What is the optimal induction strategy for older patients?

Prognoses of older patients (age ≥60 years) vary greatly following use of standard therapy, such as 3?+?7: 3 days of daunorubicin or idarubicin?+?7 days of cytarabine (ara-C). Although most older patients receive only supportive care, the principal prognostic factor among the presumably healthier treated patients is cytogenetics, with a monosomal karyotype conferring a particularly poor prognosis. However other factors are also informative and several systems incorporating multiple factors have been devised to help guide the fundamental decision as to whether a patient should receive standard therapy or, much more frequently, investigational therapy. Although physicians may be reluctant to await results of cytogenetic analysis and molecular markers (NPM, FLT3), data suggest no harm is done by waiting for these results to become available; certainly the risk of delaying therapy is less than the risk of giving a patient 3?+?7 when the risk of treatment-related mortality (TRM) is greater than the chance of a beneficial response. Nonetheless, in general the risk of TRM is less than that of resistance to therapy, even in patients aged ≥75 years. Perhaps, however, focusing on the former, there is an increasing tendency to administer azacitidine or decitabine to older patients. However there is little to suggest that on average these drugs by themselves convey what many patients would consider medically meaningful improvements in survival. Hence these drugs should not reduce the imperative of putting older patients on trials involving new drugs. Finally, confirming everyday observation, age alone is a very inadequate predictor of outcome and is likely a surrogate for other covariates. Accordingly, the common practice of assigning patients to treatment protocols based solely on age leaves much to be desired.     

What is the best sequence of treatment for patients with EGFR mutations?

The arrival of tyrosine kinase inhibitors (TKI) in first line of treatment for advanced non-small cell lung cancer with EGFR mutations has changed the strategy of treatment of theses patients. Indeed, response rates in these cases reach around 60 to 70%, with a progression-free survival greatly prolonged, up to 10 months. It seems that these patients with mutated tumor benefit from TKI whatever the treatment line, with the same efficacy. So, the best sequence of treatment (TKI in first line then chemotherapy in second line, or the opposite) needs still to be defined in this sub-group of NSCLC. The choice has to take in account the data of efficacy of TKIs and chemotherapy in the EGFR mutated tumors, with an anticipation of subsequent lines from the first line. Besides, data of toxicity and quality of life have also to be considered.     

What is the prevalence of inspiratory muscle weakness in preoperative cardiac surgery patients? An observational study

BackgroundIn patients undergoing elective cardiac surgery, the prevalence of inspiratory muscle weakness is not well-understood. This information could guide pre-operative therapy.ObjectivesTo determine the prevalence of inspiratory muscle weakness in preoperative cardiac surgery patients, and describe relationships between pre-operative factors (including maximal inspiratory pressure, MIP) and post-operative pulmonary complications (PPCs).MethodsProspective study of elective cardiac surgery patients. Pre-operative MIP was measured (cmH₂O) and PPC data were extracted from medical records (Melbourne Group Score) while age, height, weight, frailty and physical activity levels were captured via questionnaire. Backwards-stepwise logistic regression was used to describe associations.Results24 participants were recruited (79% male, age 70 ± 10.7, BMI 26.8 ± 4.14). The prevalence of inspiratory muscle weakness (MIP < 60% predicted) was 25% (n = 6). PPCs were associated with body mass index (BMI) (r = 0.464, p = 0.022).ConclusionThe prevalence of pre-operative inspiratory muscle weakness was 25%. BMI may be an important determinant of PPCs in elective cardiac surgery patients.     

What is the optimal management of older CLL patients?

CLL is the most common leukemia in older adults with a median age at diagnosis of 71. Therefore, management of patients with this disease must take into account the older age of most patients and consequences of this in terms of functional status and organ function. This review will discuss the management of CLL with regards to observation prior to the initiation of therapy, functional status, and initial treatment. We will discuss criteria for the initiation of therapy, and how initial therapy is different between older and younger patients. Finally, we will discuss specific therapies including chemoimmunotherapy and newer targeted therapies that are being used widely in the older patient population.     

Is endoscopic follow-up needed in pediatric patients who undergo surgery for GERD?

BACKGROUND: This study evaluated the role of endoscopy in the postoperative management of pediatric patients who undergo fundoplication for GERD. METHODS: Medical records of 109 otherwise healthy children who underwent operation for GERD from 1979 to 1996 were reviewed. Patients with respiratory symptoms or esophageal stenosis were excluded. All patients underwent endoscopic surveillance with endoscopy being performed in the early (within 1 year) and late (between 1 and 2 years) postoperative periods. Specifically evaluated were the appearance of the wrap and evidence of esophagitis. The risk of a recurrence of esophagitis based on wrap appearance and the presence of clinical symptoms in patients with endoscopic evidence of esophagitis were also evaluated. RESULTS: At early endoscopy 3 patients with an intact wrap and 8 with a defective wrap had esophagitis (not significant). At late endoscopy, 5 patients with an intact wrap and 17 with a defective wrap had esophagitis (p < 0.05). CONCLUSIONS: An intact wrap does not prevent recurrence of GERD. Such an occurrence is even more likely when endoscopy demonstrates a defective wrap. For all patients who have undergone fundoplication, endoscopic evaluation at 1 to 2 years is recommended to detect esophagitis in the absence of symptoms so treatment can be initiated before symptoms occur.     

What are the advances for surgical therapy of inflammatory diseases of the spine?

Surgery for rheumatoid arthritis (RA) and spondyloarthropathies is a palliative surgery, and testifies to the failure of conservative treatment. In RA, surgery is generally used to deal with upper cervical instability and peridens pannus compression. These complications can have dramatic neurological consequences and can even be life threatening. Every effort must be made to avoid unnecessary surgery but, if needed, the indication must be precise and timely to be efficient. Instrumented fusion is indicated but the need for pannus excision is discussed. In ankylosing spondylitis (AS), major deformity will be the indication for corrective surgery if this deformity induces a marked decrease in the field of vision, thoracicy or abdominal problems or respiratory and mandibular troubles in the cervical spine. Different types of osteotomies with instrumented fixation are described. In AS. surgery is also indicated in fractures that are potentially unstable. At the cervical level these fractures are a surgical emergency. Neurological compressions and spondylodiscitis are other reasons for surgery in AS. Complications of other spondyloarthropathies, which include accompanying psoriasis, reactive arthritis, enteropathic arthritis or Behcet's syndrome are occasionally treated surgically along the same lines as RA or AS. Surgery for spinal inflammatory disorders involves major procedures with a high rate of severe complications. The indications for this type of surgery must be extremely precise and both the surgeon's and the patient's expectations must be clear and realistic. The surgery should only be performed by a surgeon who is experienced with this type of patient and procedure but, furthermore, it should also only be camed out in a centre with a team of neurologists, anaesthetists, nurses and physical therapists who have the expertise to work with these pathologies and these often severely debilitated patients. Only under these conditions will the outcome justify the burden and the risks.     

Surgery for the teenager with familial adenomatous polyposis: ileo-rectal anastomosis or restorative proctocolectomy?

Increasing numbers of polyposis registries have led to more young patients being diagnosed with familial adenomatous polyposis (FAP). To provide guidelines for selecting the appropriate surgical procedure in teenagers (10–19 years), we compared the results of colectomy and ileo-rectal anastomosis (IRA, n=17 patients) to the results of resrorative proctocolectomy and ileal pouch-anal anastomosis (IPAA, n=7 patients). Charts were reviewed to obtain data on the operative technique, blood loss and transfusions, hospital stay (including the time for ileostomy closure), and early (within 30 days of surgery) and late complications. Functional results (bowel movements per 24h, use of antidiarrheal drugs, seepage, and fecal incontinence) and quality of life were evaluated prospectively with a questionnaire and physical examination. The median follow-up time was 49 months (range, 6 to 95 months) after IRA, and 36 months after IPAA (range, 4 to 87 months). Although restorative proctocolectomy and IPAA, is a longer (5.75 vs 3.1 hours), more bloody (500 vs 300 mL blood loss), and more complex operation with a longer hospital stay (12 vs 7 days) than IRA (P=0.008, P=0.006, P=0.02, respectively), no significant difference (P>0.05) was found between groups concerning the complication rate or quality of life. For teenagers with FAP and rectal carpeting, large rectal adenomas, curable cancer in the upper two-thirds of the rectum, or who are unavailable for follow-up, we recommend a restorative proctocolectomy and IPAA. For the other patients, the decision whether to perform IRA or restorative proctocolectomy with IPAA depends on the patient's desire and the surgeon's skill.

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Résumé La multiplication des registres de polypose a permis de diagnostiquer un nombre croissant de sujets jeunes proteurs d'une polypose adénomateuse familiale (FAP). Afin d'établir des recommandations dans la sélection du traitement chirurgical approprié chez des adolescents (10–19 ans), nous avons comparé les résultats de la colectomie et de l'anastomose iliéo-rectale (IRA, n=17 patients) aux résultats de procto-colectomie avec rétablissement de la continuité par l'intermédiaire d'une poche iléoanale (IPAA, n=7 patients). Les dossiers ont été revus afin d'obtenir des données sur la technique opératoire, les pertes sanguines et les transfusions, la durée de séjours hospitaliers (incluant la période nécessaire pour la fermeture de l'iléostomie), ainsi que les complications précoces (à moins de 30 jours de l'opération) et les complications tardives. Les résultats fonctionnels (nombre de selles par 24 h, usage de médications anti-diarrhéïques, fuites et incontinence fécale) et la qualité de la vie ont été évalués prospectivement à l'aide d'un questionnaire et de consultations de contrôle. Le suivi moyen a été de 49 mois (de 6 à 95 mois) après l'IRA et de 36 mois après l'IPAA (de 4 à 87 mois). Bien que la colo-poctectomie avec rétablissement de la continuité par IPAA soit plus longue (5,75-heures vs 3,1) plus sanglante (500 ml pertes sanguines vs 300 ml) et plus complexe avec un séjour hospitalier plus long (12 jours vs 7 jours) que l'IRA (P=0.008, P=0.006 et P=0.002), nous n'avons pas observé de différence P>0.05 entre les deux groupes en ce qui concerne le taux de complecations et la qualité de vie. Nous recommandons une colo-proctectomie avec rétablissement de la continuité par une IPAA chez des adolescents porteurs d'une polypose adénomateuse familiale et de tapis d'adénome du rectum présentant des cancers curables des deux tiers supérieurs du rectum chez lesquels le follow-up ne pourra que difficilement être assuré. Dans les autres cas, la décision de réaliser une IRA ou une procto-colectomie avec IPAA dépend des souhaits du patient et de l'expérience du chirurgien.

     

What is the definition of cure for aplastic anemia?

Treatment with immune suppression and bone marrow transplantation has improved the response rates and survival of patients with aplastic anemia. Measurement of response requires that common endpoints be recorded at specific times. There has been no agreement on such parameters for patients with aplastic anemia. In this paper issues related to measurement of response are reviewed and criteria for response are proposed. Adoption of uniform criteria would facilitate comparisons of treatment efficacy.