Comprehensive geriatric assessment in elderly cancer patients: an experience in an outpatient population.

AIMS AND BACKGROUND: Cancer is an age-related disease, and the increase in life expectancy will lead to a progressive increase of cancer cases in the elderly (> or =70 years of age). We have created a group called GONG (Gruppo Oncologico Geriatrico) to apply cancer geriatric assessment in elderly cancer patients, in order to select which of them are eligible for oncological treatment or supportive care only. PATIENTS AND METHODS: We applied this model to evaluate 153 patients from March 2004 to August 2005. Our model included three categories of patients: frail (at least one of the following items: Activities of Daily Living scale <80, > or =3 comorbidities unrelated to the tumor according to the Charlson Index, performance status < or =60/> or =3 according respectively to Karnofsky and the ECOG scale, > or =1 geriatric syndrome); borderline (patients with multiple comorbidities not affecting performance status or ability in daily activities); non-frail. RESULTS: Applying the aforementioned criteria, we found 30 borderline, 14 frail and 109 non-frail patients. Statistical analysis showed a significant difference in mortality between frail and non-frail patients (P <0.05), whereas there was no difference between borderline and non-frail patients. CONCLUSIONS: Our model was thus able to identify patients at higher risk of death. These results confirm the importance of cancer geriatric assessment also for the clinical evaluation of oncological patients. Additional randomized studies with a larger number of patients, also in an adjuvant setting, should be performed to confirm the effectiveness of this approach.

A novel prognostic index to determine the impact of cardiac conditions and co-morbidities on one-year outcome in patients with heart failure.

Prognostic stratification is relevant in clinical decision making in heart failure (HF). Predictors identified during hospitalization or in clinical trials may be unrepresentative of HF in the community. The aim of this study was to derive and validate, in different clinical settings, a risk stratification model for the prediction of stable HF outcomes. The study included 807 patients, 350 enrolled at discharge from the hospital (44%), 309 in the outpatient clinic (38%), and 148 in the home-care setting (18%). There were 292 patients in the derivation cohort and 515 in the validation cohort. A multivariate logistic analysis was performed to obtain the CardioVascular Medicine Heart Failure (CVM-HF) index. One-year mortality was 20.8% in the derivation cohort and 20.7% in the validation cohort. The CVM-HF index included cardiac conditions and co-morbidities and stratified the 1-year mortality risk as low (death rate 4%), average (32%), high (63%), and very high (96%). The area under the curve of the receiver-operating characteristic curve was 0.844 (95% confidence interval [CI] 0.779 to 0.89) for the derivation cohort and 0.812 (95% CI 0.76 to 0.86) for the validation cohort. Model performance was equally good in the 3 different HF settings. In a subgroup of 409 patients, the CVM-HF index (area under the curve 0.821, 95% CI 0.79 to 0.89) outperformed the most-used prognostic models (the Charlson index and the Heart Failure Risk Scoring System). In conclusion, the CVM-HF index, a novel prognostic model that is easy to derive and applicable to unselected patients, may represent a valuable tool for the prognostication of stable HF outcomes.

[Cardiovascular medicine unit: preliminary results of an in-hospital multidisciplinary intervention in heart failure]. / Unità di medicina cardiovascolare: prime esperienze di un approccio intraospedaliero multidisciplinare allo scompenso cardiaco.

BACKGROUND: In Italy the majority of patients with heart failure are admitted to Internal Medicine Divisions, where diagnostic and therapeutic procedures, suggested by guidelines, are less utilized than in Cardiology Divisions. In order to provide a better assistance to patients with heart failure, a Cardiovascular Medicine Unit was founded with interdepartmental valence (Cardiovascular and Internal Medicine) in the "Ospedali Riuniti" Hospital of Bergamo. The purpose of this study was to evaluate the preliminary results, concerning management of heart failure, in the first 6 months of activities carried out at the Cardiovascular Medicine Unit and to compare them with those of other structures that usually manage this disease. METHODS: Analysis of data concerning 150 admissions to the Cardiovascular Medicine Unit for heart failure in 147 patients during the first 6 months of 2003. Comparisons of admittance data for heart failure in the first semester 2001 deriving from the Internal Medicine Division of the "Ospedali Riuniti" Hospital of Bergamo, the TEMISTOCLE study and the Niguarda Ca' Granda Hospital of Milan. RESULTS: A higher prescription of beta-blockers and spironolactone was observed in the Cardiovascular Medicine Unit than in other structures (p < 0.001). Echocardiography and coronary angiography were performed more frequently (p < 0.001) and the number of rehospitalizations was lower for all cases (p < 0.05) as well as for heart failure (p < 0.001). The extensive use of diagnostic procedures and multidisciplinary evaluation of co-morbidities allowed to identify patients who could be managed successfully with surgical therapy; preliminary data suggest a net benefit in terms of NYHA functional class and reduction in rehospitalization in this subgroup of patients. CONCLUSIONS: These data demonstrate that the Cardiovascular Medicine model, based on integration of knowledge between cardiologists and internists, is effective with respect to organization and assistance and allows to optimize heart failure patient management.