Prognostic factors for non-cleaved follicular center-cell lymphomas and immunoblastic sarcoma. A Bayesian approach

Patient-specific factors affecting survival following hip fractures-a 14-year follow-up study in Finland

The mortality of elderly hip fracture patients is high. Eighty-five percent of all patients were followed until death. The three most protective factors for 1-year survival were ASA class; BMI; and age, and the four most protective factors for 14-year survival were age; BMI; ASA class; and subtrochanteric fracture type.

OBJECTIVE

Hip fractures are associated with increased mortality. The purpose of this study was to evaluate the protective preoperative factors regarding the survival of short-term (1 year) and long-term (14 years) follow-up in a hip fracture cohort in Finland.

METHODS

A total of 486 patients, operated on in 2005 and 2006, were retrospectively evaluated. Survival was analyzed using Bayesian multivariate analysis and relative survival with the life table method. All patients were followed for a minimum of 14 years.

RESULTS

We analyzed 330 women and 156 men, whose mean ages were 82.4 and 72.0 years, respectively. The overall mortality rate was 7% at 1 month, 22% at 12 months, and 87% at 14 years. Protective factors against mortality at 1 year were ASA class (1-3), BMI ≥ 20 kg/m², age < 85 years, alcohol involvement, Alzheimer's disease, no comorbidities, certain operative methods, and female sex. Factors promoting survival at 14 years were age < 75 years, BMI ≥ 20 kg/m², ASA class (1-2), subtrochanteric fracture, certain operative methods, alcohol involvement, and no comorbidities.

CONCLUSIONS

Protective factors for 1-year survival in order of importance were ASA class, BMI, and age, and, correspondingly, for 14-year survival, age, certain operative methods, BMI, and ASA class. The relative survival of hip fracture patients was lower than that of the general population.

Post-fracture prescribed calcium and vitamin D supplements alone or, in females, with concomitant anti-osteoporotic drugs is associated with lower mortality in elderly hip fracture patients: a prospective analysis

BACKGROUND

Several studies have shown excess mortality among hip fracture patients compared with the normal population of the same age. Finnish guidelines for medical treatment of hip fracture patients recommend anti-osteoporosis medication and the daily concomitant use of prescribed calcium and vitamin D supplements. However, whether post-fracture use of calcium and vitamin D supplements is associated with survival in such patients has not been evaluated.

OBJECTIVE

To study the association between survival in hip fracture patients and patients' sex and age, pre-fracture vitamin D status, American Society of Anesthesiologists - Physical Status (ASA-PS) class, type of fracture and post-fracture use of prescribed calcium plus vitamin D and anti-osteoporotic medication.

METHODS

The study population was 221 hip fracture patients primarily treated in acute care for a new hip fracture in 2003-4 in two Finnish hospitals. After a median of 27.5 months from the fracture, a questionnaire was sent to all patients who were still alive at the time (n = 137). The patients were queried about their use of prescribed calcium plus vitamin D supplementation and of anti-osteoporotic drugs. The follow-up time for use of anti-osteoporotic medication and prescribed calcium and vitamin D was 19.5-36 months (median 27.5 months). Data on the use of prescribed calcium plus vitamin D supplementation and anti-osteoporotic drugs were checked against information on reimbursement of drug prescriptions held by the Finnish Social Insurance Institution. A total of 4 years' (48 months') survival data for all patients in the study population was also obtained, with the dates of patient deaths being checked against Official National and Regional population statistics. Patient survival was analysed using both the Bayesian multivariate analysis and the life table method.

RESULTS

In the multivariate analysis, the combination of variables that best explained post-fracture survival was as follows: age <80 years; ASA-PS class 1-2 (ASA-PS class 1 and 2 data were combined in calculations); post-fracture use of prescribed calcium plus vitamin D supplements concomitantly with anti-osteoporotic drugs; post-fracture use of prescribed calcium plus vitamin D supplements; post-fracture use of anti-osteoporotic drugs only; and type of fracture (femoral neck or subtrochanteric). This model correctly predicted 74% of cases. At 36 months, we observed a 36% reduction in deaths in females who used prescribed calcium plus vitamin D supplementation and a corresponding 43% reduction in males. Survival of females who used anti-osteoporotic drugs concomitantly was even greater (43% reduction in deaths) over the entire follow-up period. Excess mortality was highest in females and males who used neither anti-osteoporotic drugs nor prescribed calcium and vitamin D.

CONCLUSION

Our results indicate a potential relationship between reduced mortality and post-fracture use of prescribed calcium plus vitamin D supplementation and, in females, concomitant use of anti-osteoporotic drugs. However, further investigations are needed to understand the reason for the reduction in the risk of death. Population-based, randomized, placebo-controlled trials with total mortality as the main endpoint should be conducted to verify our results.

Treatment-related factors predisposing to chronic pain in patients with breast cancer--a multivariate approach

A study was carried out to assess the factors predisposing to chronic post-treatment pain in the breast area and in the ipsilateral arm in patients treated for breast cancer using two multivariate models. In the study 509 patients with non-metastasized breast cancer who were treated during 1988-1994 completed the questionnaire about pain in the operated breast and in the ipsilateral arm 10-58 months after surgery. The factors included in the analysis were: age, type of operation, size of the tumour, number of lymph nodes removed, involvement of lymph nodes, complications of surgery, intensity of the acute postoperative pain remembered by the patient, number of doses of analgesics, number of months from surgery, adjuvant radiotherapy, chemotherapy and endocrine treatment. The most important factors included in the models of chronic pain were: intensity of the acute postoperative pain, the type of operation, involvement of regional lymph nodes and radiotherapy.

Pain and other symptoms after different treatment modalities of breast cancer

PURPOSE

The aim of this study was to analyse the risk factors that predispose women to chronic symptoms related to the treatment of breast cancer.

PATIENTS AND METHODS

A questionnaire was sent to 569 women who had undergone modified radical mastectomies with axillary evacuation (MRM) or breast resection with axillary evacuation (BCT).

RESULTS

Pain, paraesthesias and strange sensations were reported by half of the patients. The chronic pain slightly affected the daily lives of about 50% of the patients and moderately or more the daily lives of about 25% of the patients. Pain was reported significantly more often after BCT than after MRM both in the breast scar (BS) and in the ipsilateral arm (IA). The patients with chronic pain were significantly younger and had larger primary tumours. Postoperative complications increased the incidence of chronic pain in the IA. The highest incidence of pain in the IA was reported by patients who had had both radio- and chemotherapy. The fact that the incidence of pain (IA) had a significant correlation with the incidence of paraesthesias, oedema, strange sensations and muscle weakness may be an indication of nerve injury.

CONCLUSIONS

Chronic pain was more common after breast-conserving surgery than after radical surgery. Surgical complications and postoperative radiotherapy and chemotherapy increased the risk of chronic pain and other symptoms. Modifications in the treatment protocol and preclusion of postoperative complications may be necessary in order to minimize chronic treatment-related symptoms.

Flow cytometric analysis of DNA ploidy in large cleaved cell lymphomas

The results of nuclear DNA content analysis of a series of 28 patients with large cleaved follicular centre cell non-Hodgkin's lymphomas (NHL) are reported. DNA aneuploidy was found in 11 (39 per cent) cases. The DNA indices of the DNA-aneuploid peaks ranged from 1.14 to 2.28. Seven (25 per cent) cases were tetraploid. DNA ploidy was not associated with prognosis. The percentage of S phase cells (SPF) ranged from 2.0 to 30.5 per cent (median 5.1 per cent). Lymphoma patients with SPF higher than 9.7 per cent had a worse survival rate than patients with lymphoma with less than 9.7 per cent S phase cells but the difference did not reach statistical significance. The results of the DNA ploidy and SPF were comparable to those of intermediate and high grade malignancy NHLs.

Flow cytometric DNA analysis of 199 histologically favourable or unfavourable non-Hodgkin lymphomas

We have studied the nuclear DNA content of histologically favourable (n = 82) or unfavourable (n = 117) non-Hodgkin lymphomas (NHLs) diagnosed between 1957 and 1978 in the Tampere University Central Hospital. The DNA analysis was done by applying a trypsin digestion method to archival tumour samples. DNA aneuploidy was seen in 40 per cent of the unfavourable cases and in 10 per cent of the favourable cases, but varied considerably between different histological subtypes. The unfavourable cases showed high proliferative activity (S-phase fraction, SPF), while considerable variation in the SPF among the favourable NHLs was noted. Among the unfavourable NHLs, cases with DNA-aneuploid tumours had significantly (P less than 0.01) worse prognosis than stage and treatment matched cases with DNA-diploid tumours. In general, survival of the patients who had high SPF tumours was significantly lower compared with patients with low SPF tumours (P less than 0.01). However, SPF was not related to the prognosis in the unfavourable NHLs. We conclude that the flow cytometric DNA analysis revealed characteristic features in the favourable and unfavourable NHLs and may be useful in predicting the clinical outcome of patients.

The Bayesian approach to the evaluation of risk factors in acute and recurrent acute otitis media

A multivariant modelling method was used to analyse the risk, associated with 22 different factors, of contracting acute otitis media (AOM) in a prospective cohort of 1294 urban children followed up to the age of 17-32 (mean 25) months. By far the most important risk factor was the caring of the child at a day-care centre. The importance of this factor further increased with increasing recurrence of the attacks. Next in order came the existence of sibling(s) with AOM attacks during the follow-up. Prolongation of breastfeeding increased the protection against AOM during the first year of life. The frequency of AOM attacks was lowest around midsummer and highest in early winter.

Mitoses in non-Hodgkin's lymphomas. Frequency and prognostic relevance

The frequency of mitoses was investigated in 279 lymph node biopsies from untreated patients with non-Hodgkin's lymphomas. The data were correlated with histological subtypes and survival time. It could be shown that the frequency of mitoses increases parallel to the amount of large tumor cells, except for lymphoblastic varieties. The proliferative activity was not influenced by a plasmacytoid differentiation. The nodules of follicular centroblastic centrocytic lymphomas revealed more mitoses than did the diffuse lymphomas of a similar grade of malignancy which shows that the growth pattern must be considered when the frequency of mitoses is interpreted. Immuno- and centroblastic lymphomas exhibited no marked differences with regard to mitotic activity. If all lymphomas are subdivided into three groups according to the mitotic grade alone, three survival curves are obtained that differ significantly from each other. It is concluded, therefore, that the mitotic activity of malignant lymphomas is a useful prognostic parameter that, until now, has received unduly limited attention.

Multivariate prognostication in bacterial meningitis of childhood

A multivariate method for prognosticating the outcome of bacterial meningitis was computerized on the basis of initial clinical and laboratory data in 123 patients. The model, based on likelihood ratios, is simple and rapid. At the time of diagnosis, it predicted the outcome correctly in 104/123 cases (85%) in the basic group and in 67/98 independent controls (68%). The sensitivity of the method in predicting death or mild to severe neurological sequelae was 83% in both groups. The predictive value of a calculated good prognosis was 94% in the basic group and 97% in the control group, and that of a calculated poor prognosis was 63% and 26%, respectively. The predictive system can be used for rapid assessment of prognosis in individual patients and for comparisons between groups.

The cleaved cell content of non-cleaved (transformed) follicular center cell lymphomas and its clinico-pathological significance

The relationship of cleaved cell content and survival was studied in 122 patients with transformed small and large non-cleaved cell types of the Lukes and Collins classification for non-Hodgkin's lymphomas. The large non-cleaved follicular center cell (FCC) type showed higher contents of cleaved cells than did the others; the geometric mean value differed significantly from that of small non-cleaved FCC Burkitt type (p less than 0.0001) or non-Burkitt type (p less than 0.01) lymphomas. There was a tendency toward a better prognosis with large fractions of cleaved cells but no statistical difference was found. The prognostic characteristics of the neoplastic clone are better revealed by the predominant cell.

Behaviour of dendritic reticulum cells possessing immunoreactive acid cysteine-proteinase inhibitor in human lymphoid secondary follicles and in follicular-centre cell lymphomas

In our previous studies acid cysteine-proteinase inhibitor (ACPI) was shown to be a common characteristic of human squamous epithelia and dendritic reticulum cells (DRC) in lymphoid secondary follicles. In the present study, the behaviour of ACPI-immunoreactive DRC in reactive lymphoid secondary follicles and neoplastic follicles of follicular-centre cell (FCC) lymphomas was compared by the peroxidase-antiperoxidase method. The secondary follicles in reactive lymphoid tissues revealed a staining pattern characteristic of DRC comparable with the results of other studies. Contrary to this, the number of ACPI-positive DRC in the neoplastic lymphoid follicles was greatly reduced. This was occasionally accompanied by a weak reaction and in many cases the DRC were totally abolished. Moreover, morphological aberrations were observed in ACPI-positive DRC, especially diminution and shortening of dendritic processes. On occasion, ACPI-positive cell types were observed, which may represent intermediate forms between DRC and fibroblastic reticulum cells. Only one case--with a rather favourable clinical outcome (out of 41 follicular FCC lymphomas) exhibited an ACPI-positive DRC pattern comparable with that of reactive lymphoid follicles. Thus it seems that the ACPI-immunohistochemistry of DRC provides an additional tool for discerning the difference between reactive and neoplastic lymphoid follicles. This method is of particular value since it can be used with formalin-fixed, paraffin-embedded tissues. There was a tendency among the follicular FCC lymphoma patients towards a better survival rate for those with ACPI-positive DRC than for those lacking this cell type, although no statistically significant differences emerged from this limited material.