Mary Ann Weiser

Relation between the duration of remission and hyperglycemia during induction chemotherapy for acute lymphocytic leukemia with a hyperfractionated cyclophosphamide, vincristine, doxorubicin, and dexamethasone/methotrexate–cytarabine regimen

Hyperglycemia, which is not uncommon during the treatment of acute lymphocytic leukemia (ALL), has been shown to be an independent predictor of adverse outcomes among hospitalized patients with undiagnosed diabetes; it also may have the potential to affect leukemic cell proliferation through altered metabolism. The purpose of the current study was to determine the prevalence of hyperglycemia during induction chemotherapy for ALL using a regimen comprised of hyperfractionated cyclophosphamide, vincristine, doxorubicin, and dexamethasone (Hyper‐CVAD) and to determine its effect on survival, duration of disease remission, and treatment‐related complications.

Identifying risk factors for imminent death in cancer patients with acute dyspnea.

A substantial proportion of cancer patients presenting to an emergency center (EC) or clinic with acute dyspnea survives fewer than 2 weeks. If these patients could be identified at the time of admission, physicians and patients would have additional information on which to base decisions to continue therapy to extend life or to refocus treatment efforts on palliation and/or hospice care alone. The purpose of this study was to identify risk factors for imminent death (survival </= 2 weeks) and short-term survival (1, 3, or 6 months) in cancer patients presenting to an EC with acute dyspnea and to combine these factors into a model to help clinicians identify patients with short life expectancies. A random sample of 122 patients presenting to an EC with acute dyspnea was selected for a retrospective analysis. Data that were available to physicians during the initial EC visit included patient histories, triage and discharge vital signs, chest radiographs, and laboratory results. These variables were used in univariate and logistic regression models to develop predictive models for imminent death and short-term survival. Variables and interactions meeting a univariate criterion of P < 0.10 were included in stepwise regression by using forward and backward stepping. Models were compared with the use of Hosmer-Lemeshow statistics and receiver operating characteristics curves. Underlying cancers were 30% breast, 37% lung, and 34% other cancers. Triage respiration greater than 28/min., triage pulse greater than or equal to 110 bpm, uncontrolled progressive disease, and history of metastasis were found to be statistically significant predictors (alpha </= 0.05) of imminent death. Patients with uncontrolled progressive disease had a relative risk of imminent death of 21.93. Relative risks for triage respiration, pulse, and metastases were 12.72, 4.92, and 3.85, respectively. Cancer diagnosis was not predictive of imminent death but was predictive when longer time periods were modeled. It may be possible to identify patients whose death is imminent from a group of cancer patients with acute dyspnea. Some factors that predict imminent death (triage pulse and respiration) differ from those (cancer diagnosis) that predict short-term survival. Extent of disease/response to treatment is common to all models. These factors need further examination and validation. If these findings are confirmed, this quantified information can help physicians in making difficult end-of-life decisions.

Tuberculous meningitis in a patient with acute myelogenous leukemia

We present a case of tuberculous meningitis in a patient with acute myelogenous leukemia. The patient was in complete remission; he had persistent lymphopenia and CD4+ T lymphocytopenia. Diagnosis was complicated by the chronic and subacute nature of symptoms; some originally thought to be secondary to depression and chemotherapy related toxicity. Treatment was further complicated by the unusual phenomenon of paradoxical progression of disease while on appropriate therapy. This case illustrates the importance of consideration of mycobacteriosis in the differential diagnosis of chronic unexplained fever complicating treatment for acute leukemia. The natural history and essential aspects of diagnosis and treatment of CNS tuberculosis are reviewed. The clinical significance of unexplained CD4+ T lymphoctopenia and chronic lymphopenia in patients with leukemia is also discussed.

Results of General Internal Medicine Consultations for Diabetes Mellitus in 283 Cancer Patients

Background:Diabetes is a major reason for patient referral to the General Internal Medicine (GIM) Department at M.D. Anderson Cancer Center. Previous studies of various factors that affect diabetes care have not focused on cancer patients. The objective of this study was to examine the level of diabetic care received by cancer patients. Methods:We conducted a retrospective chart review of 283 consecutive GIM patients with diabetes in the years 2000 to 2001. For each patient, data were collected about the cancer, diabetes-related history, and the general internists recommendations for further diabetes care. Patients were stratified by whether their cancer was controlled (stable or in remission) or uncontrolled (being actively treated by an oncologist or said to be progressive). &khgr;2 tests and t tests were used to compare means for controlled cancer and uncontrolled cancer patient groups, with a value of P < 0.05 being considered significant. Results:Patients with controlled cancer were more likely to have a lipid profile ordered (P < 0.001) or to be referred for diabetes-specific ophthalmology evaluation (P = 0.02). On logistic regression analysis, increasing patient age was associated with less frequent HgbA1c testing (P = 0.01), and both advanced age and uncontrolled cancer were associated with less lipid testing and ophthalmology referral. Conclusions:Patients with uncontrolled advanced cancer were not as aggressively treated for diabetes, especially if they were elderly. Further work should evaluate whether the observed level of diabetes care was appropriate and could affect patient outcome.

Hypertension in cancer patients seeking acute care: An opportunity to intervene

Background:The objectives were to describe clinical factors associated with hypertension or increased blood pressure in cancer patients seeking acute care, to describe the outcomes of these patients related to hypertension or increased blood pressure, and to determine whether these patients receive appropriate treatment and follow-up instructions. Methods:We retrospectively reviewed the records of patients admitted to the emergency center at The University of Texas M. D. Anderson Cancer Center from May 1, 2001 through August 5, 2001. Patients were included in our analysis if their emergency center triage blood pressure was 140 mm Hg or greater, systolic, or 90 mm Hg or greater, diastolic and remained in this range at emergency center discharge or if they were treated with an antihypertensive medication in the emergency center. Descriptive statistics, &khgr;2 and Student t tests were utilized in the analysis. Results:Records of 143 patients were analyzed. The mean baseline, emergency center triage, and emergency center discharge blood pressure were 140/78 mm Hg, 159/84 mm Hg, and 153/81 mm Hg, respectively. Of 77 patients (54%) with controlled neoplastic disease, 54 (38%) were not receiving cancer treatment. Forty-one (30%) were admitted to the hospital and 27 (19%) returned to the emergency center with hypertension or possible hypertension-related events within 6 months. Discharge instructions regarding hypertension follow-up were documented in 9% of records. Conclusions:Most patients (54%) had controlled cancer; more than one third were not receiving cancer treatment and had good performance status. Such patients would be likely to benefit from management of hypertension. In addition, only 9% of hypertensive patients were given hypertensive specific discharge instructions. The emergency center may provide another opportunity to alert patients of abnormal blood pressures and assist in arranging follow-up.

Diagnostic Evaluation of Patients with a High Suspicion of Malignancy: Comorbidities and Clinical Predictors of Cancer

Background:The diagnosis of cancer is based on the demonstration of malignant cells obtained via biopsy or needle aspiration. For some patients, diagnostic options may be limited either because of tumor location, underlying comorbid conditions, or lack of access to care. Methods:275 of 282 consecutive patients presenting to the University of Texas M.D. Anderson Cancer Center with a suspicion of cancer between April 1, 2000 and January 23, 2003 were evaluated retrospectively. We analyzed differences in means of diagnosis, complication rates, clinical characteristics, and comorbid medical conditions between patients with and without a cancer diagnosis. Logistic regression analysis was used to determine the independent predictors of a diagnosis of cancer. Results:179 (65%) patients had a cancer diagnosis. Endoscopic ultrasonography with fine needle aspiration (EUS/FNA) and image-guided percutaneous biopsy (IGPB) were the most commonly used diagnostic techniques. Complications occurred in 6% of all cases. Independent predictors of a cancer diagnosis included age of 50 years or older, jaundice, weight loss, percentage of monocytes greater than 7, and platelet count greater than 440 × 109/L; the ROC statistic was 0.796 (CI, 0.738–0.854; P < 0.001). Controlling for age, there was no difference in comorbidity between patients with and without a cancer diagnosis. Conclusions:EUS/FNA and IGPB play an important role in the diagnosis of certain types of malignancy and are associated with a low risk for complications. Advanced age, prior history of malignancy, weight loss, abnormally high percentage of monocytes, and thrombocytosis may be predictive of a cancer diagnosis in patients with suspected malignancy. Comorbid medical conditions are common among patients and occur at rates similar to the general population. Further study is necessary to determine organ-specific predictors of malignancy and to better understand the relationship between cancer and coexisting medical conditions.