Correlation Between Symptoms and Function in Older Adults with Comorbidity

OBJECTIVES: To describe the relationship between symptom scores and mobility function measures, assess whether symptom scores and disease scores are similarly associated with mobility function, and identify clusters of symptoms that are most strongly associated with functional status in older adults.
DESIGN: Secondary analysis of cross-sectional data from three cohorts.
SETTING: Academic medical center.
PARTICIPANTS: One hundred ninety-five community-dwelling subjects with poor flexibility or cardiorespiratory fitness (fitness cohort), 211 female retirement community residents with vertebral fractures (VF cohort), and 61 subjects with Parkinson's disease (PD cohort).
MEASUREMENTS: Twenty-item self-reported symptom scale, 17-item self-reported disease scale, Medical Outcomes Study 36-item Short Form Survey (SF-36) Physical Functioning Scale, 5-item Nagi Disability scale, 10-m walk time, supine to stand time.
RESULTS: Symptom scores correlated with mobility function measures (Spearman correlation coefficients ranged from 0.222 to 0.509) at least as strongly as, if not more strongly than, did disease scores. Symptom scores remained associated with functional outcomes after controlling for disease score and demographic variables. Adding symptom scores to models that contained disease scores significantly increased the association with functional outcomes. In the fitness cohort, muscle weakness was the most explanatory single symptom, associated with an average decrease of 17.8 points on the Physical Functioning Scale. A model that included only muscle weakness, pain, and shortness of breath accounted for 21.2% of the variability in the Physical Functioning Score.
CONCLUSION: Symptoms represent useful indicators of disability burden in older adults and are promising targets for interventions to improve function in medically complex patients.     

Vitreous incarceration in sutured vs non-sutured sclerotomies after 25-gauge macular surgery

ObjectivesTo study the patterns of vitreous incarceration in sutured vs non-sutured sclerotomies in patients subjected to 25-gauge macular surgery.MethodsA prospective study of 135 eyes affected by epiretinal membrane or macular hole. Vitreal disposition was evaluated via ultrasound biomicroscopy (UBM) at the sclerotomy sites between 30 and 40 days after surgery, once the tamponade had completely disappeared.ResultsIn total, 349 sclerotomies (86.2%) of 99 patients were non-sutured while 56 sclerotomies (13.8%) of 36 patients were sutured at the end of the surgical procedure. Among the 36 patients with sutured sclerotomies, 15 out of 36 (41.6%) had at least two sclerotomies sutured. All the sclerotomy sites were evaluated (405 sclerotomies). Sclerotomy suture was significantly associated with a less aggressive pattern of vitreal incarceration (OR: 0.16, 95% CI: 0.07–0.35, p < 0.001). Compared to preoperative values, day 1 post operative IOP was not significantly different in patients with sutured sclerotomies, while patients with non-sutured sclerotomies had a significantly lower day 1 post operative IOP.ConclusionsIn 25-gauge macular surgery, UBM evaluation documented a higher rate of postoperative vitreous incarceration in the non-sutured sclerotomies, confirming the previously postulated role of the residual vitreous, left at the end of the surgery, in closing the sclerotomy site.Subject terms: Surgery, Retinal diseases     

Combination of Irinotecan,Oxaliplatin and 5-Fluorouracil as a Rechallenge Regimen for Heavily Pretreated Metastatic Colorectal Cancer Patients

Purpose

Our objective was to evaluate the benefit of re-exposing patients with refractory metastatic colorectal cancer (mCRC) to a combination of oxaliplatin, irinotecan and 5-fluorouracil treatment.

Methods

We retrospectively analysed patients with mCRC who received a combination of oxaliplatin, irinotecan and fluorouracil as a rechallenge regimen after progressing on the same drugs. Both FOLFOXIRI and FOLFIRINOX were used. Toxicity was evaluated for each treatment cycle, and survival analysis was performed using the Kaplan-Meier method.

Results

A total of 21 patients who were treated between January 2011 and December 2013 were selected for this study. Most of the patients (95.2%) had an ECOG status of 0–1. The median age at diagnosis was 52.1 years (range 36–77 years), and 14 (66.6%) patients had wild-type KRAS. Thirteen patients received FOLFIRINOX, and eight received FOLFOXIRI. Most patients had previously received at least three regimens, with 80% receiving anti-VEGF and 66% anti-EGFR antibodies. The response rate was 38%, and 24% patients had stable disease. The median time to disease progression was 4.0 months (range 1.0–9.1 months), and the median overall survival duration was 8.6 months (range 6.3–11.5 months). Most patients required dose adjustment and treatment delays. One patient experienced grade 5 neutropenic sepsis.

Conclusions

Both FOLFIRINOX and FOLFOXIRI are active and potentially feasible rechallenge treatment options for heavily pretreated patients with good performance status. With dose reduction and close monitoring for toxicity, the risk of serious adverse events can be minimised.

     

Coagulation after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy: a retrospective cohort analysis

Purpose

Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) benefit patients with peritoneal carcinomatosis. Nevertheless, this therapy is associated with considerable postoperative pain due to the extensive abdominal incision. While epidural analgesia offers efficacious pain control, CRS and HIPEC therapy is associated with perioperative coagulopathy that may impact its use. The purpose of this retrospective study is to characterize the postoperative coagulopathy in this patient subset and to develop a model that will help predict those at risk.

Methods

Our database of patients treated with CRS and HIPEC (n = 171) was reviewed to assess perioperative changes in platelet count, international normalized ratio (INR), and partial thromboplastin time (PTT). Abnormal coagulation was defined by platelet count < 100 × 10^?9·L^?1, INR ≥ 1.5, or PTT ≥ 45 sec. Severe abnormality in coagulation was defined by platelet count < 50 ×10^?9·L^?1, INR > 2.0, and/or PTT > 60 sec. A logistic regression model was developed to determine if patient, disease, and/or surgical factor(s) were associated with the development of postoperative coagulopathy. Epidural catheter management in this patient population was also reviewed.

Results

Significant differences (adjusted P < 0.007) were noted between median preoperative and postoperative platelet and INR values on postoperative days (POD) 0 through 6 and days 0 through 3, respectively. Highest observed median differences between preoperative and postoperative values showed a decrease in platelet count of 94 × 10^?9·L^?1 (POD 2 and POD 3), an increase in INR of 0.2 (POD 0 to POD 2), and a decrease in PTT of 3.1 sec (POD 5). Coagulopathy and severe coagulopathy occurred in 38% and 4.7% of patients, respectively. Predictors of coagulopathy included intraoperative transfusion of packed red blood cells (PRBCs) and perhaps the peritoneal carcinomatosis index (PCI). Epidural catheters were inserted in 26 patients for a median [IQR] duration of 7.0 [5.0-7.0] days without complication. At the time of their removal, no blood products were required to correct abnormal coagulation values.

Conclusions

Altered coagulation may appear during the postoperative period in approximately 40% of our patients treated with CRS and HIPEC. Intraoperative transfusion of RBCs and possibly increased PCI are associated with abnormal postoperative coagulation. Close monitoring of coagulation parameters is required to help ensure safe removal of an epidural catheter.