Trajectories of physical well-being among adults with acute myeloid leukemia.

Patients with acute myeloid leukemia (AML) often undergo physical decline leading to negative outcomes. Identification of distinct trajectories may help guide clinical decision making and supportive care interventions. We built group-based trajectory models (GBTM) to find trajectories of change in the Functional Assessment of Cancer Therapy Physical Well-Being sub scale (FACT-PWB, up to 5 timepoints over 0 to 200 days of follow-up) using data from adults with newly diagnosed AML in four supportive care studies. We also estimated the association of baseline characteristics (age, marital status, education, AML risk, baseline FACT-PWB, depression, anxiety) with group membership. Among 343 patients with ≥ 2 FACT-PWB scores, mean age was 69.6 (SD 12.1) years; most had intermediate risk AML (178, 51.8%), received intensive treatment (244, 71.1%), and died during follow up (199, 58.0%). The GBTM with four distinct trajectories showed the best fit. The largest group (N=153, 45.0%) showed slight improvement, while the smallest experienced early decline with later improvement (N=8, 2.4%). Baseline FACT-PWB was the only characteristic statistically significantly associated with group membership. Adults with AML show distinct trajectories of physical well-being, and many experience some decline. Exploring trajectories of self-reported and objective physical function may inform decision making and interventions. Clinical trial registration: www.clinicaltrials.gov NCT02975869, NCT03310918, NCT03372291.

Telehealth serious illness care program for older adults with hematologic malignancies: a single-arm pilot study.

ABSTRACT: Older patients with acute myeloid leukemia (AML) and myelodysplastic syndrome (MDS) feel shocked and bewildered when diagnosed. Serious illness conversations (SICs) may increase disease understanding and preparations for the future. However, SICs often happen late, in part because of clinician-perceived patient discomfort. Telehealth may promote patient comfort by allowing SICs to take place at home. This study assesses the feasibility and usability of a telehealth-delivered Serious Illness Care Program (SICP) for older adults with AML and MDS. We conducted a single-arm pilot study including 20 older adults with AML and MDS. Feasibility was measured using retention rate, with >80% considered feasible. Usability was measured using telehealth usability questionnaire (TUQ; range, 1-7): >5 considered usable. We collected other outcomes including acceptability and disease understanding and conducted post-visit qualitative interviews to elicit feedback. Hypothesis testing was performed at α = 0.10 owing to the pilot nature and small sample size. Retention rate was 95% (19/20); mean TUQ scores were 5.9 (standard deviation [SD], 0.9) and 5.9 (SD, 1.1) for patients and caregivers, respectively. We found the SICP to be acceptable. The majority of patients found the SICP to be very or extremely worthwhile (88.2%; 15/17), and reported it increased closeness with their clinician (75.0%; 12/16). After their visit, patient estimates of curability, and overall life expectancy aligned more closely with those of their clinicians. In qualitative interviews, most patients said that they would recommend this program to others (89.5%, 17/19). This study demonstrated that delivery of the telehealth SICP to older patients with AML and MDS is feasible, usable, and acceptable. This trial is registered at www.clinicaltrials.gov as #NCT04745676.

Comparison of the efficacy of three PubMed search filters in finding randomized controlled trials to answer clinical questions.

OBJECTIVE: The aim of this study was to compare the performance of three search methods in the retrieval of relevant clinical trials from PubMed to answer specific clinical questions. METHODS: Included studies of a sample of 100 Cochrane reviews which recorded in PubMed were considered as the reference standard. The search queries were formulated based on the systematic review titles. Precision, recall and number of retrieved records for limiting the results to clinical trial publication type, and using sensitive and specific clinical queries filters were compared. The number of keywords, presence of specific names of intervention and syndrome in the search keywords were used in a model to predict the recalls and precisions. RESULTS: The Clinical queries-sensitive search strategy retrieved the largest number of records (33) and had the highest recall (41.6%) and lowest precision (4.8%). The presence of specific intervention name was the only significant predictor of all recalls and precisions (P = 0.016). CONCLUSION: The recall and precision of combination of simple clinical search queries and methodological search filters to find clinical trials in various subjects were considerably low. The limit field strategy yielded in higher precision and fewer retrieved records and approximately similar recall, compared with the clinical queries-sensitive strategy. Presence of specific intervention name in the search keywords increased both recall and precision.

Corticosteroid-induced hyperglycemia is increased 10-fold in patients with pemphigus.

This study aimed to highlight the importance of routine screening for hyperglycemia and to develop a standardized, evidence-based approach for the management of pemphigus patients on prolonged systemic corticosteroid (CS) therapy. A cross-sectional study was conducted in two university-affiliated teaching hospitals using a referred sample of 200 patients with a confirmed diagnosis of pemphigus vulgaris, pemphigus foliaceus, or mucous membrane pemphigoid. All patients were receiving systemic CS therapy. A total of 150 patients responded to the survey. Six participants were excluded and 144 were included. The main outcome measure was blood glucose level to detect hyperglycemia. New-onset hyperglycemia was identified in 40% of patients who received CS therapy. None of the expected variables, including age, body mass index, family history of diabetes, corticosteroid dose, and duration of corticosteroid therapy, were independently associated with new-onset hyperglycemia. These findings indicate that the prevalence of CS-induced hyperglycemia in pemphigus patients is 40% and that in patients with pemphigus or MMP, CS therapy is associated with a markedly increased risk for hyperglycemia (odds ratio = 10.7, 95% confidence interval 1.38-83.50) compared with that of patients with the same diseases who do not receive CS therapy.

Cost-utility of lumbar decompression with or without fusion for patients with symptomatic degenerative lumbar spondylolisthesis.

BACKGROUND CONTEXT: The most common surgical treatment of symptomatic degenerative lumbar spondylolisthesis (DLS) is decompression and instrumented fusion. However, contemporary, midline-sparing, microdecompressive techniques have shown good results for selected patients with stable Grade 1 DLS. Growing concerns over the rising cost and rates of spinal fusion warrant both clinical and economic comparative effectiveness research in this common spinal diagnosis. PURPOSE: To determine the relative cost-utility of decompression with and without concomitant instrumented fusion for selected patients with DLS. STUDY DESIGN/SETTING: Comparative cost-effectiveness study. PATIENT SAMPLE: Probabilities and utilities were estimated from an observational cohort study and the current literature. Costing information was obtained from our institution (microcase costing data/patient) and the literature. Probabilities considered were perioperative and general mortality, probability of clinical improvement and clinical worsening, and reoperation. OUTCOME MEASURES: The primary outcome was the incremental cost/utility ratio (ICUR) expressed as the differential cost per relative gain in quality-adjusted life-year (QALY). METHODS: A Markov model with 10-year follow-up was developed. The analyses were carried out from the hospital's perspective. Sensitivity analysis was used to test the robustness of the model. RESULTS: The cost-utility of decompression with fusion and decompression alone at 10 years postintervention was $3,281/QALY and $1,040/QALY, respectively. Compared with decompression alone, decompression plus instrumented fusion was associated with an improvement in quality of life at a cost of $185,878 per QALY in the base-case analysis. The ICUR was invariant to changes in clinical effectiveness of decompression alone, percentage of inpatient decompressions, and varying cost or QALY discounting rates. The ICUR was sensitive to change in QALY and cost structure changes. CONCLUSIONS: For a select subgroup of patients with DLS (leg-dominant pain with a stable Grade 1 spondylolisthesis), decompression without fusion is significantly more cost effective than instrumented fusion and provides an opportunity for increased service delivery and/or cost savings for this growing population.

Promoting development and use of systematic reviews in a developing country.

INTRODUCTION: One major barrier to develop health systems is the limited capacity for conducting research and implementation of research findings. We assessed the views of researchers, decision makers and research policy makers on how the development and usage of evidence from systematic reviews can be promoted in a country with limited resources. METHODS: We surveyed 131 participants in six systematic review workshops for their views on important items influencing the production and usage of systematic reviews in a developing country. They were also asked to propose interventions to deal with potential barriers. We analysed the quantitative data using multidimensional scaling methods, and the qualitative data using content analysis approach. RESULTS: We identified seven clusters of items that contribute to the promotion of conducting and using systematic reviews. For each cluster a set of interventions are proposed that health care decision makers and research policy makers may use for promoting conduct and use of systematic reviews. The clusters are 'importance for policy makers', 'access to international research', 'priority and support for systematic reviews', 'competency and willingness of researchers to conduct reviews', 'importance for end-users', 'quality of local primary research' and 'visibility and access to local research'. DISCUSSION: The proposed interventions focus on national level initiatives for making the systematic reviews 'wanted' and improving the capacity to conduct research. Our findings emphasize the essential role of policy makers for promoting systematic reviews. They demonstrate that many barriers stem from the lower quality of and lack of access to primary research originating from developing countries.

Quality of life and life events of living unrelated kidney donors in Iran: a multicenter study.

BACKGROUND: A controlled living unrelated kidney donors (LURDs) transplant program has been started from 1988 in Iran. We surveyed LURDs to investigate the extent to which they experienced stressful life events before donation and their quality of life after donation. METHODS: Five hundred donors were approached. Donors were included in the study provided that donation had taken place at least 3 months before the study. Paykel Life Events Scale and The World Health Organization Quality of Life-Brief version (WHOQOL-Bref) were used in this study. RESULTS: Complete data were available for 424 (84.8%) donors. The mean age was 27.6+/-4.6 years and 84.4% of the participants were men. Ninety-five percent of the respondents reported having experienced at least one stressful life event during the 6 months before kidney donation. The three most frequently experienced life events were the increase in life expenses, low income, and household duties. The most stressful life events were job loss, financial problems, and death of a family member. The participants reported more stressful life events with a mean total stress score (112.6+/-75.0) double than the findings of a previous study in normal population. In all the four domains of WHOQOL-BREF, the participating donors scored lower than previously determined community norms. CONCLUSION: We observed that the quality of life of Iranian LURDs may be low and they may be at risk of experiencing more stressful life events. To be most efficient, the health services should continue after donation and compensate for mental health and psychosocial problems as well.

Dermatoglyphic asymmetry and hair whorl patterns in schizophrenic and bipolar patients.

Dermatoglyphic quantitative counts, asymmetry between two hands, and hair whorls were assessed in schizophrenic, bipolar and normal samples. Higher dermatoglyphic directional asymmetry and lower fluctuating asymmetry in bipolar patients support their hypernormal asymmetries. An inverse association between hair whorl location and dermatoglyphic asymmetry in schizophrenia may show a higher probability of lateralization problems.

Sources of knowledge in clinical practice in postgraduate medical students and faculty members: a conceptual map.

OBJECTIVES: To determine the most important knowledge sources that can influence clinical practice and to cluster them in conceptual groups based on their relative importance. METHODS: Faculty members, fellows and residents of a large teaching tertiary care hospital were asked to rate the importance of different resources in their daily clinical practice and their understanding of some common terms from evidence-based medicine. The knowledge sources were distributed in a two-dimensional map using multidimensional scaling and hierarchical cluster analysis. RESULTS: A total of 250 of 320 recruited hospital staff returned the questionnaires. The most important resources in daily practice were English journals, text books and literature searching for faculty members, experience, text books and English journals for fellows and text books, experience and peers for residents. Regional journals were the least important resources for all study groups. About 62.7% of residents did not know the meaning of 'number needed to treat', 36.8%'confidence interval', 54.9%'confounding factor' and 44.6%'meta-analysis'. The percentages for faculty members were 41.3%, 37%, 42.2% and 39.1%. The knowledge sources were placed in four clusters in a point map derived from the multidimensional scaling process. CONCLUSION: The dominance of the traditional information resources and experience-based medicine debate which is the consequence of traditional approaches to medical education may be one of the considerable barriers to the dissemination of evidence-based medicine in developing countries. The evidence-based clinical practice guidelines could be used as a useful passive-predigested source for busy clinicians to make informed decisions. A considerable Western bias may undermine the local research in developing world.