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Intensive Therapy (intensive + therapy)
Terms modified by Intensive Therapy Selected AbstractsKnowledge of residual curarization: an Italian surveyACTA ANAESTHESIOLOGICA SCANDINAVICA, Issue 3 2010P. DI MARCO Background: The use of neuromuscular blocking agents (NMBAs) is widespread in anesthetic practice; little is known about the current use of these drugs in Italy. This survey was conducted to obtain information about the most commonly used clinical tests and the train-of-four (TOF) ratios that are considered as being reliable for assessing recovery from neuromuscular blockade at the end of anesthesia and the estimated occurrence rates of post-operative paralysis in Italian hospitals. Methods: The questionnaire was given to Italian anesthesiologists attending the 62nd National Congress of the Italian Society of Anesthesia, Analgesia and Intensive Therapy. Collected data were stratified by age and the total number of surgical procedures performed in the hospitals concerned. Results: Seven hundred and fifty-four correctly compiled questionnaires were collected (response rate 88.7%). Seventy three percent of the respondents only used clinical tests for monitoring the level of neuromuscular blockade. The main clinical tests cited for the evaluation of residual paralysis were keeping the head lifted up for 5 s, protruding the tongue and opening the eyes. TOF was used by 35% of the respondents on a routine basis. Only 24% of the interviewed anesthesiologists reported that before extubation, a TOF ratio of at least 0.9 should be reached. Conclusions: Most Italian anesthetists assess the recovery from neuromuscular blockade only by clinical signs. There is poor awareness about the inability of such techniques to indicate even a significant amount of residual neuromuscular block. A more extensive use of quantitative instrumental monitoring is required for the more rational use of NMBAs. [source] Multiple myeloma , an update on diagnosis and treatmentEUROPEAN JOURNAL OF HAEMATOLOGY, Issue 5 2008Jo Caers Abstract Multiple myeloma is a plasma cell (PC) malignancy characterized by the accumulation of monoclonal PCs in the bone marrow and the production of large amounts of a monoclonal immunoglobulin or paraprotein. In the past years, new approaches in the diagnosis and treatment were introduced aiming to identify high-risk patients who need proper anti-myeloma treatment. Intensive therapy including autologous hematopoietic stem cell transplantation and the new agents bortezomib, thalidomide, and lenalidomide have improved patients' responses. Further optimalization of the different treatment schedules in well-defined patient groups may prolong their survival. Patient stratification is currently based on patient characteristics, extent of myeloma disease, and associated cytogenetic and laboratory anomalies. More and more gene expression studies are introduced to stratify patients and to individualize therapy. [source] Screening for Intracranial Stenosis With Transcranial Doppler: The Accuracy of Mean Flow Velocity ThresholdsJOURNAL OF NEUROIMAGING, Issue 1 2002Robert A. Felberg MD ABSTRACT Background. Patients with 50% intracranial arterial stenosis may require more intensive therapies for stroke prevention. Transcranial Doppler (TCD) is a convenient noninvasive screen for intracranial stenosis. The accuracy of different mean flow velocity (MFV) thresholds for determining the degree of stenosis remains uncertain. Methods. The authors prospectively compared the accuracy of TCD criteria and MFV thresholds to magnetic resonance, computed tomography, and digital subtraction angiography in patients with symptoms of recent or remote stroke or transient ischemic attack. Stenosis on angiography was measured as 0%, <50%, or ,50% diameter reduction. Results. Of 136 consecutive patients, 33 (24%) had distal internal carotid artery (ICA), middle cerebral artery (MCA), posterior cerebral artery, or basilar artery stenosis on angiography (14 patients [10%] were excluded due to incomplete TCD examinations, mainly from a lack of temporal windows). TCD showed 31 true-positive, 9 false-positive, 2 false-negative, and 94 true-negative studies. For all vessels, TCD had a sensitivity of 93.9% (confidence interval [CI] = 89%-98%), a specificity of 91.2% (CI = 87%-96%), a positive predictive value (PPV) of 77.5%, and a negative predictive value (NPV) of 97.9%. The trade-off in sensitivity and specificity for MCA MFV thresholds was as follows: MFV ,80 cm/s had a sensitivity of 100%, a specificity of 96.9% (CI = 94%-99%), a PPV of 84%, and an NPV of 100%. MFV,100 cm/s had a sensitivity of 100%, a specificity of 97.9% (CI = 96%-99%), a PPV of 88.8%, and an NPV of 94.9%. MFV,120 cm/s had a sensitivity of 68.7% (CI = 61%-78%), a specificity of 100%, a PPV of 100%, and an NPV of 94.9%. Reasons for false-positive findings include collateralization of flow in the presence of proximal ICA stenosis and prestenotic to stenotic MCA velocity ratios of 1:,2. Conclusion. TCD is both sensitive and specific in identifying ,50% intracranial arterial stenosis. A MFV threshold cutoff of 100 cm/s has an optimal sensitivity and specificity trade-off for ,50% MCA stenosis. To help avoid false-positive results, a prestenotic to stenotic MCA velocity ratio of 1:,2 should be used in addition to the MFV threshold. [source] Prognostic factors in adult acute lymphoblastic leukaemiaBRITISH JOURNAL OF HAEMATOLOGY, Issue 4 2010Jacob M. Rowe Summary Treatment of acute lymphoblastic leukaemia (ALL) in adults presents a formidable challenge. While overall results have improved over the past 3 decades, the long-term survival for patients aged less than 60 years is only in the range of 30,40% and is 10,15% if between 60 and 70 years and <5% for those over 70 years. The historic lack of clear-cut biological prognostic factors has led to over- or under-treatment of some patients. Response to initial therapy is an important prognosticator of outcome based on disease biology, as well as pharmacogenetics, which include the patient's response to drugs given. The more widespread availability of allogeneic transplantation and reduced-intensity regimens for older patients have opened up this curative modality to a greater number of patients. Hopefully, those options, as well as novel cytogenetic and molecular markers, will enable a better selection of patients who undergo intensive therapies and finally break the 30,40% cure barrier for adults with ALL. [source] Randomized controlled trial of physiotherapy in 56 children with cerebral palsy followed for 18 monthsDEVELOPMENTAL MEDICINE & CHILD NEUROLOGY, Issue 1 2001E Bower PhD MCSP Senior Research Fellow This study aimed to determine whether motor function and performance is better enhanced by intensive physiotherapy or collaborative goal-setting in children with cerebral palsy (CP). Participants were a convenience sample of 56 children with bilateral CP classified at level III or below on the Gross Motor Function Classification System (GMFCS), aged between 3 and 12 years. A 2 × 2 factorial design was used to compare the effects of routine amounts of physiotherapy with intensive amounts, and to compare the use of generalized aims set by the child's physiotherapist with the use of specific, measurable goals negotiated by the child's physiotherapist with each child, carer, and teacher. Following the six-month treatment period there was a further six-month period of observation. Changes in motor function and performance were assessed by a masked assessor using the Gross Motor Function Measure (GMFM) and the Gross Motor Performance Measure (GMPM) at three-month intervals. There was no statistically significant difference in the scores achieved between intensive and routine amounts of therapy or between aim-directed and goal-directed therapy in either function or performance. Inclusion of additional covariates of age and severity levels showed a trend towards a statistically significant difference in children receiving intensive therapy during the treatment period. This advantage declined over the subsequent six months during which therapy had reverted to its usual amount. Differences in goal-setting procedures did not produce any detectable effect on the acquisition of gross motor function or performance. [source] Impact of therapeutic advances on hypoglycaemia in type 2 diabetesDIABETES/METABOLISM: RESEARCH AND REVIEWS, Issue 4 2008Patrick J. Boyle Abstract Patients with type 2 diabetes experience hypoglycaemia less frequently than those with type 1 diabetes. Some protection against hypoglycaemia is afforded by the relatively intact glucose counter-regulatory pathways that characterize the pathophysiology of early type 2 diabetes. To some extent, this protection explains why hypoglycaemic episodes in intensively treated individuals with type 2 diabetes, when they occur, are rarely severe. As diabetes progresses and therapy intensifies to achieve recommended glycaemic goals, hypoglycaemia frequency and severity increase. Thus, when it comes to instituting intensive therapy, fear of hypoglycaemia may contribute to health-care providers' ,clinical inertia'. Because maintaining glycaemic control is so important to both public and individual health, many new therapies and technologies have been developed. This manuscript reviews and considers whether these advancements in therapy make glycaemic goals easier to achieve by minimizing hypoglycaemia. Putting the hypoglycaemia experienced by type 2 diabetes patients into appropriate clinical perspective, the impact of recent progress made in pharmacotherapy, drug delivery systems, and BG monitoring on hypoglycaemia incidence is largely positive. The extent to which this progress can effect improvement over traditional therapies will, however, depend upon patient (and provider) education, motivation and behaviour change. Copyright © 2008 John Wiley & Sons, Ltd. [source] Improving glycaemic control in children and adolescents: which aspects of therapy really matter?DIABETIC MEDICINE, Issue 4 2010T. C. Skinner Diabet. Med. 27, 369,375 (2010) Abstract In paediatric diabetes, the concept of intensive therapy in the post-Diabetes Control and Complications Trial period has become subverted by a pharmaco-technological paradigm at the expense of other aspects of care such as goal-setting and psychosocial support. This review examines which patients benefit most from intensive therapy in terms of glycaemic control (HbA1c). It also reviews published controlled trial and observational data relating to the impact of various insulin types and delivery systems on glycaemic control and canvasses the literature dealing with the impact of patient support, philosophy of care, goal setting and treating team dynamic on HbA1c. Taking into account the characteristics of those patients who benefit most from intensive therapy, the quantum of HbA1c change and the persistence of changes that have been reported in selected and non-selected patient groups, it appears that there is a clear hierarchy in aspects of therapy that improve glycaemic control for children and adolescents with Type 1 diabetes. Prime issues appear to be patient support, team cohesion and goal setting. The reported glycaemic benefits achieved by an isolated emphasis upon a pharmaco-technological paradigm are limited in children and adolescents. It appears that only after the prime issues have been first considered will the potential benefits of the insulin types and regimens then be realized. [source] A randomized controlled trial of Sweet Talk, a text-messaging system to support young people with diabetesDIABETIC MEDICINE, Issue 12 2006V. L. Franklin Abstract Aims To assess Sweet Talk, a text-messaging support system designed to enhance self-efficacy, facilitate uptake of intensive insulin therapy and improve glycaemic control in paediatric patients with Type 1 diabetes. Methods One hundred and twenty-six patients fulfilled the eligibility criteria; Type 1 diabetes for > 1 year, on conventional insulin therapy, aged 8,18 years. Ninety-two patients were randomized to conventional insulin therapy (n = 28), conventional therapy and Sweet Talk (n = 33) or intensive insulin therapy and Sweet Talk (n = 31). Goal-setting at clinic visits was reinforced by daily text-messages from the Sweet Talk software system, containing personalized goal-specific prompts and messages tailored to patients' age, sex and insulin regimen. Results HbA1c did not change in patients on conventional therapy without or with Sweet Talk (10.3 ± 1.7 vs. 10.1 ± 1.7%), but improved in patients randomized to intensive therapy and Sweet Talk (9.2 ± 2.2%, 95% CI ,1.9, ,0.5, P < 0.001). Sweet Talk was associated with improvement in diabetes self-efficacy (conventional therapy 56.0 ± 13.7, conventional therapy plus Sweet Talk 62.1 ± 6.6, 95% CI +2.6, +7.5, P = 0.003) and self-reported adherence (conventional therapy 70.4 ± 20.0, conventional therapy plus Sweet Talk 77.2 ± 16.1, 95% CI +0.4, +17.4, P = 0.042). When surveyed, 82% of patients felt that Sweet Talk had improved their diabetes self-management and 90% wanted to continue receiving messages. Conclusions Sweet Talk was associated with improved self-efficacy and adherence; engaging a classically difficult to reach group of young people. While Sweet Talk alone did not improve glycaemic control, it may have had a role in supporting the introduction of intensive insulin therapy. Scheduled, tailored text messaging offers an innovative means of supporting adolescents with diabetes and could be adapted for other health-care settings and chronic diseases. [source] Nocturnal Home Hemodialysis: Focus on the PartnerHEMODIALYSIS INTERNATIONAL, Issue 1 2003H Vos Background. Nocturnal home hemodialysis (NHD, 6 times weekly 6,8 hours) results in a better clinical and psychosocial condition of dialysis patients. However, this intensive therapy has important consequences for partners, who bear at least some responsibilities during the treatment. Methods. Since December 2001, we included 15 patients in a Dutch NHD project (,Nocturne'). All patients are assisted by their spouses. An aim of Nocturne is to study the effects of NHD on partners and other family members with questionnaires and interviews by a social worker. Results. NHD affects daily life of partners much more than conventional therapies. Partners feel very involved with the treatment. The invasion of the treatment in bed, the noise and light produced by the machine, the daily assisting of the patient, less freedom, and co-responsibility for the treatment are felt as a burden, specially during the first months of the treatment. However, the improved clinical condition of their spouse, resulting in less fatigue, less disability, less uremic symptoms, less complications, more attention for and contribution to family life, better quality of life and better mood are considered major improvements, with important positive effects for the quality of life of all family members. Additionally, partners consider the fact that they make an important positive contribution to their spouse's health valuable. All partners judged NHD, despite some negative consequences, as a major improvement of their life. Conclusion. The positive effects of NHD are more important than the negative consequences for partners of patients. However, partners need active support by nurses or social workers, specially during the first months of the treatment. [source] Barriers to the self-care of type 2 diabetes from both patients' and providers' perspectives: literature reviewJOURNAL OF NURSING AND HEALTHCARE OF CHRONIC ILLNE SS: AN INTERNATIONAL INTERDISCIPLINARY JOURNAL, Issue 1 2009Sandra PY Pun MHA Aim., To review systematically the literature about barriers to diabetes self-care from both patients' and healthcare providers' perspectives. Background., Diabetes mellitus is a global health concern due to rapidly increasing prevalence. The healthcare costs for diabetes care and related complications are high. Tight glycaemic control achieved by intensive therapy has been shown to lower the risk of complications. Despite the provision of comprehensive management programmes, patients are often unable to achieve the desired outcomes. It is essential to understand the barriers to diabetes self-care in order to promote successfully self-care behaviours. Methods., A search of OVID Medline (R), CINAHL, Cochrane Library and British Nursing Index was carried out during 1986,2007 using keywords: Type 2 Diabetes Mellitus, self care, patient compliance, patient adherence and barriers to diabetes self care. Manual searching of relevant nursing journals and sourcing of secondary research extended the search. Results., A total of 16 original research papers using various methods including survey, descriptive correlational, sequential explanatory mixed-method and qualitative exploratory design were reviewed. In total, over 8900 patients and 4550 healthcare providers were recruited from over 28 countries in these studies. Major barriers identified included psychosocial, socioeconomic, physical, environmental and cultural factors. Conclusions., Healthcare providers can enhance patient empowerment and participation with family support to achieve feasible targets. Better health care delivery systems and reforms that improve affordability, accessibility, and efficiency of care are essential for helping both providers and patients to meet desirable standards of diabetes care. Relevance to clinical practice., Understanding barriers to diabetes self-care is the first step in facilitating providers to identify their role in enabling patients to overcome these barriers. Healthcare providers can develop strategies to clarify and individualise treatment guidelines, implement continuing education, improve communication skills, and help motivate patients to achieve desired behavioral changes. [source] Multidisciplinary Teaming to Promote Effective Management of Type 1 Diabetes for AdolescentsJOURNAL OF SCHOOL HEALTH, Issue 6 2001MaryAnn Tapper Strawhacker BSN, RN Special Education Nursing Consultant ABSTRACT: Intensive diabetes therapy can reduce the long-term microvascular complications of Type 1 diabetes and improve glucose control. Managing the demands of intensive therapy however, often poses a burden on adolescents and their families. Through multidisciplinary teaming, the school health office can facilitate active participation in treatment, coordinate services, and maximize use of community resources. This paper presents a general overview of intensive diabetes therapy, psychosocial implications of chronic illness in adolescence, effects of chronic illness on the family, and behavior change strategies to improve adherence with disease management guidelines. [source] Acute kidney injury and renal replacement therapy in the intensive care unitNURSING IN CRITICAL CARE, Issue 4 2009Peter Faber Abstract Background:, Renal replacement therapy (RRT) is now offered as a routine treatment in most intensive care units (ICU) in the UK for patients suffering from acute kidney injury (AKI). It is important for all ICU staff to understand the underlying principles of the available therapeutic options and the possible complications thereof. Aims and objectives:, The objective of this review was to provide an accessible theoretical and practical update on the management of RRT. In addition to a detailed discussion of the underlying principles and indications for the various modes of RRT, we will discuss the assessment of kidney function, possible complications and anticoagulation during RRT, following a review of the current literature. Search strategies:, Pubmed, Medline and the Cumulative Index to Nursing and Allied Health Literature were searched using the keywords renal function, RRT, dialysis, renal failure kidney injury, together with intensive care, intensive therapy and critical care. We included only studies published in English from 1998 to 2008 and from these identified and included additional publications. The 12 most relevant publications are referenced in this review. Conclusion:, AKI is associated with increased mortality in ICU, and RRT should be considered early in the disease process. Continuous haemofiltration is the most common modality of treatment in this group of patients, and a detailed knowledge of the management of such patients is required. [source] Comparison of two methods for evaluating bone marrow metastasis of neuroblastoma: Reverse transcription-polymerase chain reaction for tyrosine hydroxylase and magnetic resonance imagingPEDIATRICS INTERNATIONAL, Issue 4 2004Chikayo Takemoto AbstractBackground:,The presence of bone marrow (BM) metastasis and circulating tumor cells in patients with neuroblastoma is a significant prognostic factor at diagnosis and might antedate detection of a relapse by other diagnostic studies. In this study, the clinical value of reverse transcription-polymerase chain reaction (RT-PCR) to amplify mRNA for tyrosine hydroxylase (TH) and magnetic resonance imaging (MRI) during the clinical course of patients with advanced neuroblastoma, was evaluated. Methods:,Four patients with Stage 1, 4 or 4S neuroblastoma, were studied. BM and peripheral blood (PB), including peripheral blood stem cell (PBSC), samples were examined for TH mRNA using RT-PCR. Concurrently, MRI detection of BM metastasis was used. Results:,In all cases, except one that had no evidence of BM invasion, TH mRNA in BM and PB at diagnosis were positive, and TH mRNA at diagnosis disappeared after chemotherapy. In two cases, although involvement in the neurocentrum BM was detected by MRI, TH mRNA in the iliac crest BM was negative. The pathological area still remained on MRI after intensive therapy. Conclusion:,RT-PCR for TH mRNA might be the most sensitive method for the detection of occult neuroblastoma cells in BM and PB. However, because invasion of the BM by neuroblastoma may have a focal distribution, sampling errors can occur. Therefore, not only RT-PCR but also MRI, need to be used to rule out marrow involvement, especially at diagnosis and BM relapse. [source] Is dosage of physiotherapy a critical factor in deciding patterns of recovery from stroke: a pragmatic randomized controlled trialPHYSIOTHERAPY RESEARCH INTERNATIONAL, Issue 4 2000Dr Cecily Partridge Abstract Background and Purpose The best treatment and management of stroke patients has been shown to be in stroke units by multidisciplinary rehabilitation teams. Since the composition of stroke units differs it is important to know the extent to which the different components contribute to this result. Physiotherapy is one component of most rehabilitation teams and recent systematic reviews have shown that patients with stroke receiving more physiotherapy achieve more recovery from disability. However, information about the actual amounts of physiotherapy needed to achieve this result is not known. Method A pragmatic, randomized, single-blind, controlled trial comparing recovery from disability in subjects receiving the current standard amount of 30 minutes' physiotherapy with those receiving double that amount (60 minutes). The study included measures of physical performance and function, psychological aspects of anxiety and depression, and perceived control over recovery. Results Some 114 subjects were recruited to the study; full six-week data are available for 104 subjects and six-month data for 93 subjects. Comparison of initial to six-week difference scores in the control and intervention groups of the whole sample did not show a significant difference. Scrutiny of the recovery curves of the whole sample showed that, in half the sample, three distinct patterns of recovery were demonstrated. Conclusion These results suggest that doubling the physiotherapy time available for patients in a stroke unit will not provide a measurable benefit for all patients. The subgroup analysis of patterns of recovery must be regarded as speculative, but provides the basis for hypotheses about those likely to respond well to more intensive therapy. Copyright © 2000 Whurr Publishers Ltd. [source] Quality in the outsourcing process: part I. The quality outsourcerQUALITY ASSURANCE JOURNAL, Issue 4 2001Yvonne Russell Dr. Abstract In clinical research, the definition of quality and overall responsibility for ensuring that performance parameters are adequately tracked and the necessary corrective action taken, lies firmly in the hands of the outsourcing project director/manager (outsourcer or sponsor). Meticulous planning of requirements prior to project start and strong ,general management' throughout the life of the outsourced project play a critical role in influencing both the outcome of the study and also in determining the quality of the research data. For ,quality in the outsourcing process', read ,quality outsourcing'. The implementation of a carefully formulated project-specific outsourcing strategy means that macromanagement (general management), not micromanagement (defined here as a form of ,intensive therapy for the ailing project' management), will be the primary task of the sponsor. A research team that is well-defined, with all members (sponsor and vendor alike) mindful of their individual responsibilities, in addition to being well-directed, will achieve consensus of opinion faster and deliver a quality product. An outsourcing strategy for the full clinical development program, clearly defined outsourcing standard operating procedures (SOPs) and a strategy tailored to each individually outsourced project form an integral part of the recipe to outsourcing success. Individual components of an outsourcing strategy and how one can safeguard that an outsourced project is brought to completion successfully, and to the prescribed quality standards, are addressed in detail in this article. Part two of this article, entitled ,Quality in the Outsourcing Process: II. The Vendor Selection Process and The Quality Vendor', will provide the quality outsourcer with tips and tools on how to make a quality decision in the vendor selection process and addresses further issues that are fundamental to the maintenance of quality in the outsourcing process. Copyright © 2001 John Wiley & Sons, Ltd. [source] Preliminary evidence suggests that hand,arm bimanual intensive therapy (HABIT) improves bimanual upper limb performance in children with mild to moderate hemiplegic cerebral palsyAUSTRALIAN OCCUPATIONAL THERAPY JOURNAL, Issue 1 2009Margaret Wallen No abstract is available for this article. [source] Clinical value of minor responses after 4 doses of rituximab in Waldenström macroglobulinaemia: a follow-up of the Eastern Cooperative Oncology Group E3A98 trialBRITISH JOURNAL OF HAEMATOLOGY, Issue 5 2009Morie A. Gertz Summary Waldenström macroglobulinaemia is a low-grade, lymphoplasmacytic lymphoma that is responsive to rituximab. We report the role of a minor response in predicting overall outcomes. We extended follow-up of a previously described cohort (n = 69) treated with 4 weekly doses of rituximab and observed durable responses (median time to progression, 30 months; 5-year survival rate, 66%). Patients achieving a minor response [25,50% immunoglobulin M (IgM) reduction] appeared to do as well as those achieving an objective response (>50% IgM reduction), which suggests that more aggressive or intensive therapy for minor responders is not required. Future studies of Waldenström macroglobulinaemia should report minor responses because they are associated with clinically meaningful benefits. This trial was registered at http://www.clinicaltrials.gov as #NCT00005609. [source] Anaplastic large cell lymphoma treated with a leukemia-like therapyCANCER, Issue 10 2005Oncology (AIEOP) LNH-92 protocol, Report of the Italian Association of Pediatric Hematology Abstract BACKGROUND Childhood anaplastic large cell lymphoma (ALCL) is a well defined entity with a rather poor prognosis. Different approaches have been adopted in the treatment of ALCL in various cooperative trials, including short high-dose intensive therapy and leukemia-like protocols. In the early 1990s, the Italian Association of Pediatric Hematology and Oncology (AIEOP) initiated a multicenter trial for the treatment of ALCL based on a modified LSA2-L2 protocol. METHODS Thirty-four consecutive eligible children with newly diagnosed ALCL were enrolled in the AIEOP LNH-92 protocol. Treatment was comprised of an induction of remission phase, followed by consolidation and maintenance for a total duration of 24 months, independently of disease stage. RESULTS Thirty of 34 patients (88%) achieved complete disease remission and 8 patients experienced disease recurrence. With a median follow-up of 8.4 years, the probabilities of survival and event-free survival were 85% (range, 79,91%) and 65% (range, 57,73%), respectively. Therapy was well tolerated and hematologic toxicity was the most frequent toxicity. CONCLUSIONS The leukemia-like protocol AIEOP LNH-92 was found to be an effective treatment for childhood ALCL. Its long duration may be beneficial to specific patient subgroups, but optimal treatment duration in ALCL remains to be elucidated. Cancer 2005. © 2005 American Cancer Society. [source] Disease biology rather than age is the most important determinant of survival of patients , 60 years with acute myeloid leukemia treated with uniform intensive therapyCANCER, Issue 10 2005Vikas Gupta M.D. Abstract BACKGROUND The objectives of the current study were to evaluate the outcome of patients , 60 years with acute myeloid leukemia (AML) treated uniformly with high-dose daunorubicin containing induction and modified high-dose cytosine arabinoside containing postremission therapy, and to identify factors predictive of complete disease remission (CR) and survival. METHODS Between 1998 and 2002, the authors treated 117 newly diagnosed patients (acute promyelocytic leukemia excluded) with AML , 60 years (median, 67 years; range, 60,82 years). Karyotype (Medical Research Council classification) at diagnosis was categorized as good risk (n = 3), intermediate risk (n = 69), adverse risk (n = 26), and suboptimal/not done (n = 19). A normal karyotype was seen in 41 patients and 40 (34%) had secondary AML. RESULTS The outcome of induction included the following: CR, 62 (53%); early death, 5 (4%); death during hypoplasia, 14 (12%); and resistant disease, 36 (31%). The 3-year event-free (EFS) and overall survival (OS) rates were 9% (95% confidence interval [95% CI], 3,16%) and 17% (95% CI, 9,29%), respectively. In a univariate analysis, cytogenetics, lactate dehydrogenase level, leukocyte count, and performance status were the significant factors for EFS and OS. Age was not a significant prognostic factor for either CR or survival. In a multivariate model, adverse-risk cytogenetics, previous history of myelodysplastic syndrome or antecedent hematologic disorder, and high leukocyte count (> 30 × 109/L) were independent adverse prognostic factors for survival. The impact of adverse karyotype on EFS and OS was time dependent and was observed after 50 and 150 days, respectively. CONCLUSIONS The authors concluded that candidacy for intensive therapy in older patients should be based on biologic features of disease and fitness, rather than on age. Cancer 2005. © 2005 American Cancer Society. [source] Rapid clinical assessment of hemodynamic profiles and targeted treatment of patient with acutely decompensated heart failureCLINICAL CARDIOLOGY, Issue S5 2004Greegg C. Fonarow M.D. Abstract Acutely decompensated heart failure (ADHF) is characterized by hemodynamic abnormalities and neurohormonal activation that contribute to heart failure (HF) symptoms, end-organ dysfunction, arrhythmias, and progressive cardiac failure. The management of ADHF in the emergency department (ED) can be simplified and improved by a 2-min bedside assessment that identifies any of four possible hemodynamic profiles on the basis of clinical signs and symptoms. The profiles are based on whether congestion is present or absent (wet or dry) and perfusion is adequate or limited (warm or cold). A wet-warm profile is seen more frequently in the ED than any of the other three profiles (wet-cold, dry-warm, and dry-cold). The four clinically determined profiles have been shown to predict clinical outcomes and may be used to guide initial HF therapy. The goals of treating ADHF are to stabilize the patient, reverse acute hemodynamic abnormalities, rapidly reverse dyspnea and/or hypoxemia caused by pulmonary congestion, and initiate treatments that will decrease disease progression and improve survival. An ideal agent for the wet-warm profile would rapidly reduce pulmonary congestion, produce balanced arterial and venous dilation, promote natriuresis, lack direct positive inotropic effects, and not cause reflex neuroendocrine activation. Intravenous nesiritide in conjunction with loop diuretics has been found safe and effective as initial treatment for patients with the wet-warm profile. For the wet-cold profile, more intensive therapy and invasive hemodynamic monitoring may prove useful. This review will discuss the rapid clinical determination of hemodynamic profiles in patients presenting to the ED with ADHF and the options for their initial medical management. Case studies representing the wet-warm, wet-cold, dry-warm, and dry-cold profiles will be presented and discussed. [source] | |||||||||||||||||||||||||