A general chemotherapy myelotoxicity score to predict febrile neutropenia in hematological malignancies

BACKGROUND

Chemotherapy-induced neutropenia is the most common adverse effect of chemotherapy and is often complicated by febrile neutropenia (FN). The objective of this study is to validate a classification of aggressiveness of a chemotherapy regimen and to evaluate its usefulness in a risk prediction model of FN in patients with hematological cancer at the beginning of a chemotherapy cycle.

PATIENTS AND METHODS

Two hundred and sixty-six patients were prospectively enrolled and followed during 1053 cycles. Relevant patient informations were collected at the beginning of the first cycle and the number of days of FN were counted in the follow-up [dichotomized (no FN versus >or= 1 day of FN)].

RESULTS

Aggressive chemotherapy regimen is the major predictor of FN [odds ratio 5.2 (3.2-8.4)]. The other independent predictors are the underlying disease, an involvement of bone marrow, body surface <or= 2 m(2), a baseline monocyte count <150/microl and the interaction between the first cycle in the same treatment line and a baseline hemoglobin dosage. A rule of prediction of FN was computed with these characteristics: sensitivity 78.6%, specificity 62.3%, positive predictive value 42.7% and negative predictive value 89.1%.

CONCLUSION

Further studies are needed to validate this score.

Survival and functional outcome according to hip fracture type: a one-year prospective cohort study in elderly women with an intertrochanteric or femoral neck fracture

We conducted a prospective study among elderly women with a first hip fracture to document survival and functional outcome and to determine whether outcomes differ by fracture type. The design was a one-year prospective cohort study in the context of standard day-to-day clinical practice. The main outcome measures were survival and functional outcome, both at hospital discharge and 1 year later. Functional outcome was assessed using the Rapid Disability Rating Scale version-2. Of the 170 women originally enrolled, 86 (51%) had an intertrochanteric and 84 (49%) a femoral neck fracture. There were no significant differences between the two groups with respect to median age (80 and 78 years, respectively), type and number of comorbidities and prefracture residence at the time of injury. At hospital discharge, intertrochanteric hip fracture patients had a higher mortality (p=0.006) and were functionally more impaired (p=0.005). One year later, mortality was still significantly higher after intertrochanteric fracture (relative risk 2.5; 95% confidence interval: 1.3 to 5.1; p=0.008), but functional outcome among surviving patients was similar in both groups. We conclude that intertrochanteric fractures are associated with increased mortality compared to femoral neck fractures. Functional outcome differs according to fracture type at hospital discharge, but these differences do not persist over time. These differences cannot be explained by differences in age or comorbidity. To address the mechanism(s) by which intertrochanteric fractures carry excess mortality compared to femoral neck fractures, future studies in hip fracture patients should include a comprehensive assessment of the degree of frailty, vitamin D status, and fall dynamics.

Low Mannose-Binding Lectin Concentration Is Associated with Severe Infection in Patients with Hematological Cancer Who Are Undergoing Chemotherapy

BACKGROUND

Mannose-binding lectin (MBL) is a serum lectin involved in innate immune response. Low serum MBL concentration may constitute a risk factor for infection in patients receiving myelosuppressive chemotherapy.

METHODS

We conducted a prospective, observational study that assessed MBL concentration as a risk factor for infection in patients with hematological malignancy who were hospitalized to undergo at least 1 chemotherapy cycle. MBL deficiency was defined using an algorithm that considered the serum MBL concentration and the MBL genotype. The primary end point was the ratio of duration of febrile neutropenia to the duration of neutropenia. Secondary end points included the incidence of severe infection (e.g., sepsis, pneumonia, bacteremia, and invasive fungal infection). Logistic regression analysis was conducted, and Fisher's exact test was used to analyze binary outcomes, and Kaplan-Meier estimates and log rank tests were used for time-to-event variables.

RESULTS

We analyzed 255 patients who received 569 cycles of chemotherapy. The median duration of neutropenia per cycle was 7 days (interquartile range, 0-13 days). Sixty-two patients (24%) were found to have MBL deficiency. Febrile neutropenia occurred at least once in 200 patients. No difference in the primary outcome was seen. The incidence of severe infection was higher among MBL-deficient patients than among non-MBL-deficient patients (1.96 vs. 1.34 cases per 100 days for analysis of all patients [P=.008] and 1.85 vs. 0.94 cases per 100 days excluding patients with acute leukemia [P<.001]).

CONCLUSIONS

MBL deficiency does not predispose adults with hematological cancer to more-frequent or more-prolonged febrile episodes during myelosuppressive chemotherapy, but MBL-deficient patients have a greater number of severe infections and experience their first severe infection earlier, compared with nondeficient patients.

Can we predict the duration of chemotherapy-induced neutropenia in febrile neutropenic patients, focusing on regimen-specific risk factors? A retrospective analysis

BACKGROUND

The aim of the study was to elaborate a predictive model for the duration of chemotherapy-induced neutropenia (CIN) allowing the identification of patients with a higher risk of complications, especially complicated febrile neutropenia, who might benefit from preventive measures.

PATIENTS AND METHODS

A score ranging from 0 to 4 on the basis of expected CIN was attributed to each cytotoxic agent given as part of chemotherapy treatment in solid tumours for patients with febrile neutropenia (FN). The individual scores were combined into several overall scores.

RESULTS

A total of 203 patients with FN were eligible for this retrospective analysis. We were able to identify two groups of patients with statistically different neutropenia durations with median durations until hematological recovery of ANC > or =0.5 and > or =1.0 x 10(9)/l, being respectively 6 versus 4 days (P = 0.03) and 8 versus 6 days (P = 0.01).

CONCLUSIONS

The duration of neutropenia is directly influenced by the aggressiveness of the chemotherapy regimen. In this retrospective study, we were able to identify a group of patients who needed two more additional days to recover from grade 3 and grade 4 neutropenia, based on the degree of aggressiveness of the cytotoxic agents used.

Predictors of functional outcome following intracapsular hip fracture in elderly women. A one-year prospective cohort study

OBJECTIVES

To explore potential predictors of functional outcome one year after the injury in elderly women who sustained a displaced intracapsular hip fracture and who were treated with internal fixation, hemiarthroplasty, or total hip arthroplasty.

PARTICIPANTS AND METHODS

Eighty-four women aged > or =50 years were enrolled on a consecutive basis in this one-year prospective cohort study reflecting standard day-to-day clinical practice. The main outcome measure was the rapid disability rating scale version-2 (RDRS-2) applied at hospital discharge and one year later.

RESULTS

At hospital discharge, the total hip arthroplasty group was younger and had a better functional status than the internal fixation or hemiarthroplasty groups. One year later, the best function was still observed in the total arthroplasty group, but the differences were small and failed to achieve the level of statistical significance. During that one-year period, walking ability or mobility did not change significantly after total hip arthroplasty, but a significant proportion of the women developed cognitive impairment, including mental confusion, uncooperativeness, and depression. Overall, the most significant predictors of poor functional status one year after fracture were increasing age, living in an institution at time of injury, and poor functional status at discharge.

CONCLUSIONS

In elderly women with a displaced intracapsular hip fracture, total hip arthroplasty is associated with a functional benefit within the first months after surgery. However, the extent to which this functional benefit is maintained over time, is less clear. These results support the need for randomised studies to quantify the extent to which, in elderly women, the early functional benefit of total hip arthroplasty is maintained in the long run or compromised by progressive cognitive impairment and other negative determinants of functional outcome.

Sentinel lymph node imaging and research after bone scintigraphy in breast cancer patients

The aim of the study is to see if Bone Scan (BS) - when performed the day before the operation-interferes with the results of the Sentinel Lymph Node (SLN) technique using radiocolloids (their pre-operative imaging and their peroperative research). Therefore, the data of 393 patients who had one selective lymphadenectomy of the SLN(s) followed by the complete axillary node (AxN) clearance for Breast Cancer and among whom 309 patients had one BS the day before the operation (and just before the injection-s for the SLN) and 84 did not, were analysed and compared. The two series presented the same characteristics with regard to: age, clinical staging of the tumour, kind of injection-s performed (intradermic and paratumoural and/or intraparenchymal and peritumoral), pathological size of the tumour, percentage of cases with no AxN invasion, total number of AxN removed by the surgeons. The percentages of no axillary SLN visualisation, the mean numbers of axillary SLN visualised on pre-operative lymphoscintigram as well as of SLN removed by the surgeons were not statistically different in the groups of patients with (respectively, 12.11, 2.6 and 3.03) and without BS (respectively, 12.99, 2.7 and 2.96). More noteworthy, the false negative (FN) rate of the SLN technique, albeit having a higher observed value in the group with BS (9.6%, 12/125), did not differ significantly from that in the group without BS (5.6%, 2/36). The accuracies (overall correct classification rates), the sensitivities and the negative predictive values of the SLN technique also did not differ significantly between the two groups. It is concluded that the SLN technique can be accurately performed just after one BS.

The economic cost of hip fractures among elderly women. A one-year, prospective, observational cohort study with matched-pair analysis. Belgian Hip Fracture Study Group

BACKGROUND

We conducted a prospective study to assess the costs of initial hospitalization for a first hip fracture and to evaluate the excess costs attributable to the hip fracture during the one-year period following hospital discharge.

METHODS

This investigation was designed as a one-year prospective cohort study with matched-pair analysis. Elderly women who were receiving care for a first hip fracture at four Belgian hospitals were matched, with respect to age and residence, with women (control subjects) with no history of hip fracture who lived in the same neighborhood. The initial hospitalization costs were tabulated from the hospital invoices. To estimate the costs during the year after hospital discharge, health-care services utilized by the hip-fracture patients and by the control subjects were recorded. We used the official reimbursement rates to assign a cost to these services, and the results are reported in United States dollars.

RESULTS

The mean age of the 159 patients who had a hip fracture was 79.3 years, and that of the 159 control subjects was 78.7 years. The total mean cost of the initial hospitalization was $9534 for the hip-fracture patients. The total direct costs during the year after discharge averaged $13,470 for the hip-fracture patients and $6170 for the control subjects. Thus, the excess direct cost during the one-year period following hospital discharge averaged $7300 for the hip-fracture patients. The largest cost differences were attributable to nursing-home stays (31%), rehabilitation-center stays (31%), hospitalizations (16%), and home physical-therapy services (14%). Two-fifths of the excess costs were spent during the three months following hospital discharge. Moreover, we observed a shift in resource utilization after hospital discharge.

CONCLUSIONS

Our one-year prospective study demonstrated that the costs of treating a hip-fracture patient are about three times greater than those of caring for a patient without a fracture. This study also highlights the savings to society if a hip fracture can be avoided.

Evaluation of a low-invasive strategy for prostate cancer screening with prostate-specific antigen

OBJECTIVES

To evaluate a two-step strategy for the detection of prostate cancer within the context of serial screening and compare this strategy with other screening strategies. The optimal combination of tests proposed for prostate cancer screening remains undetermined, particularly when screening is repeated over time.

METHODS

A prospective serial prostate cancer screening study with follow-up to 55 months was performed in a general community screening clinic. One thousand seven hundred seven self-referred men, 50 to 75 years old, without a history of prostate cancer agreed to undergo screening for prostate cancer on an annual basis. Serum prostate-specific antigen (PSA) measurement was the first-step screening test. If the serum PSA test was positive, a standard urologic evaluation was performed. Biopsy was recommended only if a test other than serum PSA was suspicious for cancer. The outcome measures were the biopsy rate and prostate cancer detection rate. The comparisons with other studies were age-standardized to correct for differences in age distribution.

RESULTS

The biopsy and cancer detection rates after the first test were 7.0% and 2.0%, respectively. After 4 years of the study, the cumulative biopsy rate and cumulative cancer detection rate per enrolled man was 12% and 4.1%, respectively. The comparisons between studies revealed that screening strategies using serum PSA as a first-line test had similar detection rates but lower biopsy rates than strategies performing biopsy when one of several screening tests was positive.

CONCLUSIONS

A two-step screening strategy using serum PSA alone as the initial test seemed able to detect as many cancers as when all screening tests were used at the same time but reduced the number of unnecessary biopsies.