The Palliative Prognostic (PaP) score; Palliative Prognostic Index (PPI); Feliu Prognostic Nomogram (FPN) and Palliative Performance Scale (PPS) have all been proposed as prognostic tools for ...palliative cancer care. However, clinical judgement remains the principal way by which palliative care professionals determine prognoses and it is important that the performance of prognostic tools is compared against clinical predictions of survival (CPS).
This was a multi-centre, cohort validation study of prognostic tools. Study participants were adults with advanced cancer receiving palliative care, with or without capacity to consent. Key prognostic data were collected at baseline, shortly after referral to palliative care services. CPS were obtained independently from a doctor and a nurse.
Prognostic data were collected on 1833 participants. All prognostic tools showed acceptable discrimination and calibration, but none showed superiority to CPS. Both PaP and CPS were equally able to accurately categorise patients according to their risk of dying within 30 days. There was no difference in performance between CPS and FPN at stratifying patients according to their risk of dying at 15, 30 or 60 days. PPI was significantly (p<0.001) worse than CPS at predicting which patients would survive for 3 or 6 weeks. PPS and CPS were both able to discriminate palliative care patients into multiple iso-prognostic groups.
Although four commonly used prognostic algorithms for palliative care generally showed good discrimination and calibration, none of them demonstrated superiority to CPS. Prognostic tools which are less accurate than CPS are of no clinical use. However, prognostic tools which perform similarly to CPS may have other advantages to recommend them for use in clinical practice (e.g. being more objective, more reproducible, acting as a second opinion or as an educational tool). Future studies should therefore assess the impact of prognostic tools on clinical practice and decision-making.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Summary
Background
Cellulitis and chronic oedema are common conditions with considerable morbidity. The number of studies designed to assess the epidemiology of cellulitis in chronic oedema is ...scarce.
Objectives
To investigate the prevalence and risk factors of cellulitis in chronic leg oedema, including lymphoedema.
Methods
A cross‐sectional study included 40 sites in nine countries during 2014–17. Adults with clinically proven unilateral or bilateral chronic oedema (oedema > 3 months) of the lower leg were included. The main outcome measures were frequency and risk factors for cellulitis within the last 12 months.
Results
Out of 7477 patients, 15·78% had cellulitis within the last 12 months, with a lifetime prevalence of 37·47%. The following risk factors for cellulitis were identified by multivariable analysis: wounds odds ratio (OR) 2·37, 95% confidence interval (CI) 2·03–2·78, morbid obesity (OR 1·51, 95% CI 1·27–1·80), obesity (OR 1·21, 95% CI 1·03–1·41), midline swelling (OR 1·32, 95% CI 1·04–1·66), male sex (OR 1·32, 95% CI 1·15–1·52) and diabetes (OR 1·27, 95% CI 1·08–1·49). Controlled swelling was associated with a reduced risk (OR 0·59, 95% CI 0·51–0·67). In a subgroup analysis, the risk increased with the stage of oedema International Society of Lymphology, stage II OR 2·04 (95% CI 1·23–3·38) and stage III OR 4·88 (95% CI 2·77–8·56).
Conclusions
Cellulitis in chronic leg oedema is a global problem. Several risk factors for cellulitis were identified, of which some are potentially preventable. Our findings suggest that oedema control is one of these. We also identified that advanced stages of oedema, with hard/fibrotic tissue, might be an important clinical indicator to identify patients at particular risk.
What is already known about this topic?
Chronic oedema has many different causes and is a frequent but neglected healthcare problem.
The association between chronic oedema and cellulitis is known, but few studies have clinically evaluated the size of the problem and the risk factors.
Guidelines suggests that control of oedema is important to reduce the risk of recurrent cellulitis, but the evidence is limited.
What does this study add?
Cellulitis in chronic leg oedema is common in all countries and types of health facilities.
Wounds, obesity, midline swelling, male sex and diabetes were independently associated with a recent episode of cellulitis (within the last 12 months).
Severe stages of oedema were associated with cellulitis, while controlled swelling was associated with a reduced risk.
Measures to improve the control of swelling may have a major effect on the incidence of cellulitis, being potentially preventable.
Linked Comment: P. S. Mortimer. Br J Dermatol 2021; 185:10–11.
Historically, primary lymphoedema was classified into just three categories depending on the age of onset of swelling; congenital, praecox and tarda. Developments in clinical phenotyping and ...identification of the genetic cause of some of these conditions have demonstrated that primary lymphoedema is highly heterogenous. In 2010, we introduced a new classification and diagnostic pathway as a clinical and research tool. This algorithm has been used to delineate specific primary lymphoedema phenotypes, facilitating the discovery of new causative genes. This article reviews the latest molecular findings and provides an updated version of the classification and diagnostic pathway based on this new knowledge.
Prognosis in Palliative care Study (PiPS) models predict survival probabilities in advanced cancer. PiPS-A (clinical observations only) and PiPS-B (additionally requiring blood results) consist of ...14- and 56-day models (PiPS-A14; PiPS-A56; PiPS-B14; PiPS-B56) to create survival risk categories: days, weeks, months. The primary aim was to compare PIPS-B risk categories against agreed multi-professional estimates of survival (AMPES) and to validate PiPS-A and PiPS-B. Secondary aims were to assess acceptability of PiPS to patients, caregivers and health professionals (HPs).
A national, multi-centre, prospective, observational, cohort study with nested qualitative sub-study using interviews with patients, caregivers and HPs. Validation study participants were adults with incurable cancer; with or without capacity; recently referred to community, hospital and hospice palliative care services across England and Wales. Sub-study participants were patients, caregivers and HPs. 1833 participants were recruited. PiPS-B risk categories were as accurate as AMPES PiPS-B accuracy (910/1484; 61%); AMPES (914/1484; 61%); p = 0.851. PiPS-B14 discrimination (C-statistic 0.837) and PiPS-B56 (0.810) were excellent. PiPS-B14 predictions were too high in the 57-74% risk group (Calibration-in-the-large CiL -0.202; Calibration slope CS 0.840). PiPS-B56 was well-calibrated (CiL 0.152; CS 0.914). PiPS-A risk categories were less accurate than AMPES (p<0.001). PiPS-A14 (C-statistic 0.825; CiL -0.037; CS 0.981) and PiPS-A56 (C-statistic 0.776; CiL 0.109; CS 0.946) had excellent or reasonably good discrimination and calibration. Interviewed patients (n = 29) and caregivers (n = 20) wanted prognostic information and considered that PiPS may aid communication. HPs (n = 32) found PiPS user-friendly and considered risk categories potentially helpful for decision-making. The need for a blood test for PiPS-B was considered a limitation.
PiPS-B risk categories are as accurate as AMPES made by experienced doctors and nurses. PiPS-A categories are less accurate. Patients, carers and HPs regard PiPS as potentially helpful in clinical practice.
ISRCTN13688211.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Objective To develop a novel prognostic indicator for use in patients with advanced cancer that is significantly better than clinicians’ estimates of survival.Design Prospective multicentre ...observational cohort study.Setting 18 palliative care services in the UK (including hospices, hospital support teams, and community teams).Participants 1018 patients with locally advanced or metastatic cancer, no longer being treated for cancer, and recently referred to palliative care services.Main outcome measures Performance of a composite model to predict whether patients were likely to survive for “days” (0-13 days), “weeks” (14-55 days), or “months+” (>55 days), compared with actual survival and clinicians’ predictions.Results On multivariate analysis, 11 core variables (pulse rate, general health status, mental test score, performance status, presence of anorexia, presence of any site of metastatic disease, presence of liver metastases, C reactive protein, white blood count, platelet count, and urea) independently predicted both two week and two month survival. Four variables had prognostic significance only for two week survival (dyspnoea, dysphagia, bone metastases, and alanine transaminase), and eight variables had prognostic significance only for two month survival (primary breast cancer, male genital cancer, tiredness, loss of weight, lymphocyte count, neutrophil count, alkaline phosphatase, and albumin). Separate prognostic models were created for patients without (PiPS-A) or with (PiPS-B) blood results. The area under the curve for all models varied between 0.79 and 0.86. Absolute agreement between actual survival and PiPS predictions was 57.3% (after correction for over-optimism). The median survival across the PiPS-A categories was 5, 33, and 92 days and survival across PiPS-B categories was 7, 32, and 100.5 days. All models performed as well as, or better than, clinicians’ estimates of survival.Conclusions In patients with advanced cancer no longer being treated, a combination of clinical and laboratory variables can reliably predict two week and two month survival.
Clinicians' prognoses in patients with advanced cancer are imprecise. The aim of this study was to compare doctors', nurses' and patients' survival predictions and to identify factors which influence ...accuracy.
Some 1018 patients with advanced cancer were recruited. Survival estimates were obtained from the attending doctor, nurse, multidisciplinary team (MDT) and patient (n = 829, 954, 987 and 290 estimates, respectively) and were compared with actual survival. Clinician and patient characteristics were recorded.
MDTs', doctors' and nurses' predictions were accurate 57.5%, 56.3% and 55.5% of occasions, respectively. Nurses were less accurate than the MDT (P = 0.007) but were no worse than doctors (P = 0.284). Estimates of clinicians and patients were more optimistic (doctors: 31%; nurses: 34%; MDT: 31.1%; patients: 45.1%) than pessimistic (12.7%, 11%, 11.4% and 2.7%). Nurses' accuracy increased if they had reviewed the patient within 24 h. Most patients (61.4%) wanted to know their prognosis. Only 37.1% were willing to offer an estimate regarding their own survival. Patients' prognostic estimates were less accurate than health care professionals' (P < 0.001).
MDTs were better at predicting survival than doctors' or nurses' alone. Patients were substantially worse. Among nurses, recency of review was related to improved prognostic accuracy.
Connell F, Brice G, Jeffery S, Keeley V, Mortimer P, Mansour S. A new classification system for primary lymphatic dysplasias based on phenotype.
Traditional classification systems for lymphoedema are ...of limited use for the diagnosis of specific forms of primary lymphoedema. The understanding of primary lymphoedema has been impeded by confusing terminology and a tendency to simply divide patients into three categories based on the age of onset: lymphoedema congenita manifests at or shortly after birth, lymphoedema praecox is apparent before the age of 35 years and lymphoedema tarda manifests thereafter. The clinical presentation in the spectrum of primary lymphoedema disorders is very variable; the phenotypes of primary lymphoedema conditions vary in the age of onset, site of the oedema, inheritance patterns, associated features and genetic causes. Different inheritance patterns are recognised and there are numerous associated anomalies. Some subgroups, such as Milroy disease and Lymphoedema distichiasis, are well characterised, but others are not.
A new clinical classification for primary lymphoedema has been developed as a diagnostic algorithm. Its use is demonstrated on 333 probands referred to our lymphoedema clinic. Grouping patients by accurate phenotyping facilitates molecular investigations, understanding of inheritance patterns, and the natural history of different types of primary lymphoedema. Descriptions of the diagnostic categories, some of which have not been previously clearly defined as distinct clinical entities, are illustrated by clinical cases.
The so-called Colonels’ coup of April 21, 1967, was a major event in the history of the Cold War, ushering in a seven-year period of military rule in Greece. In the wake of the coup, some eight ...thousand people affiliated with the Communist Party were rounded up, and Greece became yet another country where the fear of Communism led the United States into alliance with a repressive right-wing authoritarian regime. In military coups in some other countries, it is known that the CIA and other agencies of the U.S. government played an active role in encouraging and facilitating the takeover. The Colonels’ coup, however, came as a surprise to the United States (which was expecting a Generals’ coup instead). Yet the U.S. government accepted it after the fact, despite internal disputes within policymaking circles about the wisdom of accommodating the upstart Papadopoulos regime. Among the dissenters was Robert Keeley, then serving in the U.S. Embassy in Greece. This is his insider’s account of how U.S. policy was formulated, debated, and implemented during the critical years 1966 to 1969 in Greek-U.S. relations.
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