Biomedical subjects

Stephen S Cha

Publications and source records attributed to Stephen S Cha.

At least 19 recordsLinked to original sources

PubMed2006

Surgery versus conservative therapy in carpal tunnel syndrome in people aged 70 years and older.

BACKGROUND: Carpal tunnel syndrome is common in the general population, with a prevalence that increases with age. Although good satisfaction has been described after carpal tunnel release, little is known about the long-term outcome of treatment in elderly individuals with carpal tunnel syndrome. METHODS: The authors reviewed data from a population-based sample of 102 patients aged 70 years and older with carpal tunnel syndrome. They used valid and sensitive mailed follow-up outcome [Boston Carpal Tunnel, satisfaction (American Academy of Orthopaedic Surgeons), and health status (Short Form-36) questionnaires to assess symptoms, functional status, expectations of treatment, and satisfaction with the results at a minimum of 2 years after initial diagnosis. RESULTS: Seventy patients with a mean age of 77.0 years (range, 70.2 to 88.5 years) responded to the survey, with a mean follow-up of 4.8 years. Patients who had surgery were more likely to have had more severe disease than those treated nonoperatively (Mantel-Haentzel test, p < 0.001). Satisfaction was 93 percent after surgical treatment and 54 percent after nonsurgical treatment. Patients who had surgery had significantly better relief of symptoms (t test, p < 0.01), functional status (t test, p < 0.05), satisfaction (t test, p < 0.001), and expectations with treatment (t test, p < 0.05) scores as compared with those who had nonsurgical treatment. CONCLUSIONS: In patients over the age of 70, surgery appears to be associated with better symptom relief, functional status, satisfaction, and expectations with treatment than nonoperative therapy does. Age should not be considered a contraindication for carpal tunnel surgery, nor should nonoperative therapy be favored in this age group.

Aged↗

PubMed2006

Two-dimensional echocardiographic methods for assessment of left atrial volume.

Left atrial (LA) size is an important predictor of cardiovascular events. Various methods of LA volume assessment exist, but their differences have not been defined. This prospective study included 631 patients (331 men; mean age of 68 +/- 14 years) without a history of atrial arrhythmias, stroke, valvular heart disease, pacemaker implantation, or congenital heart disease. All underwent echocardiography with comprehensive diastolic function assessment and LA volume measurement by 3 commonly used methods: biplane area-length, biplane Simpson's method, and the prolate-ellipsoid method. Mean LA volumes were 39 +/- 14 ml/m2 by the area-length method, 38 +/- 13 ml/m2 by the Simpson's method, and 32 +/- 14 ml/m2 by the prolate-ellipsoid method. In 92% of patients, the prolate measurement was smaller than the 2 biplane methods. Pairwise correlations (r) were 0.98 for area-length versus Simpson's, 0.85 for prolate versus area-length, and 0.86 for prolate versus Simpson's (all p values <0.001). For distinguishing normal (n = 62) from pseudonormal diastolic function (n = 240) using receiver-operating curve analysis, areas under the curves were 0.76, 0.78, and 0.75 for the area-length, Simpson's, and prolate methods, respectively (all p values <0.001, no significant intermethod differences). In conclusion, our findings suggest that there are systematic differences among existing LA volume methods. Biplane area-length and Simpson's methods compare closely, whereas the prolate-ellipsoid method generally yields smaller volumes.

Adolescent↗

PubMed2006

The association between impact factors and language of general internal medicine journals.

BACKGROUND: We sought to determine the associations between journal country of origin and language and journal impact factor of general medicine journals. METHODS: For each "Medicine, General and Internal" journal listed in the Institute for Scientific Information (ISI) Journal Citation Reports (JCR), the 2003 impact factor, language (ie, English, multiple languages [including English], or non-English), and country of origin (ie, US or non-US) were determined. The mean log impact factors of the journals by language, country of origin, and a combination of country of origin and language were compared. RESULTS: Of the 102 "Medicine, General and Internal" journals listed in the ISI JCR, 41 (40%) were published in the US and 83 (81%) were published in English. English-language journals had a significantly greater 2003 mean log impact factor than non-English journals and journals originating in the US had a significantly greater impact factor than journals originating elsewhere. However, the mean log impact factor of English-language journals originating in the US did not differ significantly from that of English-language journals originating elsewhere. CONCLUSION: Journal impact factor is more associated with journal language (ie, English versus non-English), rather than journal country of origin.

Bibliometrics↗

PubMed2006

Secular trends in incidence of atrial fibrillation in Olmsted County, Minnesota, 1980 to 2000, and implications on the projections for future prevalence.

BACKGROUND: Limited data exist on trends in incidence of atrial fibrillation (AF). We assessed the community-based trends in AF incidence for 1980 to 2000 and provided prevalence projections to 2050. METHODS AND RESULTS: The adult residents of Olmsted County, Minnesota, who had ECG-confirmed first AF in the period 1980 to 2000 (n=4618) were identified. Trends in age-adjusted incidence were determined and used to construct model-based prevalence estimates. The age- and sex-adjusted incidence of AF per 1000 person-years was 3.04 (95% CI, 2.78 to 3.31) in 1980 and 3.68 (95% CI, 3.42 to 3.95) in 2000. According to Poisson regression with adjustment for age and sex, incidence of AF increased significantly (P=0.014), with a relative increase of 12.6% (95% CI, 2.1 to 23.1) over 21 years. The increase in age-adjusted AF incidence did not differ between men and women (P=0.84). According to the US population projections by the US Census Bureau, the number of persons with AF is projected to be 12.1 million by 2050, assuming no further increase in age-adjusted incidence of AF, but 15.9 million if the increase in incidence continues. CONCLUSIONS: The age-adjusted incidence of AF increased significantly in Olmsted County during 1980 to 2000. Whether or not this rate of increase continues, the projected number of persons with AF for the United States will exceed 10 million by 2050, underscoring the urgent need for primary prevention strategies against AF development.

Adult↗

PubMed2006

Physicians' attitudes toward complementary and alternative medicine and their knowledge of specific therapies: a survey at an academic medical center.

The purpose of this study was to evaluate the attitudes of physicians at an academic medical center toward complementary and alternative medicine (CAM) therapies and the physicians' knowledge base regarding common CAM therapies. A link to a Web-based survey was e-mailed to 660 internists at Mayo Clinic in Rochester, MN, USA. Physicians were asked about their attitudes toward CAM in general and their knowledge regarding specific CAM therapies. The level of evidence a physician would require before incorporating such therapies into clinical care was also assessed. Of the 233 physicians responding to the survey, 76% had never referred a patient to a CAM practitioner. However, 44% stated that they would refer a patient if a CAM practitioner were available at their institution. Fifty-seven percent of physicians thought that incorporating CAM therapies would have a positive effect on patient satisfaction, and 48% believed that offering CAM would attract more patients. Most physicians agreed that some CAM therapies hold promise for the treatment of symptoms or diseases, but most of them were not comfortable in counseling their patients about most CAM treatments. Prospective, randomized controlled trials were considered the level of evidence required for most physicians to consider incorporating a CAM therapy into their practice. The results of this survey provide insight into the attitudes of physicians toward CAM at an academic medical center. This study highlights the need for educational interventions and the importance of providing physicians ready access to evidence-based information regarding CAM.

Journal Article↗

PubMed2006

Splenectomy as part of cytoreductive surgery in ovarian cancer.

OBJECTIVE: Epithelial ovarian carcinoma with extensive upper abdominal disease may require splenectomy for optimal tumor cytoreduction. We describe patients who required splenectomy during tumor reduction procedures for primary or recurrent epithelial ovarian carcinoma. METHODS: Data were abstracted from records of 112 patients who underwent splenectomy as part of primary or secondary cytoreductive surgery. RESULTS: Of 112 patients, 66 had primary and 46 had secondary cytoreduction. Some patients also required bowel resection (50%), formal lymphadenectomy (31%), or urinary tract resection (5%). The most common indications for splenectomy were direct metastatic involvement (46%), facilitation of an en bloc resection of perisplenic disease (41%), and intraoperative trauma (13%). Histologically, 65% had hilar involvement; 52%, capsular involvement; and 16%, parenchymal metastases. Short-term complications included wound infections (7), pneumonias (5), thromboembolic events (9), and sepsis (5). Sepsis was associated with an anastomotic bowel leak in 1 patient, with fungal infections in 2 patients (1 pneumonia and 1 pelvic abscess), and with no identifiable infectious source in 2. Two patients required reoperation for bleeding: 1 for diffuse intraabdominal bleeding, including the splenic bed, and 1 for pelvic sidewall bleeding. The perioperative mortality rate at splenectomy was 5%: 3 from sepsis (1 anastomotic leak, 2 pneumonias), 2 from pulmonary embolism, and 1 for which the precise cause of death was not ascertainable. The primary cytoreduction group had a median survival of 1.8 years, with an estimated 2-year survival rate of 46%. The median survival in the secondary debulking group was 1.7 years, with an estimated 2-year survival of 42%. CONCLUSIONS: In patients with clinically significant upper abdominal disease, splenectomy as part of primary or secondary cytoreductive surgery is associated with modest morbidity and mortality. The risk-benefit ratio of aggressive surgical cytoreduction must be considered.

Adult↗

PubMed2006

Prediction of cardiovascular outcomes with left atrial size: is volume superior to area or diameter?

OBJECTIVES: We sought to compare left atrial (LA) volume to LA area and diameter for the prediction of adverse cardiovascular outcomes. BACKGROUND: The incremental value of LA volume compared with LA area or diameter as a cardiovascular risk marker has not been evaluated prospectively for patients with sinus rhythm or atrial fibrillation (AF). METHODS: Left atrial size was assessed with biplane LA volume, four-chamber LA area, and M-mode dimension for 423 patients (mean age 71 +/- 8 years, 56% men) who were prospectively followed for development of first AF, congestive heart failure, stroke, transient ischemic attack, myocardial infarction, coronary revascularization, and cardiovascular death. RESULTS: Of the 317 subjects in sinus rhythm at baseline, 62 had 90 new events during a mean follow-up of 3.5 +/- 2.3 years. All three LA size parameters were independently predictive of combined outcomes (all p < 0.0001). The overall performance for the prediction of cardiovascular events was greatest for LA volume (area under the receiver operator characteristic curve: indexed LA volume 0.71; LA area 0.64; LA diameter 0.59). A graded association between the degree of LA enlargement and risk of cardiovascular events was only evident for indexed LA volume. For subjects with AF, there was no association between LA size and cardiovascular events. CONCLUSIONS: Left atrial volume is a more robust marker of cardiovascular events than LA area or diameter in subjects with sinus rhythm. The predictive utility of LA size for cardiovascular events in AF was poor, irrespective of the method of LA size quantitation.

Age Factors↗

PubMed2006

Incidence and mortality risk of congestive heart failure in atrial fibrillation patients: a community-based study over two decades.

AIMS: We sought to determine whether the incidence of and survival following congestive heart failure (CHF) in patients with atrial fibrillation (AF) have changed over time. METHODS AND RESULTS: Olmsted County, Minnesota residents diagnosed with first AF during 1980-2000 were identified and followed in medical records to 2004. The trends of incidence and survival of CHF over time were assessed. Of the 3288 subjects (mean age 71+/-15 years) diagnosed with first AF and without CHF prior to or at AF diagnosis, 790 (24%) developed a first CHF during a mean follow-up of 6.1+/-5.2 years (unadjusted incidence, 44 per 1000 person years). Age- and sex-adjusted CHF incidence was unrelated to calendar year of AF diagnosis (P = 0.86). The age- and sex-adjusted mortality risk following CHF was higher than that in patients without CHF (hazard ratio 3.4, 95% confidence interval 3.1-3.8, P < 0.0001). There were no detectable changes over time with respect to the absolute (P = 0.94) or the relative (P = 0.68) mortality risk after CHF diagnosis. CONCLUSION: In this study spanning two decades, there appeared to have been no significant reduction in terms of the incidence and mortality risk of CHF following first AF diagnosis.

Aged↗

PubMed2006

The safety of open inguinal herniorraphy in patients on chronic warfarin therapy.

BACKGROUND: The perioperative management of warfarin therapy increases the complexity of open inguinal herniorraphy. METHODS: One thousand consecutive patients undergoing open inguinal herniorraphy were retrospectively reviewed. Patients on warfarin therapy were categorized into 3 groups: continued warfarin (CW), discontinued warfarin (DW), and discontinued warfarin with anticoagulation bridge (DWB). RESULTS: Eighty-eight patients were on chronic warfarin therapy. Warfarin was continued in 19 patients, discontinued in 54, and discontinued with bridge in 15 patients. Operative times were similar between the 3 groups. Length of stay was longest in the discontinued warfarin with bridge group (CW 0.74, DW 0.54, and DWB 3.33 days; P < .0001). There was no significant difference in postoperative complications. The incidence of surgical site hematoma was higher in the continued warfarin and discontinued warfarin with bridge groups (CW 11%, DW 2%, and DWB 13%; P = .14). CONCLUSIONS: Continuation of warfarin may be a safe alternative to discontinuation of warfarin therapy in select patients undergoing open inguinal herniorraphy.

Aged↗

PubMed2006

Innovative reflecting interview: effect on high-utilizing patients with medically unexplained symptoms.

This pilot study was conducted to determine the effect of an innovative reflecting interview on the health care utilization, physical health, mental function, and health care satisfaction of high-utilizing primary care patients with medically unexplained physical symptoms. Twenty-four high-utilizing patients met study selection criteria and were randomly assigned to a no-intervention control group or a reflecting interview intervention group. Outcomes were measured at 4 weeks, 6 months, and 1 year after the date of study enrollment. Results indicated that high-utilizing patients with medically unexplained physical symptoms who participated in a reflecting interview had reduced total health care costs, primarily through the reduction of hospitalization or inpatient expenses, despite a modest increase in outpatient primary care clinic visits. These data suggest that participation in a reflecting interview and regular visits with a primary care clinician can decrease health care utilization without adversely affecting patient satisfaction.

Adult↗

PubMed2006

Description of a research-based health activism curriculum for medical students.

INTRODUCTION: Few curricula train medical students to engage in health system reform. AIM: To develop physician activists by teaching medical students the skills necessary to advocate for socially equitable health policies in the U.S. health system. SETTING: Montefiore Medical Center, the University Hospital of the Albert Einstein College of Medicine, Bronx, NY. PROGRAM DESCRIPTION: We designed a 1-month curriculum in research-based health activism to develop physician activists. The annual curriculum includes a student project and 4 course sections;health policy, research methods, advocacy, and physician activists as role models; taught by core faculty and volunteers from academic institutions, government, and nongovernmental organizations. PROGRAM EVALUATION: From 2002 to 2005, 47 students from across the country have participated. Students reported improved capabilities to generate a research question, design a research proposal,and create an advocacy plan. DISCUSSION: Our curriculum demonstrates a model for training physician activists to engage in health systems reform.

Curriculum↗

PubMed2006

Efficacy of a simple, low-cost educational intervention in improving knowledge about risks and benefits of screening mammography.

OBJECTIVES: To assess the efficacy of a minimal cost and involvement educational intervention in improving women's knowledge about screening mammography and to explore patient perceptions of the educational intervention. PARTICIPANTS AND METHODS: During the study period (March 10, 2005, to July 1, 2005), 1446 participants in the Mayo Mammography Health Study scheduled for a mammogram within 4 weeks at the Mayo Clinic in Rochester, Minn, were randomized to 2 study groups and mailed surveys about mammograms. The 2 groups received separate surveys; both surveys contained knowledge-based questions about mammography, but the educational intervention group survey also contained qualitative questions that assessed the educational pamphlets. RESULTS: Of the 668 surveys returned (responders), 248 (34.4%) were from the control group, and 420 (58.3%) were from the intervention group. Approximately 80% of responders had had more than 7 prior mammograms. Significant increases in knowledge about mammography were found in the educational intervention compared with the control group on questions regarding age to begin screening mammography (67.9% vs 54.4%; P < .001), recommended frequency of mammograms (86.4% vs 75.4%; P < .001), overall reduction in mortality due to screening mammography (55.2% vs 8.9%; P < .001), and proportions of women who required follow-up mammograms (35.5% vs 14.9%; P < .001) or biopsy (59.5% vs 13.3%; P < .001). Qualitative data results indicated that most women who received the educational intervention found the pamphlets helpful and informative despite having had many previous mammograms. CONCLUSION: The results suggest that providing women scheduled for screening mammograms with physician-approved educational material before their appointment significantly increases knowledge about screening mammography, risks and benefits, and possible follow-up.

Breast Neoplasms↗

PubMed2006

Assessment and diagnosis of attention-deficit/hyperactivity disorder by family physicians.

In this study, our aim was to determine the extent to which family physicians in Minnesota follow the American Academy of Pediatrics (AAP) guideline in the assessment and diagnosis of attention-deficit/hyperactivity disorder (ADHD) in school-aged children and to identify barriers to using the guideline. We surveyed 1,000 randomly chosen members of the Minnesota Academy of Family Physicians. Of 303 respondents, 36% always referred children for a diagnosis and 99.7% referred children for a diagnosis of ADHD some of the time. Fifty-four percent were unaware of the AAP guideline. However, among those who said they evaluate children for ADHD, most followed the criteria in the AAP guideline. For example, most family physicians (97%) used a child's response to stimulant medication in their assessment. Respondents also said that barriers to ADHD assessment included lack of reimbursement and training.

Attention Deficit Disorder with Hyperactivity↗

PubMed2005

Time trends of ischemic stroke incidence and mortality in patients diagnosed with first atrial fibrillation in 1980 to 2000: report of a community-based study.

BACKGROUND AND PURPOSE: With the changes in management of atrial fibrillation (AF) over time, it is possible that the time trends of post-AF stroke incidence and mortality have changed. We sought to determine whether the incidence and survival of ischemic stroke after AF diagnosis have improved. METHODS: We identified the Olmsted County, Minn, residents who developed first AF from 1980 to 2000 and followed them in medical records to 2004. The outcomes were first ischemic stroke and death. RESULTS: Of the 4117 subjects diagnosed with first AF and without previous stroke, 446 (11%) sustained a first ischemic stroke during a mean follow-up time of 5.5+/-5.0 years. The age- and sex-adjusted incidence of stroke decreased, on average, by 3.4% per year (P=0.0001), concurrent with an increase in warfarin and aspirin use (both P<0.0001) and reduction of systolic blood pressure (P<0.001). The age-adjusted ischemic stroke incidence was higher in women (P=0.039), but not after adjusting for systolic blood pressure (P=0.41). Compared with the general Minnesota white population, the relative mortality hazard ratio was 1.88 for men and 1.84 for women without stroke and 3.03 for men and 3.80 for women (P<0.05) with stroke. The relative mortality hazard did not vary by age or calendar year of AF diagnosis. CONCLUSIONS: Post-AF ischemic stroke incidence decreased significantly from 1980 to 2000, during which time a substantial increase in the use of antithrombotic therapy and reduction of systolic blood pressure was evident. The relative mortality risk of stroke, however, had not improved over time.

Adolescent↗

PubMed2005

Excessive fluid accumulation during stem cell mobilization: a novel prognostic factor of first-year survival after stem cell transplantation in AL amyloidosis patients.

High-dose melphalan followed by stem cell transplantation (HDM-SCT) has become the treatment of choice for patients with immunoglobulin light chain amyloidosis (AL). Unfortunately, treatment mortality can be excessive in certain subpopulations. We have noted that patients who gained more than 2% body weight during mobilization had a poorer outcome following HDM-SCT. Excluding 2 patients for lack of weight record and denial of consent, 126 patients between July 1997 and June 2003 were retrospectively studied. Weight increased more than 2.0% during mobilization in 51.6% of the patients. Patients who accumulated more than 2.0% tended to have more proteinuria, more organs involved, lower serum albumin, more diuretic use, and dosage adjustment during mobilization. First-year mortality was significantly higher in those with more than 2% weight gain (33.9% versus 9.8%, P = .002). Multivariate analysis showed weight gain, glomerular filtration rate, and septal thickness to be independent predictors of first-year mortality. The increase in mortality was noted even after the excess weight was diuresed prior to conditioning. The impact on mortality dissipated after the first year. Weight gain during mobilization appears to be a new marker of adverse outcome following HDM-SCT. Better prognostication may improve the treatment mortality rate of these patients.

Adult↗

PubMed2005

Predictors of blood pressure control in patients with diabetes and hypertension seen in primary care clinics.

BACKGROUND: Blood pressure (BP) is not well controlled in the majority of patients with both diabetes and hypertension. This study was designed to identify predictors of BP control in patients with both diabetes and hypertension who are seen in primary care clinics. METHODS: This retrospective study was conducted by identifying a cohort of patients diagnosed with diabetes before January 1, 2000 (inception) who met predefined criteria for hypertension at inception and who received primary care in the ensuing 3-year study period (January 1, 2000, to February 31, 2002). Using the mean of all BP values between January 1, 2002, and December 31, 2002, subjects were divided into two groups: those with controlled BP and those with uncontrolled BP. The distribution of clinical predictors was compared between the two groups. Independent predictors were identified using multivariate logistic regression. RESULTS: Predictors of poor BP control were as follows: 1) isolated systolic hypertension at inception (OR= 0.62, CI = 0.47 to 0.82); 2) uncontrolled BP at inception (OR = 0.71, CI = 0.55 to 0.93); 3) use of oral hypoglycemic drugs versus diet and exercise alone or insulin use (OR = 0.73, CI = 0.56 to 0.95); 4) use of three or more antihypertensive drugs (OR = 0.74, CI = 0.56 to 0.97); and 5) older age (OR = 0.98, CI = 0.97 to 0.99). Predictors of better control were 1) use of nitrates (OR = 1.82, CI = 1.26 to 2.64); 2) history of coronary heart disease (OR = 1.47, CI = 1.08 to 2.00); and 3) at least one annual visit to subspecialist physician (OR = 1.43, CI = 1.09 to 1.88). CONCLUSIONS: Patients with both diabetes and hypertension who are older, have isolated systolic hypertension, use oral hypoglycemic drugs, or use three or more antihypertensive drugs should be targeted for better BP control. The roles of nitrate medication and subspecialist physicians in achieving better BP control needs further study.

Aged↗

PubMed2005

Left atrial index is a predictor of exercise capacity in patients with hypertrophic cardiomyopathy.

BACKGROUND: Left atrial (LA) enlargement is related to diastolic dysfunction and mitral regurgitation (MR), both of which are common in patients with hypertrophic cardiomyopathy (HCM). This study investigates the association between LA size and exercise capacity in patients with HCM. METHODS: All HCM patients who underwent a treadmill test with direct measurement of oxygen consumption (VO2) and a standard transthoracic echocardiography within 30 days in the years 2001-2003 were identified. Patients with significant comorbidities were excluded. Exercise capacity was defined as percentage of predicted peak VO2. Clinical and echocardiographic parameters were compared with those of a group of normal subjects. RESULTS: Compared with normal subjects, HCM patients had increased left atrial (LA) volume index (36 vs 21 mL/m2; P < .0001) and mitral E/e' ratio (14 vs 9; P < .0001); 27% of the patients had at least moderate MR. LA volume index demonstrated borderline correlation with exercise capacity (r = -.20; P = .06) but was an independent predictor of exercise capacity in a multivariate linear analysis, together with body mass index, heart rate at rest, and left ventricular end-systolic diameter. Including the parameters E/e' ratio or moderate or severe MR did not add incremental value to the model. CONCLUSION: LA volume index, reflecting the combined influences of MR and diastolic dysfunction, was independently associated with objective measures of exercise capacity in patients with isolated HCM.

Cardiomyopathy, Hypertrophic↗

PubMed2005

5-Fluorouracil-based chemotherapy for advanced colorectal cancer in elderly patients: a north central cancer treatment group study.

Although 5-fluorouracil (5-FU)-based chemotherapy is commonly used in patients with advanced colorectal cancer (CRC), little data exist on the tolerability and benefit of therapy in elderly patients. To compare toxicity, dose intensity, response rate, time to tumor progression, and overall survival for older and younger patients, we conducted a pooled analysis of 1748 patients, divided into 4 quartile-based age groups, from 4 North Central Cancer Treatment Group trials testing 5-FU with or without leucovorin for advanced CRC. Patients aged > 65 years had modestly higher rates of severe toxicity (grade >/= 3) overall (53% vs. 46%) and higher rates of diarrhea (21% vs. 16%), stomatitis (17% vs. 13%), and infection (4% vs. 2%). Toxicity rates were similar between patients aged 66-70 years and patients aged > 70 years. The response rate did not differ by age group (2-sided; P = 0.90); it was significantly lower for patients with higher performance status scores (30% for score of 0/1; 17% for 2/3; 2-sided; P = 0.001). Performance status, not age, was predictive of time to tumor progression and overall survival. The older patients with CRC treated with 5-FU have modestly higher rates of severe toxicity, mainly diarrhea and stomatitis. Supportive measures to control diarrhea and stomatitis may be particularly important in elderly patients. Age alone should not be used to determine whether older patients are treated, because performance status is predictive of dose intensity, response rate, time to tumor progression, and overall survival.

Aged↗