By P. Garik. Columbia College of Missouri.
One large retrospective analysis found a statisti- tant AML (median age of 64 years) was well tolerated and resulted cally signiﬁcant improvement in overall survival for Dec over Aza in an overall response rate of 46% cheap innopran xl 80mg line heart attack jack 1 life 2 live. Individu- and many patients require inpatient hospitalization for at least the als up to the age of 75 years who achieve sufﬁcient disease control ﬁrst cycle of therapy and potentially for several weeks afterward for after upfront AML therapy and have few comorbidities should be daily transfusions and infectious complications 40 mg innopran xl with visa pulse pressure and stroke volume relationship. Ten-day Dec considered for consolidation with allogeneic stem cell transplanta- induction has also been associated with treatment mortality rates tion (alloSCT) purchase innopran xl with mastercard blood pressure medication that does not cause joint pain, ideally with reduced intensity conditioning regi- indistinguishable from those of intensive chemotherapy in elderly mens cheap innopran xl 40 mg with visa 01 heart attackm4a, because this remains the only potential curative therapeutic individuals. Analyses of the SEER database clearly largely outpatient therapy and for whom treatment-related mortality show that older individuals (46 of 5480 patients or 0. Two-year survival rates after AML Novel agents for older AML patients diagnosis in alloSCT recipients aged 65-69 and 70-74 years were Despite advances in our understanding of and options for the also surprisingly high, at 50% and 30. Clearly, there is a need for individuals) may preclude alloSCT in the majority of older patients. Sorror discusses criteria for the selection patients. Unfortunately, it is estimated that only 5%-10% of adult of AML patients for hematopoietic stem cell transplantation. AML patients enroll in clinical trials nationwide,16 making it difﬁcult to impossible to determine which agents are superior to the For those individuals in remission who are not eligible for alloSCT, currently available options in a timely fashion. Moreover, to date, the standard approach has been to administer “consolidation” many agents in recent clinical development for this patient popula- chemotherapy consisting of lower doses of the same agents used in tion have turned out to be either too toxic in older individuals or induction therapy. To date, there is no consensus on the number of ineffective in improving overall survival for elderly patients with consolidation chemotherapy cycles (range 1-4), number of agents Hematology 2014 17 (cytarabine alone vs cytarabine anthracycline), and drug dose (high- vs intermediate-dose cytarabine) needed for the best possible outcomes for older patients with AML. In the Medical Research Council AML11 trial, 1314 older patients with AML who achieved remission after 2 cycles of standard induction were prospectively randomized to receive 1 additional chemotherapy course (total 3 courses) or an additional 3 courses after remission (total 6 courses). Long-term outcomes did not differ between patients treated with 3 versus 6 cycles, suggesting the lack of any beneﬁt beyond 1 cycle of consolidation therapy. For lack of better information, older patients with favorable- or intermediate-risk AML who achieve CR after upfront cytarabine and anthracycline-based chemotherapy typically are offered 2-4 cycles of intermediate- to high-dose cytarabine. In contrast, patients with adverse karyotype AML who achieve CR have been shown to fare poorly regardless of intensive induction and consolidation chemotherapy and therefore should be referred for investigational therapy in the postremission setting. Despite lower morphologic CR rates compared with intensive chemotherapy, many older patients with AML achieve adequate disease control and prolonged survival with hypomethylating therapy and are therefore recommended to continue on therapy indeﬁnitely until evidence of disease progression, mirroring the treatment Figure 1. Potential treatment approach for the older adult with AML. In been shown to prolong overall disease-free survival in some the absence of appropriate trials, ﬁt older individuals with favorable individuals. Fit older patients with intermediate-risk AML patients may be offered upfront intensive chemotherapy or hypomethylating Older individuals with AML who are deemed ineligible or unsuit- therapy. Individuals with AML with adverse karyotype and unﬁt able for alloSCT should be counseled early in the course of the older patients with AML (regardless of karyotype) are unlikely to disease about their overall prognosis, speciﬁcally the fact that, beneﬁt from intensive induction or consolidation chemotherapy and although current and investigational treatment approaches may therefore should be treated preferentially with hypomethylating extend survival, they will not be curative. Surveys of newly agents or investigational therapies. Fit patients with intermediate- or diagnosed patients with AML have demonstrated that the majority poor-risk AML who achieve CR should be referred for alloSCT, of individuals do not recall being offered more than one treatment preferably with reduced-intensity conditioning. Other patients in option and grossly overestimate their long-term prognosis and CR may be treated with consolidation chemotherapy (intermediate chance for cure, although the treating physicians clearly docu- 19,52 karyotype AML), hypomethylating therapy (adverse karyotype), or mented discussion of these issues in the patients’ medical charts. Any patients with relapsed/refractory AML A mutual understanding between the patient, his/her family mem- should be strongly encouraged to pursue experimental therapy. It is important to keep in mind that AML will be not resuscitate/do not intubate directives, and end-of-life care when a life-ending disease for the majority of these patients. In general, individuals without life-threatening organ than a deﬁned therapeutic algorithm. Given median survival durations of 12 months with In the current era, the majority of older patients with AML should be currently available agents, all older adults with AML should be offered deﬁnitive antileukemic therapy to prolong both quantity and 18 American Society of Hematology quality of life remaining. Epigenetic biology, QOL, and long-term treatment goals should all be consid- therapy is associated with similar survival compared with intensive ered in the selection of the most appropriate therapeutic approach chemotherapy in older patients with newly diagnosed acute myeloid for each patient. Favorable prognostic impact of NPM1 mutations in older patients with cytogenetically normal de novo Acknowledgments acute myeloid leukemia and associated gene- and microRNA- The author is supported in whole or in part by funding from the expression signatures: a Cancer and Leukemia Group B study. J Clin Cancer Clinical Investigator Team Leadership Award awarded by Oncol. Treatment of de novo Conﬂict-of-interest disclosure: The author has been afﬁliated with acute myeloid leukemia in the United States: a report from the Patterns the speakers’ bureau for Incyte and was on an advisory board for of Care program. Off-label drug use: decitabine and azacytidine for DOI10. High-dose daunorubicin in older patients with acute myeloid leukemia. Wang MD, Department of Medicine, Roswell Park Cancer 18. Outcomes and prognostic factors Institute, Elm and Carlton Streets, Buffalo, NY 14263; Phone: (716)845- for patients with acute myeloid leukemia admitted to the intensive care 3544; Fax: (716)845-8741; e-mail: eunice. Decision-making and quality of life in older adults with acute myeloid leukemia or advanced References myelodysplastic syndrome. The impact of acute myeloid American Cancer Society; 2014. Quality of life beyond 6 months Recommendations of the Working Group Geriatric Oncology of the after diagnosis in older adults with acute myeloid leukemia. Crit Rev German Society for Haematology and Oncology (DGHO), the Austrian Oncol Hematol. Society for Haematology and Oncology (OGHO) and the German 22. Treating octogenarian and Society for Geriatrics (DGG). Intensive induction is German Acute Myeloid Leukemia Cooperative Group.
DuPaul ADHD Rating Scale IV consists of 18 items adapted from the symptom list for ADHD delineated in the DSM-IV order innopran xl 40mg without a prescription blood pressure 3rd trimester. Factor analytic studies have indicated that the nine-item Inattention factor and the nine-item Hyperactivity-Impulsivity factor of this measure closely correspond to the two-dimensional structure in the DSM-IV discount innopran xl 80 mg fast delivery blood pressure different in each arm. Estimates of internal consistency buy generic innopran xl 80mg online prehypertension in spanish, test--retest 37 reliability order 80mg innopran xl visa blood pressure too high, and concurrent validity strongly support the psychometric integrity of this measure. Global Assessment Scale (GAS) is a single rating scale for assessing the overall functioning of a patient. The scale values range from 1 to 100, with 1 being the hypothetical sickest person and 100 being the hypothetical healthiest person. There are ten equal intervals ranging from 1-10, 11- 20, 21-30 and so on up until 91-100; if a patient falls in the upper two intervals, it is considered “positive mental health. The GAS is found to have good reliability based on five studies with an intraclass correlation coefficient range of 0. Hamilton Anxiety Scale (HAMA or HAM-A) is a rating scale developed to quantify the severity of anxiety symptomatology, often used in psychotropic drug evaluation. It consists of 14 items, each defined by a series of symptoms. Each item is rated on a 5-point scale, ranging from 0 (not 39 present) to 4 (severe). It uses 4-point scale: 0= “not at all”; 1=”a little”; 2=”some”; 3=”a lot”. No reliability or validity information is 40 available. Impaired Driving Score (IDS) is used to compare the various aspects of driving poorly, and the score represents an accumulative effect size across the multiple driving variables: summed SDs of steering, driving off the road, veering across the midline, inappropriate braking while on the open road, missed stopped signals, collisions, exceeding speed limit, SD of speed, time at stop sign deciding when to turn left, and time to complete left turns. A higher IDS reflects poorer driving skill, with more driving across midline and off road, more speeding, higher SD of speed, less time spent at stop signs and executing left turns, and more crashes. An IDS of 0 represents average driving, an IDS less than 0 represents better than average driving (e. Inattention/Overactivity With Aggression Conners’ Teacher Rating Scale (IOWA CTRS) is revised from the 39-item Conners’ Teacher scale. Teachers rate their child’s symptoms from zero to three (0=not at all, 1=just a little, 2=pretty much, 3=very much). They only tested the sensitivity and specificity scores of the IO scale, and the scores depend on the screen score being rated. Therefore, it recommended the use of an IO scale for at least 11 points for research purpose, and Attention deficit hyperactivity disorder 170 of 200 Final Update 4 Report Drug Effectiveness Review Project 42 7 points for clinical purpose. The differential validity of IO and A factors had been tested as 43 well. Life Participation Scale for ADHD-Revised (LPS-ADHD-R) is a 24- item, parent-rated scale 5 assessing changes in adaptive functioning related to ADHD treatment. Mental Component Summary (MCS) provides the clinician with information on the patient’s HRQL summarized in just two values, thereby reducing the number of statistical analyses needed and offering easier interpretation of the data. The MCS have been demonstrated to have good 44 discriminant validity for identifying differences between clinically meaningful groups. Montgomery Asberg Depression Rating Scale (MADRS): The MADRS was originally a subscale of Comprehensive Psychopathological Rating Scale, developed by Montgomery and Asberg in 1979. This scale measures the effect of treatment on depression severity, and as such requires a baseline assessment (before treatment) with subsequent assessments during course of treatment. The MADRS measures the severity of a number of symptoms on a scale from 0-6 (Table 2), including mood and sadness, tension, sleep, appetite, energy, concentration, suicidal ideation and 45 restlessness. Multidimensional Anxiety Scale for Children (MASC) is a 39-item self-report scale assessing physical symptoms, social anxiety, harm avoidance, and separation anxiety using an anchored ordinal scale from 0 (never true) to 3 (often true) that shows excellent internal and test-retest 5 reliability (score range 0-117). Pediatric Anxiety Rating Scale (PARS) assesses frequency, severity, and associated impairment of separation anxiety, social phobia, and generalized anxiety symptoms based on clinician interviews with patients and parents. Items were derived from DSM-IV criteria for anxiety disorders. A checklist is used to assess symptoms experienced during the preceding 7 days. The clinician then integrates child and parent reports to rate each symptom on 7 dimensions using a 6-point scale (0 = none, 1Y5 = minimal to extreme). The PARS total score (ranging from 0 to 5 25) is the sum of scores on five of the 7 dimensions. It is a validated 10- min math test developed to evaluate response to stimulant medication. Con taining 400 age- appropriate math problems, the test is scored to obtain an objective measure of academic performance by grading the number of attempted (PERMP-A) and completed problems. Subjects are given different levels of the math test based on their ability, as determined by a math pretest completed during the practice visit. Different versions of the math tests for a given level are used across the multiple classroom sessions so that subjects did not repeat the same test more than once during the classroom day. PERMP has been shown to be sensitive to dosage and time 47 effects of stimulant medications. Personality Inventory for Children-Revised (PIC-R): This empirically derived 280-item true/false instrument (caregiver report) assesses psychosocial adjustment in preschool through adolescent youths. Twelve scales measure three development dimensions (achievement, development, Attention deficit hyperactivity disorder 171 of 200 Final Update 4 Report Drug Effectiveness Review Project intelligence) and nine adjustment dimensions (anxiety, depression, delinquency, family relations, hyperactivity, psychosis, social skills, somatic concern, and withdrawal). The scales are 48 interpreted through actuarial guidelines derived for T-score ranges that vary by scale. Physician’s Global Rating Scale is a 7-point rating of the overall functioning of a patient.
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