[The clinical features, survival analysis, and geriatric assessment of 85 patients with follicular lymphoma: a single-center study].

Objective: To retrospectively analyze the clinical characteristics and prognosis of 85 newly diagnosed patients with follicular lymphoma (FL), as well as the prognostic value of comprehensive geriatric assessment (CGA) in patients with FL aged ≥ 60 years old. Methods: The clinical data and prognosis of 85 newly diagnosed FL patients admitted from August 2011 to June 2022 were collected. The clinical features, laboratory indicators, therapeutic efficacy, survival and prognostic factors of patients were statistically analyzed, and the prognosis of patients was stratified using various geriatric assessment tools. Results: ① The patients with FL were mostly middle-aged and older, with a median age of 59 (20-87) years, including 41 patients (48.2%) aged ≥60 years. The ratio of male to female was 1∶1.36. Overall, 77.6% of the patients were diagnosed with Ann Arbor stage Ⅲ-Ⅳ, and 17 cases (20.0%) were accompanied by B symptoms. Bone marrow involvement was the most common (34.1%). ②Overall, 71 patients received immunochemotherapy. The overall response rate was 86.6%, and the complete recovery rate was 47.1% of 68 evaluated patients. Disease progression or relapse in the first 2 years was observed in 23.9% of the patient. Overall, 14.1% of the patients died during follow-up. ③Of the 56 patients receiving R-CHOP-like therapies, the 3-year and 5-year progression-free survival (PFS) rates were 85.2% and 72.8%, respectively, and the 3-year and 5-year overall survival (OS) rates were 95.9% and 88.8%, respectively. The univariate analysis showed that age ≥60 years old (HR=3.430, 95% CI 1.256-9.371, P=0.016), B symptoms (HR=5.030, 95% CI 1.903-13.294, P=0.016), Prognostic Nutritional Index (PNI) <45.25 (HR=3.478, 95% CI 1.299-9.310, P=0.013), Follicular Lymphoma International Prognostic Index (FLIPI) high-risk (HR=2.918, 95% CI 1.074-7.928, P=0.036), and PRIMA-prognostic index (PRIMA-PI) high-risk (HR=2.745, 95% CI 1.057-7.129, P=0.038) significantly predicted PFS. Moreover, age ≥60 years old and B symptoms were independent risk factors for PFS. Progression of disease within 24 months (POD24) significantly predicted OS in the univariate analysis. Conclusions: FL is more common among middle-aged and older women. Age, B symptoms, PNI score, FLIPI high-risk, PRIMA-PI high-risk, and POD24 influenced PFS and OS. The CGA can be used for treatment selection and risk prognostication in older patients with FL.

[The prognostic effects of two comprehensive geriatric assessment methods in elderly patients with acute myeloid leukemia].

Objective: To evaluate the prognostic effects of two comprehensive geriatric assessment (CGA) methods in elderly patients with acute myeloid leukemia (AML). Methods: Ninety-seven patients with newly diagnosed AML at Beijing Hospital from August 2008 to December 2019 were included (≥60 years old). All patients were evaluated by two methods of CGA. One was IACA index proposed by Beijing Hospital, including instrumental activities of daily living (IADL), age, Charlson comorbidity index (CCI), albumin; the other was proposed by Italian FIL study group (FIL-CGA), including activities of daily living (ADL), IADL, age, and modified cumulative illness rating score for geriatrics (MCIRS-G). Results: Among 97 patients, 54 patients received standard chemotherapy, 16 with decitabine, 2 with targeted therapy and 25 with the best supportive therapy. The overall response rate (ORR) in 72 treated patients were 67.7%, 33.3% and 0 respectively in fit, unfit and frail groups according to IACA index (P=0.001). Based on FIL-CGA, the ORRs of fit, unfit and frail groups were 52.5%, 41.7% and 35.0% respectively (P=0.418). The 1-year OS rates of fit, unfit and frail groups regarding IACA method were 78.7%, 27.7% and 0 respectively (P<0.01). The 1-year OS rates of fit, unfit and frail groups regarding FIL-CGA method were 67.8%, 28.2% and 13.9% respectively (P<0.01), while no significant difference was seen between unfit group and frail group (P=0.111). The early death rates of fit, unfit and frail groups by IACA were 0, 6.0% and 28.6% respectively (P=0.006), while those by FIL-CGA were 2.3%, 5.9%, 13.9% respectively (P=0.123). Conclusion: Compared with FIL-CGA method, IACA predicts more effectively the treatment response, survival and early mortality in elderly patients with AML.

[The prognosis value of comprehensive geriatric assessment in elder patients with acute myeloid leukemia in a single center].

Objective: To evaluate the prognostic significance of comprehensive geriatric assessment (CGA) in Chinese elderly acute myeloid leukemia (AML) patients. Methods: 73 AML patients over the age of 60 were enrolled. CGA stratification included the following 3 instrument assessment: activity of daily living (ADL) ; instrumental activity of daily living (IADL) ; comorbidity score according to the Modified cumulative illness rating score for geriatrics (MCIRS-G) . According to CGA and age, the enrolled patients were grouped into 'fit', 'unfit' and 'frail' categories. Results: The median age of 73 elderly AML patients were 75 years old. According to CGA, 37 (50.1%) patients were classified as 'fit', 14 (19.2%) as 'unfit', and 22 (30.7%) as 'frail'. 33 (89.2%) patients in fit group received induction chemotherapy, or demethylation treatment, as 8 (57.9%) in unfit, 10 (45.5%) in frail. The overall response rate was 68.7%、62.5%, 75.0% in fit, unfit, and frail group, respectively (χ(2)=0.615, P=0.769) .The early mortality (8 weeks) in three groups were different: 5.4%, 7.1%, 27.3%, respectively (P<0.05) . The 1-year overall survival in the 'fit', 'unfit' and 'frail' groups was 64.9%, 28.6% and 22.7%, respectively (P<0.05) . The CGA score, age, ECOG score, WHO classification (2016) were the prognostic factors of AML patients. Conclusion: CGA can be used to determine the prognosis of elderly AML patients.

[A comparative study of comprehensive geriatric assessment in elder patients with non-Hodgkin's lymphoma].

Objective: To measure the comprehensive geriatric assessment (CGA) in elder non-Hodgkin's Lymphoma (NHL) patients in a cross-sectional study; to compare the differences between Eastern Cooperative Oncology Group (ECOG)-performance status (PS) and CGA. Methods: CGA stratification included the following 3 instrument assessments: activity of daily living (ADL);instrumental activity of daily living (IADL);comorbidity score according to the modified cumulative illness rating score for geriatrics (MCIRS-G). According to CGA and age, NHL patients, aged ≥60 years, were classified as"fit","unfit"and"frail"groups. ECOG-PS was evaluated and compared with CGA. Results: According to CGA, 51.6% senior NHL patients (33 cases) were classified as"fit", 12.5%(8 cases) as"unfit"and 35.9%(23 cases) as"frail". Several comorbidities were observed in majority patients, such as cardiovascular disease, diabetes mellitus and hypertension. In the"younger aged"patients between 60 to 64ys, 25%(3/12) was considered as"frail". However, this proportion increased to 42.9%(6/14) in patients older than 80ys. Moreover, impaired CGA was observed in 38.9%(21/54) of ECOG-PS ≤1 patient. Conclusions: Impaired CGA is as common as approximately half in elderly NHL patients and more than one third even in ECOG-PS ≤1 patients. ECOG-PS may underestimate the impaired fitness function in elder NHL patients.

[Comprehensive geriatric assessment can predict the clinical outcomes of elderly patients with diffuse large B cell lymphoma in China].

Objective: To validate comprehensive geriatric assessment (CGA) system in Chinese elderly diffuse large B cell lymphoma (DLBCL) patients. Methods: Patients ≥ 65 years of age who had been diagnosed with de novo DLBCL were screened for eligibility (n=99). CGA was performed during staging procedures through application of the following instruments: age, comorbidity score according to the Cumulative Illness Rating Score for Geriatrics(CIRS-G), activities of daily living (ADL), and instrumental activities of daily living (IADL). Results: All patients were classified as "ft" , "unfit" , and "frail" . Forty-nine (49.5%), 14 (14.1%), and 34 (36.4%) patients were categorized into the fit, unfit, and frail groups, respectively. The overall response rate was 91.8%, 64.3%, and 69.5% in fit, unfit, and frail group, respectively (χ(2)=9.311, P=0.007). Eleven (22.4%), 7 (50.0%), and 16(44.4%) patients showed disease relapse/progression in fit, unfit, and frail group, respectively (χ(2)=6.309, P=0.040). The 2-year probability of overall survival was 90.6%, 43.0%, and 58.5% in fit, unfit, and frail group, respectively (χ(2)=14.774, P=0.001). The 2-year probability of progression-free survival was 72.9%, 32.5%, and 37.3% in fit, unfit, and frail group, respectively (χ(2)=11.038, P=0.004). Conclusion: The CGA index can predict the clinical outcomes of elderly DLBCL patients in China.

The physician as advocate.

Health-care advocacy extends beyond the understanding of environmental, social, and economic factors that affect health. Patient advocacy is more than a role--it is a principle that governs the patient-physician relationship and the practice of medicine. Physicians should be reminded that the healing power of medicine is not self-appointed. The authority of medicine derives from the principle of patient advocacy--that is, for 3,500 years society has identified, separated, and commissioned physicians for the sole purpose of providing care to sick and suffering patients. If we physicians compromise on patient advocacy, we will surely surrender this commission.

Ragweed immunotherapy in adult asthma.

BACKGROUND: Although allergen immunotherapy is effective for allergic rhinitis, its role in treating asthma is unclear. METHODS: We examined the efficacy of immunotherapy for asthma exacerbated by seasonal ragweed exposure. During an observation phase, adults with asthma who were sensitive to ragweed kept daily diaries and recorded peak expiratory flow rates between July and October. Those who reported seasonal asthma symptoms and medication use as well as decreased peak expiratory flow were randomly assigned to receive placebo or ragweed-extract immunotherapy in doses that increased weekly for an additional two years. RESULTS: During the observation phase, the mean (+/- SE) peak expiratory flow rate measured in the morning during the three weeks representing the height of the pollination season was 454 +/- 20 liters per minute in the immunotherapy group and 444 +/- 16 liters per minute in the placebo group. Of the 77 patients who began the treatment phase, 64 completed one year of the study treatment and 53 completed two years. During the two treatment years, the mean peak expiratory flow rate was higher in the immunotherapy group (489 +/- 16 liters per minute, vs. 453 +/- 17 in the placebo group [P = 0.06] during the first year, and 480 +/- 12 liters per minute, vs. 461 +/- 13 in the placebo group [P = 0.03] during the second). Medication use was higher in the immunotherapy group than in the placebo group during observation and lower during the first treatment year (P = 0.01) but did not differ in the two groups during the second year (P = 0.7). Asthma-symptom scores were similar in the two groups (P = 0.08 in year 1 and P = 0.3 in year 2). The immunotherapy group had reduced hay-fever symptoms, skin-test sensitivity to ragweed, and sensitivity to bronchial challenges and increased IgG antibodies to ragweed as compared with the placebo group; there was no longer a seasonal increase in IgE antibodies to ragweed allergen in the immunotherapy group after two years of treatment. Reduced medication costs were counterbalanced by the costs of immunotherapy. CONCLUSIONS: Although immunotherapy for adults with asthma exacerbated by seasonal ragweed exposure had positive effects on objective measures of asthma and allergy, the clinical effects were limited and many were not sustained for two years.

Home peak expiratory flow rate monitoring in patients with asthma.

OBJECTIVE: To describe how the peak expiratory flow rate (PEFR) is measured, review published studies of the accuracy in which patients and physicians can estimate the severity of asthma by clinical observations only, and review published studies of the benefits of home PEFR monitoring. DESIGN: A review of home PEFR monitoring and its associated benefits for both the physician and the patient is presented. RESULTS: An accurate assessment of the severity of asthma is crucial for the optimal treatment of the patient with asthma; however, patients and their physicians are often unable to estimate correctly the degree of airway obstruction. Peak flow measurement is a simple, inexpensive method of objectively determining airflow obstruction. Management of asthma based on home PEFR measurements can result in early recognition and prompt treatment of asthma exacerbations. Home PEFR monitoring in the setting of a comprehensive self-management program can lead to fewer symptoms of asthma, fewer days absent from work or school, fewer emergency examinations, fewer hospitalizations, lower requirements of inhaled beta-antagonists and oral corticosteroid therapy, and better pulmonary function. CONCLUSION: For best results, home PEFR monitoring should be coupled with a thorough educational program on asthma and periodic office spirometry.

Assessment of basic physical examination skills of internal medicine residents.

BACKGROUND: Internal medicine faculty at the Mayo Clinic designed a clinical evaluation exercise that separates assessment of physical examination skills from that of medical interviewing and reasoning skills. This report summarizes the first year's experience with assessment of basic physical examination skills. METHOD: A core faculty of five general internists and three internist subspecialists designed a 45-item general examination checklist (e.g., measure blood pressure, examine mouth, palpate liver, drape to ensure privacy). In addition, the core faculty generated a menu of 27 focused examination skills (e.g., examine for carpal tunnel syndrome) from which the faculty examiner would select five items for the resident to perform. Each checklist item was scored 0, 1, or 2 for a maximum possible score of 100. The core faculty selected a criterion-based scoring reference and established a passing score of 90 based on practice examinations with residents and faculty. The core faculty made an instructional videotape of a model examination that was available to all residents. In 1991-92, prior to examination, the checklist was distributed to all first-year categorical (43), preliminary (25), and newly appointed second-year residents (eight). RESULTS: Of the 76 residents examined, 11 (14%) failed and 65 (86%) passed. All failing scores were 86 or lower. The absence of scores 87, 88, and 89 suggested that faculty upgraded borderline performances. All 11 residents who initially failed retook the examination and passed. The five most commonly missed items were (1) inspect the skin, (2) complete examination in logical sequence, (3) palpate aorta, (4) auscultate anterior breath sounds, and (5) palpate axillary and inguinal nodes. Other important observed errors were failure to measure vital signs, confusion of liver and spleen, failure to use bell on stethoscope, and inadequate breast examination. Twenty-eight residents completed an optional feedback form. Reviews were mixed but generally favorable. CONCLUSION: Assessment of the basic physical examination skills of the internal medicine residents was useful, and such skills were able to be assessed separately from physical diagnosis skills and interviewing skills. Direct observation of basic physical examination skills revealed important deficiencies, which provided opportunity for remediation.

Magnitude and directional effects of marital sex-role incongruence on marital adjustment.

PIP: Economic and social forces have converged to influence the fundamental nature of marriage in the 1980s. Marriages are shifting from the complementary type, in which the husband is employed and the wife cares for the household and children, to the parallel type, in which both spouses are employed and both are responsible for the housework. This study examines the relationship between marital sex role incongruence and marital adjustment. Both the magnitude and the direction of the incongruence are related to marital adjustment level. The study's major hypothesis is that the relationship between marital sex-role incongruence and marital adjustment is a function of both the magnitude of the incongruence and the direction of the disagreement. Couples in the study were recruited from a moderately sized midwestern university community. 103 couples agreed to participate but 73 couples actually returned the questionnaire. Of these 73 couples, 63% were randomly recruited through door-to-door solicitation, 29% were recruited from an evangelical Christian organization and church, and 8% were recruited from acquaintances of the 1st author. After deleting incomplete questionnaires, final sample size was 67 couples. Each member of a marital dyad completed a questionnaire including a Dyadic Adjustment Scale to measure marital adjustment, a Sex-Role Egalitarianism Scale to measure marital sex-role orientation, a Marlowe-Crowne Social Desirability Scale Short Form C to measure social desirability bias, and a demographic information sheet. Findings indicate that direction of incongruence plays a very important role in determining the impact of marital sex-role incongruence on marital adjustment; namely, the greater the incongruence is in the direction of the wife being more egalitarian relative to her husband, the more negative is the estimated impact on marital adjustment. Conversely, the greater the incongruence is in the direction of the husband being more egalitarian than his wife, the more positive is its estimated impact on marital adjustment.^ieng