Risk factors for recurrent falls in older adults: A systematic review with meta-analysis

Older adults who fall recurrently (i.e., 2 or more falls/year) are at risk of functional decline and mortality. Understanding which risk factors for recurrent falls are most important will inform secondary fall prevention strategies that can reduce recurrent falls risk. Thus, we conducted a systematic review with meta-analysis to determine the relative risk of recurrent falls for different types of falls risk factors. MEDLINE, EMBASE, PsycINFO, and CINAHL databases were searched on April 25, 2019 (Prospero Registration: CRD42019118888). We included peer-reviewed prospective studies which examined risk factors that contributed to recurrent falls in adults aged ≥ 60 years. Using the falls risk classification system of Lord and colleagues, we classified each risk factor into one of the following domains: 1) balance and mobility; 2) environmental; 3) psychological; 4) medical; 5) medication; 6) sensory and neuromuscular; or 7) sociodemographic. We calculated the summary relative risk (RR) for each domain and evaluated the risk of bias and quality of reporting. Twenty-two studies were included in this systematic review and meta-analysis. Four domains predicted recurrent falls: balance and mobility (RR:1.32;95 % CI:[1.10, 1.59]), medication (RR:1.53;95 % CI:[1.11, 2.10]), psychological (RR:1.35;95 % CI:[1.03, 1.78]), and sensory and neuromuscular (RR:1.51;95 % CI:[1.18, 1.92]). Each of these four domains can be viewed as a marker of frailty. The risk of bias was low, and the study quality was high (minimum:19/22). Older adults with markers of frailty are up to 53 % more likely to experience recurrent falls. Strategies that identify and resolve frailty markers should be a frontline approach to preventing recurrent falls.

Pan-Asian adapted ESMO Clinical Practice Guidelines for the management of patients with intermediate and advanced/relapsed hepatocellular carcinoma: a TOS-ESMO initiative endorsed by CSCO, ISMPO, JSMO, KSMO, MOS and SSO

The most recent version of the European Society for Medical Oncology (ESMO) Clinical Practice Guidelines for the diagnosis, treatment and follow-up of hepatocellular carcinoma (HCC) was published in 2018, and covered the diagnosis, management, treatment and follow-up of early, intermediate and advanced disease. At the ESMO Asia Meeting in November 2018 it was decided by both the ESMO and the Taiwan Oncology Society (TOS) to convene a special guidelines meeting immediately after the Taiwan Joint Cancer Conference (TJCC) in May 2019 in Taipei. The aim was to adapt the ESMO 2018 guidelines to take into account both the ethnic and the geographic differences in practice associated with the treatment of HCC in Asian patients. These guidelines represent the consensus opinions reached by experts in the treatment of patients with intermediate and advanced/relapsed HCC representing the oncology societies of Taiwan (TOS), China (CSCO), India (ISMPO) Japan (JSMO), Korea (KSMO), Malaysia (MOS) and Singapore (SSO). The voting was based on scientific evidence, and was independent of the current treatment practices, the drug availability and reimbursement situations in the individual participating Asian countries.

Phase I study of pemetrexed (P) and pegylated liposomal doxorubicin (PLD) in patients with refractory breast, ovarian, primary peritoneal, or fallopian tube cancer

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Background: P and PLD are clinically active as single agents and synergistic in preclinical models. This phase I, open-label trial determined the maximum tolerated dose (MTD) and safety profile of P followed by PLD in patients (pts) with breast or gynecologic cancers. Methods: Using standard phase I (3+3 dose escalation) study design, cohorts of 3–9 pts received escalating doses of P followed by PLD in 28-day cycles: P 400–500 mg/m2 on Days 1 and 15 and PLD 30–45 mg/m2 on Day 1. All pts received folic acid (350–1000 μg daily) and vitamin B12 (1000 μg) until 21 days after last dose of P. Pts continued until dose-limiting toxicity (DLT) or disease progression (PD) occurred. Results: From 11/05 to 1/08, 29 pts were registered/treated. Median age: 60.6 years (range, 47.5–80.1); ECOG performance status 0/1: 28%/72%; primary disease sites: ovarian (55%), breast (35%), peritoneal (10%); prior therapies: chemotherapy (100%), surgery (72%), hormones/biologics (35%), radiation (21%). Dosing results are shown below. At dose level (L) 2 and L3, 1 pt/cohort had DLTs; L5 was added and 3/3 pts had DLTs; 4 more pts were treated at L4 (1 pt replaced). Most frequent drug-related Grade 3–4 hematologic toxicities: neutropenia (86%), leukopenia (59%), thrombocytopenia (48%), anemia (41%). Most frequent drug-related Grade 3–4 nonhematologic toxicities: hand-foot syndrome (14%), hypokalaemia (10%). Major reasons for discontinuation: PD (48%), toxicity (28%), pt request (14%). Overall best responses (n=24): 5 pts (21%) had partial response (PR), 14 pts (58%) had stable disease (SD), 2 pts (8%) had PD, 3 pts (13%) were not evaluable. All 5 PR and 8 SD pts were ovarian; 5 SD and both PD pts were breast. Conclusions: P followed by PLD was reasonably tolerated in this heavily-pretreated population. The MTD was P 500 mg/m2 and PLD 40 mg/m2. These dose levels may be carried forward to phase II studies in more specific patient populations.

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Effect of race on the safety and efficacy outcomes of gemcitabine plus paclitaxel treated patients with metastatic breast cancer (MBC): Analyses from a phase III trial

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Background: Population-based studies often attribute racial disparities in breast cancer outcomes to differences in access to treatment, quality of care, or other socioeconomic factors. In a controlled clinical trial setting, these systemic differences between races should be minimal. To evaluate the potential impact of race on outcomes in a controlled clinical setting, we retrospectively analyzed data from a phase III trial (B9E-MC-JHQG; NCT00006459 ) of patients (pts) with MBC. Methods: Analyses were performed on the JHQG trial database after 440 total pt deaths for both study arms. Demographics, safety, and efficacy were analyzed using safety population data from 3 racial groups: Caucasian (CA), Asian (AS), and Hispanic (HP). CA was the reference for all pair-wise comparisons. The logistic model was used to calculate odds ratios for tumor response and the Cox model was used to calculate hazard ratios for time-to-event parameters, adjusting for significant prognostic factors. Results: We report analyses of the gemcitabine (G) + paclitaxel (T) treatment arm. Demographics were balanced across the 3 groups with the exception that ER+/PR+ status was lower for AS compared to CA and HP; unknown ER/PR status was higher for AS. AS had significantly less neutropenia, fatigue, and nausea, but more anemia compared to CA and HP. Median number of treatment cycles completed was lower, but mean dose intensities for G and T were slightly higher, for AS. Response rate and progression-free survival were similar in the 3 groups. Overall survival (OS) and post-study chemotherapy (PSC) were significantly reduced for AS. Conclusions: Our analysis suggests that AS pts were better able to tolerate GT therapy compared to CA and HP pts. However, AS pts had the poorest OS outcome of the 3 racial groups, potentially due to reduced participation in PSC.

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Phase III trial of gemcitabine plus docetaxel (GD) compared to capecitabine plus docetaxel (CD) with planned crossover to the alternate single agent in metastatic breast cancer (MBC)

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Background: GD and CD are efficacious in patients (pts) with MBC. This study compared safety and efficacy of GD and CD induction regimens, where the alternate, single-agent, crossover therapy (GD to C or CD to G) was predetermined. Primary endpoint was time to progressive disease (TTP). Secondary endpoints included toxicities, overall response (ORR), and overall survival (OS). Methods: This multicenter, open-label, phase III study enrolled MBC pts with possible prior anthracycline therapy, adjuvant or neoadjuvant taxane therapy, but no taxane therapy for MBC ≤6 months prior to entry. Enrollment of 442 pts (221 per arm) was planned with 385 progressions required to achieve 80% power for a 2-month observed difference in median TTP between arms. Pts were randomized to: GD: G 1,000mg/m2 Days 1, 8 plus D 75 mg/m2 Day 1, q21 days; or CD: C 1,000 mg/m2 BID, Days 1–14 plus D 75 mg/m2 Day 1, q 21 days. Upon disease progression, pts were given crossover C or G at doses and schedules identical to induction. ORR was assessed by RECIST. Results: Demographics of 472 enrolled pts were balanced between arms; 57% had prior anthracycline. GD caused greater myelosuppression than CD, but without greater febrile neutropenia. Gastrointestinal toxicities, mucositis, and hand-foot syndrome were greater with CD. More pts in the CD arm (n=61, 26.2%) versus the GD arm (n=41, 17.2%) discontinued due to toxicity (p=0.023). ORR, TTP, and OS were not significantly different comparing GD and CD. However, ORR and TTP were significantly greater for the GD to C crossover monotherapy compared to CD to G. Post-hoc analysis of crossover pts showed that the TTP sum from induction through crossover was 6.1 months greater for GD to C. Conclusions: GD and CD had similar efficacy with toxicity profiles consistent with prior clinical experience. Results suggest that the GD to C crossover sequence may provide a clinical benefit over CD to G.

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Sequential evaluation of portal venous hemodynamics by Doppler ultrasound in patients with severe acute hepatitis

OBJECTIVES

Portal hypertension may develop in patients with severe acute hepatitis. Sequential changes of portal venous hemodynamics in acute hepatitis is not well understood. This study evaluated portal hemodynamic changes and prognostic values in patients with severe, acute hepatitis.

METHODS

Doppler studies, liver function tests, and virology studies were done in the inclusion, the 3rd month, and the 6th month for patients with severe, acute hepatitis. An indocyanine green clearance was done in the inclusion. Doppler portal hemodynamic studies were done in the hilar area by an average of two measurements.

RESULTS

A total of 88 consecutive patients was included. Nine of them died. On initial study, fatalities were generally older patients with more delayed indocyanine green clearance, lower portal vein velocity, lower albumin values, higher bilirubin values, longer prothrombin time, and ascites. Using stepwise logistic regression, portal blood flow and prothrombin time were the two independence prognostic factors. By multiple linear regression, portal blood flow was associated with ascites, and average portal blood velocity was associated with bilirubin. During the hospital days, transient, depressed portal blood velocities followed by a hyperdynamic stage were found in survivors. The portal vein velocity changes for fatalities either were kept at a lower level or had a declining pattern.

CONCLUSIONS

Doppler ultrasound detects portal hemodynamic changes for patients with severe, acute hepatitis. Sequential portal hemodynamic studies will be helpful for evaluating patients with severe, acute hepatitis.

High-activity 125I interstitial irradiation in the treatment of pediatric central nervous system tumors: a pilot study

Malignant pediatric tumors of the central nervous system (CNS) have a poor prognosis, with local failure rates as high as 50%. In an attempt to improve local tumor control, we used stereotactic interstitial therapy with 125I implants in patients with recurrent/secondary or newly diagnosed CNS malignancies. Catheters were placed using computed tomography (CT) guidance; computerized dosimetry was completed with the aid of orthogonal films. Implants delivered 1,000 cGy/day to the tumor periphery (0.5 cm beyond the boundary of enhancement on CT scans), to a total dose of 60 Gy. Hyperfractionated external beam irradiation (HEBI), started 2-4 weeks after removal of implants, delivered total doses of 66-70.4 Gy in 110-cGy fractions twice daily to a 3-cm margin around the implant volume. Eight of the 11 patients with newly diagnosed tumors also received 48.4 Gy HEBI to the craniospinal axis. Tumor regression was noted at 2 months after implantation in the 4 patients treated for recurrent/secondary tumors; local progression was subsequently documented in 2 cases at 6 and 20 months after implantation, while a third patient died 6 months after implantation with no evidence of local recurrence. The remaining recurrent/secondary tumor patient has no evidence of active recurrence 15 months after implantation. Local control was maintained in 9 of the 11 patients treated for primary tumors for a median of 27 months (range 15 to 48+ months). The two local failures occurred at 5 and 7 months after implantation. Six patients are alive without evidence of progressive disease (median = 23 months after implantation). There were no severe acute toxicities, but 7 patients later developed histologically confirmed tumor necrosis. Quality of life assessment (QLA) following initial primary therapy with implantation was evaluated utilizing an established criteria and found to be excellent with only one child showing marked QLA score decrease which was related to neurosurgical intervention for radiation-induced necrosis and dysfunctional family social situation. This small series suggests that stereotactic 125I implantation followed by HEBI merits further evaluation in selected children with supratentorial malignant lesions.

Interstitial iodine 125 and concomitant cisplatin followed by hyperfractionated external beam irradiation for malignant supratentorial glioma. Preliminary experience at the University of Tennessee, Memphis

Between November 1989 and October 1992, 28 consecutive patients with glioblastoma multiforme (n = 18) or anaplastic astrocytoma (n = 10; includes one patient with oligodendroglioma with anaplastic astrocytoma component) were treated with interstitial iodine 125 (60 Gy over 6 days) and with concomitant cisplatin (via infusion on days 2-6 of the implant), then followed by hyperfractionated external beam irradiation (110 cGy delivered twice daily; 66 Gy planned total dose). Of 26 patients (60%) who received both 125I and HEBI, 15 are alive with no evidence of recurrent disease at a median follow-up of 18 months post-125I (range: 11 to 34 months). Four other disease-free patients succumbed to nontumor-related events. Two patients with local control had distant failure outside the HEBI treatment fields. Overall local control is 77%. Local failure occurred in 6 patients (23%) 2 to 11 months post-125I. Time to disease progression ranged from 4 to 18 months (median: 10 months). Survival (measured from the date of diagnosis) has ranged from 6 to 26 months (median: 15 months). All patients have maintained Karnofsky Performance Status within 20 points of their preimplant status, with the exception of a single patient who, following diagnosis of radiation necrosis and surgical intervention for symptomatic relief, had a 30-point drop in KPS. Radiation necrosis or persistent mass effect were noted by neuroimaging in seven patients, four of whom required surgical intervention following failed medical management. Ototoxicity, nephrotoxicity, peripheral nerve dysfunction, or hematologic toxicities have not been observed. This new innovative treatment approach offers a promising alternative to the normally dismal prognosis for patients with malignant gliomas.

Treatment of choroidal melanoma with I-125 plaque

PURPOSES

To evaluate efficacy of I-125 episcleral plaque therapy in patients with ocular melanoma and determine survival, eventual visual acuity, and complications.

METHODS AND MATERIALS

Between July 1, 1984 and January 1, 1991, 144 patients with diagnosis of ocular melanoma were treated with high activity I-125 episcleral plaques. Tumor volumes ranged from 14 to 3449 mm3. Lesion size included small (n = 15; height < 5 mm, and/or largest basal diameter of 8-16 mm) and large (n = 45; height > 8 mm, and/or largest basal diameter > 16 mm). Apical doses ranged from 74.25 to 83.66 Gy with scleral doses ranging from 41 and 160 Gy. Follow-up has ranged from 25 to 90 months (Med = 46 months).

RESULTS

Ocular survival was noted in 130/144. Reasons for enucleation included progressive tumor growth (n = 4), extrascleral extension (n = 4), or blind/painful eye (n = 6), 94 patients developed complications which included cataract (n = 43), optic neuropathy (n = 12), neovascular glaucoma (n = 8) and retinopathies (n = 31). Visual acuity testing pre-episcleral plaque therapy revealed 102 patients with 20/200 vision; at last follow-up 59 patients demonstrated visual acuity testing of 20/200 or better.

CONCLUSION

The use of episcleral I-125 plaque therapy allows for safe and effective therapy in patients with ocular melanoma of various size depending on location and probable visual acuity outcome. A total apical dose of 75 Gy given at 60-65 cGy/hour provides durable local control with acceptable complication rates.

Concomitant cisplatin and hyperfractionated external beam irradiation for advanced malignancy of the head and neck

The combination of cisplatin and hyperfractionated external beam irradiation (HEBI), followed by salvage surgery when indicated, was evaluated in patients with advanced stage squamous cell carcinoma of the head and neck. Thirty patients with stage III (n = 5) or IV (n = 25) disease received intravenous cisplatin 100 mg/m2 by 6-hour continuous infusion on days 1, 21, and 42 of HEBI. Radiation fractions of 110 cGy were given twice daily, separated by 4 to 6 hours, beginning within 12 hours after cisplatin delivery. Doses to the primary site ranged from 60 to 76.35 Gy (median: 72.3 Gy), with 60 to 74 Gy to nodal sites. Follow-up ranged from 4 to 28 months (median: 19 months). Clinical complete response of the primary site was seen in 27 of 29 patients (93%), and complete clinical clearance of adenopathy in 20 of 26 (76%). A second biopsy 6 to 8 weeks after completion of treatment showed residual disease in both the primary and nodal sites in three patients, and in only the primary site in one patient. Four patients with persistent adenopathy had pathologic confirmation at surgery. Four patients had recurrence after negative biopsy results 6 to 9 months after treatment biopsy. At present, with median follow-up of 19 months, eight patients (26%) have died secondary to uncontrolled primary or nodal disease. Two patients have died of nonrelated causes. Overall, 10 of 30 patients (66%) remain alive with no evidence of disease. Mucositis and weight loss were the most common side effects of treatment. Seven patients developed significant xerostomia, and four have cisplatin-related hearing loss requiring amplification. The early evidence of excellent response (89% pathologic complete response of primary sites; 78% complete response of nodal sites), coupled with acceptable treatment morbidity, warrants further study of this approach.

Justification of maternal serum alphafetoprotein screening in a population with low incidence of neural tube defects

A prospective study of maternal serum alphafetoprotein (alpha-FP) screening of 9838 women in an area with low prevalence of neural tube defects and predominance of anencephalics revealed that an intervention point of single serum alpha-FP level above 2.8 times the median was appropriate for this population. Ninety per cent of anencephalics and all fetuses with anterior abdominal wall defects were detected. There was no spina bifida among the population screened. Two per cent of the population screened had serum alpha-FP level above this cut-off level. Thirty-two per cent of twin pregnancies, 7 per cent of small-for-gestational age infants and 9 per cent of pregnancies which ended in either abortion or perinatal death in the population screened also had one serum alpha-FP level above this intervention point. The false positive rate was 66 per cent. This false positive rate was only reduced to 63 per cent if instead of one, two serum alpha-FP level above this intervention point was considered abnormal. Using this strategy there was no significant reduction in the detection rate of fetal anomalies and other pregnancy complications. Because of the predominance of anencephalics in this population the diagnosis of fetal anomaly in women with abnormal serum alpha-FP level was made by ultrasound examination alone. The reason amniocentesis was not performed in these patients was to avoid unnecessary loss of normal pregnancies which may result from this procedure.

An intercomparison between two methods of obtaining percentage depth doses for irregular shaped fields and comparison of each method with experimental data for 60Co and 10 MV X rays

Measurements of central ray tissue-air ratio (TAR) for 60Co for a large number of irregularly shaped fields typically encountered in the cancer clinic were compared with TAR values either calculated by the Clarkson method using scatter air ratios or obtained from tables of square field data using the area/perimeter approach. Irregular field shapes included the "L", pentagonal, rectangular, upper and lower mantle and split fields. Agreement between both calculational methods and direct measurement is within +/- 2% if careful attention is given to central ray position as affected by the proper use of off-centre ratios in air. In the case of 10 MV X-rays, eight randomly chosen irregular fields again yielded an average agreement between both methods of calculation and experimental data of less than 1% and an agreement of less than 0.5% between the A/P and Clarkson calculations.

Californium Cf-252 for pelvic radiotherapy

Clinical data about therapy concerning tumors of the female gynecological cancers of the cervix, vagina and uterus are reviewed. Dosimetric, laboratory and radiobiological research data form the basis for an approach to such tumors using Cf-252 as a form of boost brachytherapy. Extreme personnel hazards are a real and important consideration and indicate that maximal containment and isolation procedures should be exercised in its use. But it is anticipated that new possibilities for successful radiotherapy of an important cagegory of tumor will be realised by its clinical evaluation and application.

Method for localizing and calculating vaginal dose in brachytherapy

Contrast agents in the vagina are being used to determine the position of vaginal surfaces relative to applicators in an effort to assess dose at these sites. Computer treatment planning allows consideration of dose at many more sites than was formerly possible, but dose prescription to critical tumor volumes then becomes of greater importance. Vaginal reference dose points VR, VL, VA, and VP are proposed. With dose specification determined at these points, the problem of low vaginal dose from overly wide vaginal ovoid geometries and related difficulties can be avoided. Attention to central vaginal doses can reduce the probability of central pelvic recurrence in the vagina. We have found the VR, VL doses were much larger than VA, VP doses in standard loaded implant configurations.