Team performance and risk-adjusted health outcomes in the Program of All-Inclusive Care for the Elderly (PACE)

PURPOSE: The Program of All-Inclusive Care for the Elderly (PACE) is a community-based program providing primary, acute, and long-term care to frail elderly individuals. A central component of the PACE model is the interdisciplinary care team, which includes both professionals and non-professionals. The purpose of this study was to examine the association between the team's overall performance and the risk-adjusted health outcomes of program enrollees. DESIGN AND METHODS: The study included interdisciplinary teams in 26 PACE programs and 3,401 individuals enrolled in them. We combined information about individuals' health, functional, and mental status from DataPACE with an overall measure of team performance. We used multivariate regression techniques to test the hypothesis that better team performance is associated with better risk-adjusted health outcomes: survival and short-term (within 3 months of enrollment) and long-term (within 12 months of enrollment) improvements in functional status and in urinary incontinence. RESULTS: Team performance was significantly associated with better functional outcomes (both short and long term) and with better long-term urinary incontinence outcomes. There was no significant association with survival. IMPLICATIONS: This study provides empirical evidence for the relationship between team performance and patient outcomes in long-term care. It suggests that PACE programs can improve patient outcomes by improving the functioning of care teams.     

Exertional symptoms and exercise capacity in individuals with brain injury

PURPOSE: To examine factors affecting cycling exercise performance in individuals with acquired brain injury. METHODS: Thirty individuals with acquired brain injury and 18 sedentary controls (SC) participated. Heart rate, bicycle power output and rating of perceived exertional (RPE) were recorded, throughout incremental cycle ergometer exercise. The SC group and 18 moderately impaired individuals from the ABI group performed a 25-W (B25) protocol. The remaining 12 individuals performed a 10-W protocol (B10). RESULTS: The B10 group terminated exercise at the lowest RPE, percentage age predicted maximal heart rate (% APMHR) and bicycle power output, followed by the B25 and then the SC group (RPE: Kruskal - Wallis test P < 0.001, %APMHR and bicycle power output: one-way ANOVA P < 0.01). RPE was correlated with %APMHR and percentage of peak bicycle output (B10 group: R2 0.1 to 0.67; B25 group: 0.69 - 0.83; SC group: 0.76 - 0.91). There was no difference in RPE at the same relative work intensity between the B25 and the sedentary control group (P > 0.05). Forward regression analysis revealed fatigue levels were predictive of %APMHR at test termination (beta = -0.411, P < 0.05) and quadriceps strength was predictive of peak bicycle power output (beta = 0.612, P < 0.05). CONCLUSIONS: Individuals with brain injury terminated exercise at lower exercise intensities but rated exertion no differently from healthy individuals. General fatigue levels predicted %APMHR and quadriceps strength predicted peak bicycle power output.     

PDGFRA Amplification is Common in Pediatric and Adult High‐Grade Astrocytomas and Identifies a Poor Prognostic Group in IDH1 Mutant Glioblastoma

High‐grade astrocytomas (HGAs), corresponding to World Health Organization grades III (anaplastic astrocytoma) and IV (glioblastoma; GBM), are biologically aggressive, and their molecular classification is increasingly relevant to clinical management. PDGFRA amplification is common in HGAs, although its prognostic significance remains unclear. Using fluorescence in situ hybridization (FISH), the most sensitive technique for detecting PDGFRA copy number gains, we determined PDGFRA amplification status in 123 pediatric and 263 adult HGAs. A range of PDGFRA FISH patterns were identified and cases were scored as non‐amplified (normal and polysomy) or amplified (low‐level and high‐level). PDGFRA amplification was frequent in pediatric (29.3%) and adult (20.9%) tumors. Amplification was not prognostic in pediatric HGAs. In adult tumors diagnosed initially as GBM, the presence of combined PDGFRA amplification and isocitrate dehydrogenase 1 (IDH1)^R132H mutation was a significant independent prognostic factor (P = 0.01). In HGAs, PDGFRA amplification is common and can manifest as high‐level and focal or low‐level amplifications. Our data indicate that the latter is more prevalent than previously reported with copy number averaging techniques. To our knowledge, this is the largest survey of PDGFRA status in adult and pediatric HGAs and suggests PDGFRA amplification increases with grade and is associated with a less favorable prognosis in IDH1 mutant de novo GBMs.     

Neoadjuvant gemcitabine and cisplatin chemotherapy for locally advanced urothelial cancer of the bladder

BACKGROUND:

The purpose of this study was to investigate the effect of neoadjuvant chemotherapy with gemcitabine and cisplatin (GC) on pathologic down‐staging of patients with locally advanced urothelial cancer (UC) of the bladder.

METHODS:

This was a retrospective cohort study of patients treated with radical cystectomy (RC) for clinical stage cT2‐T4, N any, M0 bladder UC at Strong Memorial Hospital from 1999 to 2009. The primary exposure variable was use of neoadjuvant chemotherapy (GC vs none). The primary outcome was stage pT0 at RC. Secondary outcomes included other down‐staging end points in the bladder ( RESULTS: A total of 160 eligible patients were identified, of whom 25 were treated with neoadjuvant GC before RC (GC + RC) and 135 without neoadjuvant chemotherapy (RC only). Stage pT0 at cystectomy was found in 20% of patients in the GC + RC group and in 5% of patients in the RC group (adjusted risk difference [aRD] = 16%, P = .03). For other down‐staging end points, the estimated treatment effect was as follows (all point estimates favoring chemotherapy): P = .005); P = .004); P = .008); margins aRD = 8% (P = .41); nodes aRD = 4% (P = .74).

CONCLUSIONS:

Neoadjuvant GC was found to be capable of down‐staging UC in the bladder; however, no effect on disease in nodes was seen in this study. Cancer 2012;. © 2011 American Cancer Society.