Survival outcomes in patients with acute myeloid leukaemia who received subsequent therapy for relapse in QUAZAR AML-001.

In the phase 3 QUAZAR AML-001 trial (NCT01757535) of patients with acute myeloid leukaemia (AML) in remission following intensive chemotherapy (IC) and ineligible for haematopoietic stem cell transplant (HSCT), oral azacitidine (Oral-AZA) maintenance significantly prolonged overall survival (OS) versus placebo. The impact of subsequent treatment following maintenance has not been evaluated. In this post hoc analysis, OS was estimated for patients who received subsequent AML therapy, and by regimen received (IC or lower-intensity therapy). First subsequent therapy (FST) was administered after treatment discontinuation in 134/238 Oral-AZA and 173/234 placebo patients. OS from randomization in patients who received FST after Oral-AZA versus placebo was 17.8 versus 12.9 months (HR: 0.82 [95% CI: 0.64-1.04], median follow-up: 56.7 months); OS from FST was similar between arms. Among patients who received injectable hypomethylating agents as FST, median OS was 8.2 versus 4.9 months in the Oral-AZA versus placebo groups (HR: 0.66 [95% CI: 0.41-1.06]). Forty-eight patients (16/238 Oral-AZA, 32/234 placebo) received HSCT following treatment discontinuation, including six Oral-AZA patients still in first remission; Oral-AZA OS benefit persisted when censoring these patients. Oral-AZA maintenance can prolong AML remission duration without negatively impacting survival outcomes after salvage therapies.

Graded Cardiac Response Criteria for Patients With Systemic Light Chain Amyloidosis.

PURPOSE: Binary cardiac response assessment using cardiac biomarkers is prognostic in light chain amyloidosis. Previous studies suggested four-level cardiac responses using N-terminal prohormone of brain natiuretic peptide improves prognostic prediction. This study was designed to validate graded cardiac response criteria using N-terminal prohormone of brain natiuretic peptide/brain natiuretic peptide. PATIENTS AND METHODS: This retrospective, multicenter study included patients with light chain amyloidosis who achieved at least a hematologic partial response (PR) and were evaluable for cardiac response. Four response criteria were tested on the basis of natriuretic peptide response depth: cardiac complete response (CarCR), cardiac very good partial response (CarVGPR), cardiac PR (CarPR), and cardiac no response (CarNR). Response was classified as best response and at fixed time points (6, 12, and 24 months from therapy initiation). The study primary outcome was overall survival. RESULTS: 651 patients were included. Best CarCR, CarVGPR, CarPR, and CarNR were achieved in 16%, 26.4%, 22.9%, and 34.7% of patients, respectively. Patients in cardiac stage II were more likely to achieve CarCR than patients in cardiac stage IIIA and IIIB (22% v 13.5% v 3.2%; P < .001). A deeper cardiac response was associated with a longer survival (5-year overall survival 93%, 79%, 65%, and 33% for CarCR, CarVGPR, CarPR, and CarNR, respectively; P < .001). Fixed time-point analyses and time-varying covariates Cox regression analysis, to minimize survivorship bias, affirmed the independent survival advantage of deeper cardiac responses. Four-level response performed better than two-level response as early as 12 months from therapy initiation. CONCLUSION: Graded cardiac response criteria allow better assessment of cardiac improvement compared with the traditional binary response system. The study re-emphasizes the importance of early diagnosis, which increases the likelihood of deep cardiac responses.

Toxicities of high-dose chemotherapy and autologous hematopoietic cell transplantation in older patients with lymphoma.

High-dose chemotherapy and autologous hematopoietic cell transplantation is an effective consolidation therapy in lymphoma; however, its use in elderly patients has been limited because of concerns for greater toxicity in this group. We investigated the toxicities of carmustine, etoposide, cytarabine, and melphalan (BEAM) and autologous hematopoietic cell transplantation (AHCT) in 346 patients in 2 age groups: 279 patients aged 60 to 69 years and 67 patients aged ≥70 years. The majority developed severe toxicities; the most common were febrile neutropenia, gastrointestinal, infections, and cardiovascular. Older patients were at higher risk for grade ≥3 cardiovascular toxicities (hazard ratio [HR], 3.36; 95% confidence interval [CI], 2.25-5.00; P < .001) and skin toxicities (HR, 2.45; 95% CI, 1.08-5.54, P = .032). In the older group, nonrelapse mortality at 100 days and at 2 years was 2.99% (95% CI, 0.55-9.32) and 6.2% (95% CI, 1.97-13.95), respectively, vs 1.79% (95% CI, 0.68-3.92) and 2.91% (95% CI, 1.37-5.42), respectively, in the younger group. When adjusting for the number of grade ≥3 toxicities within the first 100 days, older patients had a 1.71-fold (95% CI, 1.08-2.71) increased risk for progression or death relative to younger patients. Although BEAM followed by AHCT is effective, it is associated with significant organ toxicities, especially in patients aged ≥70 years. Interventions to mitigate toxicities while maintaining efficacy are much needed.

T Cell Depletion as an Alternative Approach for Patients 55 Years or Older Undergoing Allogeneic Stem Cell Transplantation as Curative Therapy for Hematologic Malignancies.

T cell-depleted (TCD) allogeneic hematopoietic stem cell transplantation (HSCT) is curative treatment for hematologic malignancies in adults, shown to reduce graft-versus-host disease (GVHD) without increased relapse. We retrospectively reviewed a single-center, 11-year experience of 214 patients aged ≥ 55 years to determine tolerability and efficacy in the older adult. Most patients (70%) had myeloid diseases, and most acute leukemias were in remission. Median age was 61 years, with related and unrelated donors ≥8/10 HLA matched. Hematopoietic cell transplantation-specific comorbidity index scores were intermediate and high for 84%. Conditioning regimens were all myeloablative. Grafts were peripheral blood stem cells (97%) containing CD3 dose ≤103-4/kg body weight, without pharmacologic GVHD prophylaxis. With median follow-up of 70 months among survivors, Kaplan-Meier estimates of overall and relapse-free survival were 44% and 41%, respectively (4 years). Cumulative incidence of nonrelapse mortality at day +100 was only 10%. Incidence of GVHD for acute (grades II to IV) was 9% at day +100 and for chronic was 7% at 2 and 4 years (8 extensive, 1 overlap). Median Karnofsky performance status for patients > 2 years post-transplant was 90%. As 1 of the largest reports for patients ≥2 aged ≥55 years receiving TCD HSCTs, it demonstrates curative therapy with minimal GVHD, similar to that observed in a younger population.

Retrospective outcome data for hematopoietic stem cell transplantation in patients with concurrent coronary artery disease.

Hematopoietic stem cell transplantation (HSCT) represents an extended period of physiologic stress. It is unknown whether patients with pre-existing coronary artery disease (CAD) may be poor transplant candidates. There are no data analyzing the risk of transplantation in this population. Sixty-nine patients with CAD who underwent 72 transplantations, autologous and allogeneic, were identified retrospectively. Fifty-five percent of these patients had prior percutaneous coronary intervention, 42% had verifiable history of myocardial infarction, and 23% had prior coronary artery bypass grafting. Outcomes were compared to 1109 patients without established CAD who underwent 1183 transplants during the same time period. Cancer diagnoses in the 2 groups were similar, predominantly lymphoma, multiple myeloma, and leukemia. There was no significant difference between the CAD group and the control group with respect to type of transplant (autologous 68% versus 64%, P = .612, myeloablative 86% versus 85%, P = .867). Treatment-related mortality was no different in the CAD group versus the control group (5.6% versus 4.9%, P = .777), nor were there differences in mortality at 1 year (15.3% versus 16.6%, P = .871), urgent intensive care unit admission (11.1% versus 9.9%, P = .686), or length of stay (25.5 days versus 28.4 days, P = .195). These findings suggest many patients with underlying coronary artery disease may be safely managed through hematopoietic stem cell transplantation.

Effect of education on blood pressure control in elderly persons: a randomized controlled trial.

BACKGROUND: It is not clear which educational strategy is most effective in helping patients to change their lifestyles. This study compared the efficacy of two different educational models on reducing blood pressure (BP). METHODS: This was a randomized controlled trial in ambulatory hypertensive patients >65 years of age. Workshops that aimed to develop self-management and patient empowerment (PEM) were compared to workshops that used a compliance-based model (CEM). The primary outcome was change in systolic BP at 3 months compared with basal values between groups (net reduction), measured by 24-h ambulatory BP monitoring. RESULTS: A total of 30 patients were educated with PEM and 30 others with CM. Both groups were statistically similar with regard to age (67 v 70 years), systolic BP (157 v 156 mm Hg) and diastolic BP (88 v 88 mm Hg), diabetes (23% v 31%), and basal natriuresis 116 v 121 mEq/day). There were more women in the PEM group (57% v 30%). The PEM group showed a significant reduction of 8 mm Hg (95% confidence interval [CI] 2 to 15), whereas the CM group showed a reduction of 3 mm Hg (95% CI -3 to 8), with a net reduction of 6 (95% CI -3 to 14). Mean net night-time systolic BP reduction was 12 mm Hg (95% CI 2 to 22). BP control was 70% in PEM group vs 45% in CM group (P = 0.045). The relative odds ratio for BP control for the PEM group after adjustment for age, sex, diabetes, basal blood pressure and changes in pharmacological treatment was 3.7 (95% CI 1.05 to 13.1). CONCLUSION: Based on these study results, the self-management education model was significantly more effective than the compliance-based model in BP control.

Programa de Atención Controlada (PAC) para pacientes con diabetes mellitus aplicado en un hospital de comunidad / Control Care Program (CAP) for patients with diabetes mellitus implemented in a community hospital

En relación a las complicaciones micro y macroangiopáticas de pacientes con diabetes, existe una extensa evidencia que demuestra claramente la ventaja de mantener un estricto control tanto sobre la glucemia, como sobre los factores de riesgo. Sin embargo, el control de estos pacientes sigue siendo deficitario, debido por una parte a la dificultad de iniciar y mantener modificaciones en el estilo de vida, y una adherencia al tratamiento por un tiempo suficiente como para alcanzar un buen control metabólico. Por otra parte, la atención del paciente se estructura en las demandas que se generan durante la consulta, que es además fragmentada, duplicativa, desorganizada y focalizada en el tratamiento de las complicaciones.Persisten aún muchos factores que actúan como barreras para implementar un tratamiento adecuado de la diabetes mellitus (DM). Entre ellas, influyen la organización de los cuidados médicos, los factores psico-sociales de los pacientes, sus situaciones vitales, su instrucción formal y la educación diabetológica. Además, el nivel de conocimiento de los médicos, sus convicciones y personalidad también actúan sobre el control de los pacientes. Existe evidencia de que los programasde manejo de enfermedades crónicas mejoran los resultados en los pacientes con enfermedades crónicas. Con el objetivo de mejorar la expectativa y calidad de vida de estos pacientes, implementamos estrategias específicas de tratamiento dentro del marco de Programas de Manejo de Enfermedades Crónicas de nuestra Institución. Se describen en el presente trabajo las características de este programa, sus objetivos, estrategias y procesos de implementación.