Quality of life and survival prediction in terminal cancer patients: a multicenter study

BACKGROUND: It remains unclear whether health-related quality of life (HRQoL) measurements from patients and staff can be combined with medical data to predict survival in patients with terminal cancer. METHODS: The correlations between survival and potential health-related quality-of-life (HRQoL) prognostic variables were explored in 2 independent cohorts of patients with terminal cancer (248 patients in Cohort 1 and 756 patients in Cohort 2) after adjusting for clinical and demographics variables using Cox regression models. RESULTS: At the onset of the terminal phase (Cohort 1), the hazards of dying increased by 28% in the presence of dyspnea and by 68% in the presence of nausea/emesis; however, the most important predictors of worse survival were the presence of liver metastases (hazard ratio [HR], 2.5; 95% confidence interval [95% CI], 1.8-3.8), lung tumor (HR, 2.4; 95% CI, 1.7-3.4), and tumor burden (HR, 2.0; 95% CI, 1.4-2.7). In contrast, for patients who were seen in later stages of their terminal disease (Cohort 2), dyspnea (HR, 1.5; 95% CI, 1.1-1.9) and the coexistence of weakness with a diagnosis of digestive tumors (HR, 5.2; 95% CI, 1.2-21.8), breast tumors (HR, 3.1; 95% CI, 1.6-6.2), and genitourinary tumors (HR, 3.5; 95% CI, 1.6-7.8) were more predictive of survival than the type of tumor primary. Emotional functioning along with anxiety, spiritual distress, and lack of insight were not associated consistently with survival in both cohorts. CONCLUSIONS: Health care professionals should focus on physical HRQoL indicators, such as nausea and emesis, dyspnea, and weakness, to gather prognostic clues in patients with terminal cancer. These symptoms may reflect consequences of cancer cachexia and the progress of patients toward this terminal syndrome. Psychosocial distress did not appear to be associated consistently with survival; however, future studies should clarify further the prognostic significance of "positive attitudes", such as hope and optimism, in patients with advanced cancer.     

Comparative effects of antiplatelet, anticoagulant, or combined therapy in patients with valvular and nonvalvular atrial fibrillation: a randomized multicenter study

OBJECTIVES: This trial evaluated the efficacy and safety of the combination of antiplatelet and moderate-intensity anticoagulation therapy in patients with atrial fibrillation associated with recognized risk factors or mitral stenosis. BACKGROUND: Warfarin was more effective than aspirin in preventing stroke in these patients; combined therapy with low anticoagulant intensity was ineffective. Mitral stenosis patients were not investigated. METHODS: We performed a multicenter randomized trial in 1,209 patients at risk. The intermediate-risk group included patients with risk factors or age >60 years: 242 received the cyclooxygenase inhibitor triflusal, 237 received acenocumarol, and 235 received a combination of both. The high-risk group included patients with prior embolism or mitral stenosis: 259 received anticoagulants and 236 received the combined therapy. Median follow-up was 2.76 years. Primary outcome was a composite of vascular death and nonfatal stroke or systemic embolism. RESULTS: Primary outcome was lower in the combined therapy than in the anticoagulant arm in both the intermediate- (hazard ratio [HR] 0.33 [95% confidence interval (CI)0.12 to 0.91]; p = 0.02) and the high-risk group (HR 0.51 [95% CI 0.27 to 0.96]; p = 0.03). Primary outcome plus severe bleeding was lower with combined therapy in the intermediate-risk group. Nonvalvular and mitral stenosis patients had similar embolic event rates during anticoagulant therapy. CONCLUSIONS: The combined antiplatelet plus moderate-intensity anticoagulation therapy significantly decreased the vascular events compared with anticoagulation alone and proved to be safe in atrial fibrillation patients.     

Platelet aggregation inhibition blocks C-reactive protein and interleukin-6 (IL-6) elevation after the coronary angioplasty: effect of the -174 G/C IL-6 gene polymorphism

C-reactive protein (CRP), interleukin-6 (IL-6), and the -174 GC IL-6 gene polymorphism were analyzed after coronary angioplasty in 50 patients, 25 of whom were treated with the glycoprotein IIb/IIIa platelet receptor inhibitor eptifibatide for 24 hours. It was found that glycoprotein IIb/IIIa inhibition significantly blocked postangioplasty CRP increases in all patients but blocked IL-6 increases only in patients carrying the -174 GG genotype.     

Radioactive iodine therapy for Graves' disease in childhood and adolescence

While the diagnosis of Graves' disease in childhood and adolescence is relatively straightforward, its treatment remains controversial. The first choice therapy is the use of anti-thyroid drugs, although side effects are more frequent than in adults and remission is low. Surgery is not usually indicated as initial treatment. Instead, it is generally recommended after recidive of the disease or due to side effects of medical treatment. The use of radioiodine therapy is increasing in this age group, especially in North America, and control of the hyperthyroidism is achieved in 3 to 6 months in 90% of the cases. There is no evidence that radioiodine therapy is associated with a higher risk of thyroid cancer, and the occurrence of side effects is lower than surgery. Based on the positive results obtained with this therapy, patients with poor responsiveness to medical treatment should be considered for early radioiodine therapy.     

An open-label, comparative study of the efficacy and safety of once-daily dose of enoxaparin versus unfractionated heparin in the treatment of proximal lower limb deep-vein thrombosis

BACKGROUND: Treatment of deep-vein thrombosis (DVT) with a once-daily regimen of enoxaparin, rather than a continuous infusion of unfractionated heparin (UFH) is more convenient and allows for home care in some patients. This study was designed to compare the efficacy and safety of these two regimens for the treatment of patients with proximal lower limb DVT. METHODS: 201 patients with proximal lower limb DVT from 13 centers in Brazil were randomized in an open manner to receive either enoxaparin [1.5 mg/kg subcutaneous (s.c.) OD] or intravenous (i.v.) UFH (adjusted to aPTT 1.5-2.5 times control) for 5-10 days. All patients also received warfarin (INR 2-3) for at least 3 months. The primary efficacy endpoint was recurrent DVT (confirmed by venography or ultrasonography), and safety endpoints included bleeding and serious adverse events. The rate of pulmonary embolism (PE) was also collected. Hospitalization was at the physician's discretion. RESULTS: Baseline patient characteristics were comparable between groups. The duration of hospital stay was significantly shorter with enoxaparin than with UFH (3 versus 7 days). In addition, 36% of patients receiving enoxaparin did not need to be hospitalized, whereas all of the patients receiving UFH were hospitalized. The treatment duration was slightly longer with enoxaparin (8 versus 7 days). There was a nonsignificant trend toward a reduction in the rate of recurrent DVT with enoxaparin versus UFH, and similar safety. CONCLUSIONS: A once-daily regimen of enoxaparin 1.5 mg/kg subcutaneous is at least as effective and safe as conventional treatment with a continuous intravenous infusion of UFH. However, the once daily enoxaparin regimen is easier to administer (subcutaneous versus intravenous), does not require aPTT monitoring, and leads to both a reduced number of hospital admissions and an average 4-day-shorter hospital stay.     

Motoneurons innervating facial muscles after hypoglossal and hemihypoglossal-facial nerve anastomosis in rats

Hypoglossal-facial nerve anastomosis (HFA) is the most popular surgical procedure to reinnervate facial muscles after injury of the facial nerve. Section of the hypoglossus causes paralysis and atrophy of the hemi-tongue. In the attempt to overcome this consequence, the hemihypoglossal-facial nerve anastomosis (HHFA) has been proposed and only a half of the main trunk of the hypoglossus is connected to the distal stump of the facial nerve. In the rat, we have studied experimentally the anatomical nuclear changes after HFA and HHFA with the aim of establishing the quantitative motoneuron innervation of facial muscles obtained with each one of the two operative options. Horseradish peroxidase (HRP) injected in both types of anastomosis labeled not only hypoglossal motoneurons, but also facial motoneurons. HFA appeared to offer a significant quantitative motoneuron innervation higher than HHFA and then a higher probable better functional recovery. Both HFA and HHFA performed immediately after section of the facial nerve in rats did not result in a phenomenon of motor hyperinnervation. In our experimental model, the proximal facial nerve stump was coagulated at the stylomastoid foramen to avoid regeneration. Then, the labeled motoneurons into the facial nucleus could really be the expression of axonal projections from facial motoneurons to the hypoglossus nerve and facial muscles. No labeled motoneurons were seen contralaterally as we observed previously after section and repair of several nerves.