Surgical dilemma: liver resection or liver transplantation for hepatocellular carcinoma and cirrhosis. Intention-to-treat analysis in patients within and outwith Milan criteria

Background:

The optimal role of surgery in the management of hepatocellular carcinoma (HCC) is in continuous evolution.

Objective:

The objective of this study was to analyse survival rates after liver resection (LR) and orthotopic liver transplantation (OLT) for HCC within and outwith Milan criteria in an intention-to-treat analysis.

Methods:

During 1997–2007, 179 patients with cirrhosis and HCC either underwent LR (n= 60) or were listed for OLT (n= 119). Patients with incidental HCC after OLT, preoperative macrovascular invasion before LR, non-cirrhosis and Child–Pugh class C cirrhosis prior to OLT were eliminated, leaving 51 patients primarily treated with LR and 106 patients listed for primary OLT (84 of whom were transplanted) to be included in this analysis. A total of 66 patients fell outwith Milan criteria (26 LR, 40 OLT) and 91 continued to meet Milan criteria (25 LR, 66 OLT).

Results:

The median length of follow-up was 26 months. The mean waiting time for OLT was 7 months. During that time, 21 patients were removed from the waiting list as a result of tumour progression. Probabilities of dropout were 2% and 13% at 6 and 12 months, respectively, for patients within Milan criteria, and 34% and 57% at 6 and 12 months, respectively, for patients outwith Milan criteria (P < 0.01). Tumour size >3 cm was found to be the independent factor associated with dropout (hazard ratio [HR] 6.0). Postoperative survival was slightly higher after OLT, but this was not statistically significant (64% for OLT vs. 57% for LR). Overall survival from time of listing for OLT or LR did not differ between the two groups (P= 0.9); for patients within Milan criteria, 1- and 4-year survival rates after LR were 88% and 61%, respectively, compared with 92% and 62%, respectively, after OLT (P= 0.54). For patients outwith Milan criteria, 1- and 4-year survival rates after LR were 69% and 54%, respectively, compared with 65% and 40%, respectively, after OLT (P= 0.42). Tumour size >3 cm was again found to be an independent factor for poor outcome (HR 2.4) in the intention-to-treat analysis.

Conclusions:

Survival rates for patients with HCC are similar in LR and OLT. Liver resection can potentially decrease the dropout rate and serve as a bridge for future salvage LT, particularly in patients with tumours >3 cm.     

Asthma Control and Patient Satisfaction Among Early Pediatric Users of Montelukast

Objective: To assess asthma control and patient satisfaction among pediatric users of montelukast in a clinical practice setting.

Study Design: A prospective study of 175 children with persistent asthma, 6 to 14 years of age, who initiated treatment with montelukast between Feb-1998 and Aug-1998, in primary care and pediatric offices across the United States. Data on asthma control and satisfaction with treatment was collected in physicians' offices after enrollment and by survey to the patients' homes at 1 month of treatment.

Results: Across the study population, improvements in mean scores for asthma control and parent satisfaction were observed at the 1-month follow-up compared with baseline. At 1 month, 57.7% of patients had none of four issues indicative of poor asthma control, compared with 19.4% at baseline. Similarly, after 1 month of treatment with montelukast, 2.7 times as many parents reported being very satisfied with asthma therapy (using montelukast) compared with the previous controller therapy regimen at baseline. During the 1-month follow-up period, montelukast was used as the only controller medication by 18.3% of patients, and in combination with another controller medication by 81.7%.

Conclusions: Observations from this study over one month suggest that a significant percentage of pediatric patients successfully managed their asthma with montelukast and their parents were satisfied with their medication, compared to baseline.     

Factors influencing the acceptance of changes in antiretroviral therapy among HIV-1-infected patients

Physicians routinely consider modifying antiretroviral therapy (ART) regimen for their patients with HIV. Little is known about the factors associated with patients' willingness to accept providers' recommended ART changes. This multicenter prospective observational study examined factors associated with willingness to accept ART changes recommended by their providers among HIV-infected adults from six urban outpatient HIV clinics. Patients were surveyed using the Patient Attitudes about Altering Antiretroviral Therapy Survey questionnaire (PAAARTS). Factors associated with willingness to accept ART changes were assessed using a multivariate generalized estimating equation (GEE) model to account for correlated responses. The Classification and Regression Trees (CART) analysis was also performed to determine subgroups of patients with higher acceptance of change. 216 of 289 patients (75%) definitely accepted recommended changes. Odds for acceptance were 3.2, 2.3, and 2.8 times higher for patients with higher attitudes and beliefs about ART (p < 0.01; 95% confidence interval [CI] = 1.59, 6.52), patients who rated their provider's care as excellent (p < 0.05; 95% CI = 1.07, 4.78), and non-Hispanic patients (p < 0.05; 95% CI 1.03, 7.57), respectively. CART analysis showed similar results and identified that when patients had less positive attitude about ART, acceptance rates were higher for non-Hispanic patients with higher assessments of their patient-provider communication. While most patients accepted providers' recommendation for ART changes, this willingness was influenced by both patients' attitudes and beliefs about ART and their assessment of either the effectiveness of patient-provider communication or their rating of providers' care. ART acceptance rates among Hispanic patients were lower.     

Efficacy and feasibility of a novel tri-modal robust exercise prescription in a retirement community: a randomized, controlled trial

OBJECTIVES: To test the feasibility and efficacy of current guidelines for multimodal exercise programs in older adults. DESIGN: Randomized, controlled trial. SETTING: Retirement village. PARTICIPANTS: Thirty-eight subjects (14 men and 24 women) aged 76.6 +/- 6.1. INTERVENTION: A wait list control or 10 weeks of supervised exercise consisting of high-intensity (80% of one-repetition maximum (1RM)) progressive resistance training (PRT) 3 days per week, moderate-intensity (rating of perceived exertion 11 to 14/20) aerobic training 2 days per week, and progressive balance training 1 day per week. MEASUREMENTS: Blinded assessments of dynamic muscle strength (1RM), balance, 6-minute walk, gait velocity, chair stand, stair climb, depressive symptoms, self-efficacy, and habitual physical activity level. RESULTS: Higher baseline strength and psychological well-being were associated with better functional performance. Strength gains over 10 weeks averaged 39+/-31% in exercise, versus 21+/-24% in controls (P=.10), with greater improvements in hip flexion (P=.01), hip abduction (P=.02), and chest press (P=.04) in the exercise group. Strength adaptations were greatest in exercises in which the intended continuous progressive overload was achieved. Stair climb power (12.3+/-15%, P=.002) and chair stand time (-7.1+/-15%, P=.006) improved significantly and similarly in both groups. Reduction in depressive symptoms was significantly related to compliance (attendance rate r=-0.568, P=.009, PRT progression in loading r=-0.587, P=.02, and total volume of aerobic training r=-0.541, P=.01), as well as improvements in muscle strength (r=-0.498, P=.002). CONCLUSION: Robust physical and psychological adaptations to exercise are linked, although volumes and intensities of multiple exercise modalities sufficient to cause significant adaptation appear difficult to prescribe and adhere to simultaneously in older adults.     

Diagnosing and treating breast cancer in elderly women: a call for improved understanding

Breast cancer is the most common nondermatological malignancy in women, and the incidence increases with age until the eighth decade. Breast cancer pathology and biology appear to be different in elderly patients than in younger ones, and therefore treatment recommendations cannot be generalized from one group to the other. Most elderly women can tolerate breast cancer surgery without significant complications and should be offered a definitive surgical procedure. Improved mechanisms to predict which patients will tolerate and benefit from various therapies are under development. Because most breast cancers in the elderly are hormone responsive, hormonal therapy remains the mainstay of systemic treatment in the adjuvant and metastatic settings. Chemotherapy can be used in elderly women, but treatment decisions must be individualized based upon risk-benefit analyses. Elder-specific studies are underway to identify the most-efficacious and best-tolerated therapies for breast cancer in this population. Primary care physicians must be aware of these issues to provide adequate counseling and care to these patients.