparing the AHI from simultaneous STD and PSG recordings.

Conclusion:

These data suggest that the STD is accurate in confirming the diagnosis of OSA where there is a suspicion of the disorder. Better agreement occurred during simultaneous recordings.

Citation:

Santos-Silva R; Sartori DE; Truksinas V; Truksinas E; Alonso FFFD; TufikS; Bittencourt LRA. Validation of a portable monitoring system for the diagnosis of obstructive sleep apnea syndrome. SLEEP 2009;32(5):629-639.     

Sao Paulo Epidemiologic Sleep Study: Rationale,design, sampling,and procedures

ObjectivesTo present the rational design, sampling, and procedures utilized in an Epidemiologic Sleep Study carried out in 2007 to establish the epidemiologic profile of sleep disorders in the adult population of a large metropolitan city, Sao Paulo, Brazil.MethodsA population-based survey adopting a probabilistic three-stage cluster sample of Sao Paulo was used to represent the population according to gender, age (20–80 years), and socioeconomic class. Questionnaires, actigraphy, polysomnography (PSG), and blood samples were collected to investigate associations between sleep patterns and disturbances according to social-demographic status, activity/rest cycle, physical activity habits, mood disturbances, memory complaints, sexual dysfunction in males, drug addiction, genetic markers, and anthropometric, clinical, biochemical, hematological, endocrine, immunologic, and inflammatory indicators.ResultsA total of 1101 questionnaires were administered at home. A total of 156 volunteers were substituted, who were equivalent to the remaining sample in terms of age, gender, and socioeconomic class. A total of 1042 volunteers underwent PSG recordings at a Sleep Institute, and the refusal rate was 5.4%.ConclusionThe Sao Paulo Sleep Study is a pioneering investigation, incorporating and integrating up-to-date methodologies for understanding sleep profiles and sleep disorders in large populations. This study will provide reliable information for the planning of health policies and programs aimed to control such disorders and their consequences in the city of Sao Paulo and similar urban environments.