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PubMed1993

Prognostic significance of bromodeoxyuridine high labeled bladder cancer measured by flow cytometry: does flow cytometric determination predict the prognosis of patients with transitional cell carcinoma of the bladder.

We studied whether flow cytometric determination of proliferative cell activity estimated by the bromodeoxyuridine in vitro labeling technique provides significant prognosticators beyond the classical histological evaluation in the patient with bladder cancer. We evaluated 81 patients with transitional cell carcinoma of the bladder using fresh bladder specimens. Clinical followup of at least more than 24 months was requested, with the mean followup being 37.9 +/- 10.5 months. Tumor grade and stage were the histological prognostic parameters. Flow cytometric bivariate measurements of deoxyribonucleic acid (DNA) ploidy and bromodeoxyuridine labeled cell index were evaluated. Tumors with a bromodeoxyuridine labeled cell index of more than 10.7%, which was the value of the mean plus 2 times the standard deviation obtained in grade 1 bladder tumors, were designated as high bromodeoxyuridine labeled cell index tumors. A total of 51 patients with low bromodeoxyuridine labeled cell index tumors demonstrated a 98.0% 3-year actuarial survival rate estimated by the Kaplan-Meier method, compared to 42.9% for those with high index tumors. Multivariate survival analysis was performed with Cox's proportional regression model to study statistical individual prognostic values of histological and flow cytometric parameters. Histological tumor grade was the single most important prognostic factor (risk ratio 13.2, p < 0.05), with tumor stage being the second most important (risk ratio 9.2, p < 0.05), followed by bromodeoxyuridine labeled cell index status (risk ratio 6.9, p < 0.05). DNA ploidy status did not influence the clinical outcome. When grade 3 tumors were classified as low and/or high bromodeoxyuridine labeled cell index tumors, 3-year actuarial survival rates were 85.7% and 27.3%, respectively. These results indicate that DNA/bromodeoxyuridine bivariate analysis can be used as an effective adjunct to histological examination for prognostication and decision-making in treatment of bladder cancer patients.

Actuarial Analysis↗

PubMed2003

Survival and prognostic factors in patients with ovarian cancer.

OBJECTIVE: To assess incidence during a 10-year study period and to identify and discuss clinical relevance for prognostic factors of survival within a cohort of Norwegian ovarian cancer patients. METHODS: Incidence and prognostic factors of survival within a population-based cohort of ovarian cancer patients from one health region in Norway were examined over the 10-year period 1987 through 1996. A total of 571 histologically verified cases of primary ovarian cancer originally registered either in the Cancer Registry of Norway or in the hospital's discharge registers were included in the study. Pearson chi(2) test was used in univariate analyses of cofactors by 5-year survival, and Kaplan-Meier survival curves were computed and tested statistically by the log rank test. A multivariable proportional hazard model (Cox) was applied to assess the prognostic significance of the different covariates. RESULTS: The incidence and crude 5-year survival remained stable over the 10-year study period. The standardized incidence rate for the time periods 1987-1991 and 1992-1996 was 11.9/100,000 and 12.5/100,000, respectively. The crude 5-year survival rate for the cohort was 39%, whereas median survival was 32 months. Cox multivariable regression analysis showed that the only independent significant prognostic factors were International Federation of Gynecology and Obstetrics stage (P <.001), size of residual tumor at the end of primary surgery (P <.001), and age at diagnosis (P <.01). Variables such as time period, histologic type and grade, treating hospital, comorbidity, or CA 125 were insignificant in predicting 5-year survival. CONCLUSION: The results underline the importance of improved surgical management of ovarian cancer, as residual tumor is the only prognostic factor achievable.

Adult↗

PubMed1995

Prognostic factors and risk group analysis in follicular carcinoma of the thyroid.

BACKGROUND: The understanding of prognostic factors has facilitated stratification of risk groups in differentiated carcinoma of the thyroid. The prognostic factors have clearly identified the risk groups as low, intermediate, and high risk. Risk group categorization has facilitated a selective surgical approach for thyroid carcinoma. METHODS: A retrospective review of 228 patients with follicular carcinoma of the thyroid was undertaken. Various prognostic factors and risk groups were analyzed. Univariate and multivariate analyses were performed, and the survival curves were plotted by the Kaplan-Meier method. Fifty-nine (26%) patients presented with Hürthle cell histology. The risk groups revealed 62 patients in the low, 84 in the intermediate, and 82 in the high risk groups. RESULTS: The 10-year survival for low, intermediate, and high risk groups was 98%, 88%, and 56%, respectively, and the 20-year survival for the same groups was 97%, 87%, and 49%, respectively. Adverse prognostic factors included age older than 45 years (p < 0.001), Hürthle cell variety (p = 0.05), extrathyroidal extension, tumor size exceeding 4 cm, and the presence or absence of distant metastasis (p < 0.001). Gender, focality, and presence of lymph node metastasis had no significant impact on prognosis. CONCLUSIONS: Patients in the low risk group have excellent survival, whereas the high risk group behaves poorly. Appropriate selection of treatment for the primary disease and adjuvant therapy should be considered on the basis of the prognostic factors and risk group analysis.

Adenocarcinoma, Follicular↗

PubMed1996

Overexpression of p53 protein and DNA content are important biologic prognostic factors for thyroid cancer.

BACKGROUND: Many factors gave been reported to be of prognostic importance for thyroid cancer. Biologic aggressiveness may influence postoperative recurrences and the prognosis of thyroid cancer. Immunohistochemical staining for the p53 protein and DNA content are novel factors that suggest biologic aggressiveness. METHODS: Retrospective study of the survival rate after operation of differentiated thyroid cancer was undertaken at Osaka Police Hospital. Age, gender operative method, extent of lymph node dissection, use of radioiodine, primary or recurrent tumor, tumor size and invasion, lymph node involvement, presence of distant metastases, DNA ploidy, percentage of S phase and G2M phase fractions, positive staining for the p53 protein, and histologic type and subtype were evaluated as possible prognostic factors by univariate and multivariate analyses of survival. RESULTS: Positive staining for the p53 protein was related to postoperative local recurrence, and DNA ploidy was related to distant metastatic recurrence. Univariate analysis suggested that age, tumor size and invasion, lymph node involvement, presence of distant metastases, percentage of S phase fraction, histologic subtype, DNA ploidy, and positive staining for the p53 protein were significant prognostic factors. Multivariate analysis suggested that positive staining of the protein and DNA ploidy were independent prognostic factors for overall survival. CONCLUSIONS: Both positive staining for the p53 protein and DNA ploidy, which suggest biologic aggressiveness, are independent prognostic factors for overall survival of patients with thyroid cancer, Examination of these biologic factors may provide new information regarding postoperative recurrences and the prognosis of thyroid cancer.

Aged↗

PubMed1997

Prognostic value of p53 in non-small cell lung cancer: relationship with proliferating cell nuclear antigen and cigarette smoking.

p53 mutations are among the most frequent genetic alterations reported in human lung cancer. Although the prognostic value of altered p53 expression is still debated, it is accepted widely that estimation of the proliferation rate has an important prognostic role. Moreover, an association between certain types of human lung cancers and tobacco use is well known. Drawing from this background, we investigated the immunohistochemical expression of mutant oncogenic p53 protein, and related it to the smoking history of 61 patients with non-small cell lung carcinoma (NSCLC) and to the expression pattern of proliferating cell nuclear antigen (PCNA), which is considered to be an important negative prognostic factor in several neoplasms. We found p53 overexpression in 22 (36.1%) specimens, including 16 squamous carcinomas (41%) and six (27.2%) adenocarcinomas. PCNA nuclear staining was detected in 98.4% of the specimens, and a significantly higher PCNA expression score was found in all of the p53-positive samples. When the patient survival time was compared, p53 accumulation had a statistically significant negative prognostic value (P < .001). This was supported by a Kaplan-Meier survival percentage plot of immunohistochemically p53-undetectable specimens and p53-detectable specimens. These latter patients had a greatly reduced survival time. A relationship was established between p53 immunohistochemical detection and the smoking history of the patients. None of the specimens from the nonsmoking patients expressed immunohistochemically detectable p53 protein. Altered p53 expression was detected in 40.7% of smoking patients. Our findings support the hypothesis of involvement of p53 mutations in tobacco-induced carcinogensis and indicate that altered p53 expression plays an important prognostic role in NSCLC in smokers.

Biomarkers, Tumor↗

PubMed2001

Prognostic assessment of nonmetastatic renal cell carcinoma: a clinically based model.

OBJECTIVES: Determining the recurrence risk in patients treated for renal cell carcinoma (RCC) is important for providing prognostic information and planning potential surveillance strategies. The pathologic stage has been the most widely used single prognostic variable. However, with minimally invasive treatment modalities, the pathologic stage may not be readily available. We developed a biostatistical prognostic model for postoperative RCC that is independent of the pathologic stage. METHODS: The records of 296 patients who underwent open nephrectomy for RCC at Johns Hopkins Hospital between 1990 and 1999 were reviewed. Cox proportional hazards regression analysis was used to generate a prognostic model. RESULTS: The recurrence risk (R(rec)) was determined from this model: R(rec)=1.55 x presentation (0-1)+0.19 x clinical size (in centimeters). Using this equation, 79% of patients were identified as low risk compared with 45% of patients considered low risk by pathologic stage (pT1). Moreover, the separation between the high and low-risk survival curves increased. CONCLUSIONS: This model is the first to our knowledge that uses purely clinical variables to assess the postoperative prognosis in patients with RCC. These results, although not validated, provide substantial evidence that preoperative clinical variables may be used instead of the pathologic stage to determine the risk of recurrence. Uncoupling the reliance on pathologic stage for prognostic information removes a potential barrier to novel minimally invasive treatments for renal malignancy and provides a standard to which observation protocols can be compared. In the future, this model may facilitate selection of appropriate patients for less toxic adjuvant or neoadjuvant therapies.

Aged↗

PubMed2002

Prognostic-factors-based risk-stratification model for invasive urothelial carcinoma of the urinary bladder in Taiwan.

Objectives. To develop a prognostic-factors-based predictive model for invasive urothelial carcinoma of the urinary bladder derived from statistical comparison of clinical characteristics.Methods. The medical records for patients with invasive urinary bladder urothelial carcinoma were reviewed. Clinical data for age, sex, serum lactate dehydrogenase, creatinine, albumin, alkaline phosphatase, alanine aminotransferase, total bilirubin and hemoglobin levels, white blood cell and platelet counts, positive urine cytology, Eastern Cooperative Oncology Group performance status score, tumor size, histologic grading, T stage, presence of lymph node metastases, squamous differentiation, hydronephrosis, prostatic involvement, Charlson comorbidity index, surgical procedures, and adjuvant chemotherapy status were recorded. Univariate and multivariate analyses were performed to test independent factors for prediction of survival and disease recurrence.Results. After univariate and multivariate analyses, six independent prognostic factors were found: T stage, grading, prostatic involvement, Eastern Cooperative Oncology Group performance status score, and pretreatment serum creatinine and albumin levels. A scoring system was developed on the basis the relative risk associated with the proposed prognostic factors and patients were stratified into three groups according to their scores, with statistically significant prognostic differences revealed for each of the between-group comparisons. Independent factors affecting recurrence-free survival and best predicted disease recurrence were pretreatment serum creatinine, T stage, and surgical procedure.Conclusions. This prognostic-factors-based risk-stratification model for invasive urothelial carcinoma of the urinary bladder may help clinicians predict outcome and select the most appropriate therapeutic modalities. The incidence of recurrent disease is significantly higher for patients with poor renal function before treatment or advanced T stage and those undergoing transurethral tumor resection instead of radical cystectomy.

Aged↗

PubMed2000

Prognostic value of nuclear morphometry on needle biopsy from patients with prostate cancer: is volume-weighted mean nuclear volume superior to other morphometric parameters?

OBJECTIVES: To compare the prognostic value of stereologically estimated volume-weighted mean nuclear volume (MNV) with other nuclear morphometric parameters using pretreatment needle-biopsy specimens of prostate cancer. METHODS: The MNV, mean nuclear area, form factor, and coefficients of variation for nuclear area (VNA) and form factor were measured on pretreatment needle biopsy specimens from 66 patients with prostate cancer (clinical Stage B, n = 9; Stage C, n = 14; and Stage D, n = 43), all of whom underwent androgen deprivation therapy. The prognostic value of those morphometric parameters, as well as Gleason score and clinical stage, was examined in terms of cause-specific patient survival using univariate and multivariate analysis (Cox proportional hazard model). RESULTS: Univariate analysis of the nuclear morphometric parameters revealed that MNV, mean nuclear area, VNA, coefficient of variation for form factor, and clinical stage were significant prognostic factors for cause-specific patient survival. However, when the patients with Stage D disease were selectively analyzed for survival, only the VNA was a significant prognostic parameter. Furthermore, the multivariate analysis, including the morphometric parameters, clinical stage, and Gleason score revealed that only VNA and clinical stage were independent variables. CONCLUSIONS: The present comparative study could not demonstrate any prognostic superiority of MNV over other nuclear morphometric parameters in patients with prostate cancer.

Aged↗

PubMed2001

Prognostic importance of degree of differentiation and cyst rupture in stage I invasive epithelial ovarian carcinoma.

BACKGROUND: Previous studies on prognostic factors in stage I invasive epithelial ovarian carcinoma have been too small for robust conclusions to be reached. We undertook a retrospective study in a large international database to identify the most important prognostic variables. METHODS: 1545 patients with invasive epithelial ovarian cancer (International Federation of Gynaecology and Obstetrics [FIGO] stage I) were included. The records of these patients were examined and data extracted for univariate and multivariate analysis of disease-free survival in relation to various clinical and pathological variables. FINDINGS: The multivariate analyses identified degree of differentiation as the most powerful prognostic indicator of disease-free survival (moderately vs well differentiated hazard ratio 3.13 [95% CI 1.68-5.85], poorly vs well differentiated 8.89 [4.96-15.9]), followed by rupture before surgery (2.65 [1.53-4.56]), rupture during surgery (1.64 [1.07-2.51]), FIGO 1973 stage Ib vs Ia 1.70 [1.01-2.85]) and age (per year 1.02 [1.00-1.03]). When the effects of these factors were accounted for, none of the following were of prognostic value: histological type, dense adhesions, extracapsular growth, ascites, FIGO stage 1988, and size of tumour. INTERPRETATION: Degree of differentiation, the most powerful prognostic indicator in stage I ovarian cancer, should be used in decisions on therapy in clinical practice and in the FIGO classification of stage I ovarian cancer. Rupture should be avoided during primary surgery of malignant ovarian tumours confined to the ovaries.

Cell Differentiation↗

PubMed2006

A prognostic index for AIDS-associated Kaposi's sarcoma in the era of highly active antiretroviral therapy.

BACKGROUND: AIDS-associated Kaposi's sarcoma remains common in individuals with HIV-1 infection in the era of highly active antiretroviral therapy (HAART). We developed a simple model for predicting mortality on the basis of clinical characteristics present at the time of diagnosis of Kaposi's sarcoma. METHODS: Of 5873 individuals with HIV-1 infection, 326 (6%) developed Kaposi's sarcoma; for 262 (80%) this was their first AIDS-defining illness. We did univariate and multivariate Cox regression analyses to identify covariates predictive of overall survival and validated our model with an independent data set of 446 patients with Kaposi's sarcoma. RESULTS: In the primary model, we developed a prognostic score from 0 to 15 starting at 10. Having Kaposi's sarcoma as the AIDS-defining illness (-3 points) and increasing CD4 count (-1 point for every complete 100 cells per mm3) improved prognosis; age of 50 years or older (2 points) and having another AIDS-associated illness at the same time (3 points) conveyed a poorer prognosis. In individuals with prognostic scores of 0, 5, 10, and 15, probability of survival at 1-year was 0.993, 0.967, 0.834, and 0.378, and at 5 years was 0.984, 0.918, 0.631, and 0.084, respectively. Increasing prognostic score by 1 increased 1-year death hazard ratio by 40% (95% CI 28-53%; bootstrapped hazard ratio 1.39, 1.25-1.51). The index had concordance of 76.8% (71.7-82.3). INTERPRETATION: We identified four prognostic factors that can be used to obtain an accurate prognostic index at diagnosis of AIDS-associated Kaposi's sarcoma. This index is widely applicable and can be used to guide therapeutic options.

AIDS-Related Opportunistic Infections↗

PubMed2001

A prognostic model for predicting survival in cirrhosis with ascites.

BACKGROUND/AIMS: Parameters evaluating renal function and systemic hemodynamics are of prognostic significance in cirrhosis with ascites but are rarely used in the evaluation of survival of these patients. The aim of the current study was to develop a prognostic model to estimate survival of patients with cirrhosis and ascites. METHODS: 216 Cirrhotic patients admitted to hospital for the treatment of ascites were evaluated. Thirty-two demographic, clinical and laboratory variables, including parameters assessing liver and renal function and systemic hemodynamics, were analyzed as predictive factors of survival by using a Cox regression model. RESULTS: Four variables had independent prognostic value: renal water excretion, as assessed by measuring diuresis after water load, mean arterial pressure, Child-Pugh class, and serum creatinine. According to these features a prognostic index was calculated that allows to estimate survival in patients with cirrhosis and ascites. The model accurately predicted survival in an independent series of 84 patients with cirrhosis and ascites. CONCLUSION: A prognostic model that uses four easily available variables and predicts prognosis in cirrhotic patients with ascites has been developed. This model may be useful in the evaluation of patients with ascites for liver transplantation.

Ascites↗

PubMed1999

Optimal timing of liver transplantation for patients with primary biliary cirrhosis: use of prognostic modelling.

BACKGROUND/AIMS: Liver transplantation remains the only definitive treatment for patients with end-stage primary biliary cirrhosis, although the optimal timing of the procedure remains uncertain. The aim of the study was to use prognostic modelling to determine the optimal timing of transplantation for patients with primary biliary cirrhosis. METHODS: A prognostic model for predicting the survival of patients after transplantation was generated using the Cox regression model with data from 312 patients transplanted for primary biliary cirrhosis at the Queen Elizabeth Hospital, Birmingham. The prognosis after transplantation was compared to that without transplantation (using a previously published prognostic index for non-transplantation) both in these patients and in 98 non-transplanted primary biliary cirrhosis patients dying from the liver disease, in order to establish at what stage the prognosis with transplantation was better than without transplantation. RESULTS: The prognostic index for transplantation included the following significant prognostic variables: serum bilirubin, serum albumin, age, year of transplantation, and the presence of ascites or treatment with diuretics. Comparison of prognosis with and without transplantation showed that the predicted gain in survival after transplantation becomes increasingly positive when the 6-month survival probability in the absence of transplantation falls below 0.85. In the non-transplanted patients this occurs on average about 8 months before death. CONCLUSIONS: Comparison of the prognosis with and without transplantation provides a rational method for determining the optimum timing of the procedure which occurs approximately when the predicted 6-month survival probability without transplantation falls below 0.85.

Female↗

PubMed2001

Bcl-2 is an independent prognostic factor and adds to a biological model for predicting outcome in operable non-small cell lung cancer.

INTRODUCTION: The underlying biology of a tumour may hold the key to predicting the outcome for an individual patient as well as identifying potential therapeutic targets. Using epidermal growth factor receptor (EGFR) and matrix metalloproteinase (MMP)-9 immunoexpression combined with microvessel counts we have developed a prognostic model for operable non-small cell lung cancer (NSCLC) which predicts outcome independent of stage (Thorax, 56 (2001) 561-566). The aim of this study was to evaluate the impact of bcl-2 expression upon survival in this model. METHODS: This was a retrospective analysis of 167 patients with resected stage I-IIIa NSCLC and >60 days post-operative survival. Minimum follow-up was 2 years. Immunohistochemistry was performed on paraffin-embedded tissue sections for bcl-2, EGFR, MMP-9 and the microvessel marker CD34 to evaluate the relationships between, and impact on survival of these biological markers. RESULTS: Tumour cell MMP-9 (P=0.002), microvessel count > median (P=0.01), bcl-2 (P=0.02) and stage (P=0.02) were independent prognostic factors. Bcl-2 expression was associated with an improved survival in all sub-groups of our prognostic model. CONCLUSION: bcl-2, EGFR and MMP-9 expression and angiogenesis provide prognostic information independent of TNM stage. Prognostic models offer the potential of tailoring the therapeutic management for an individual patient.

Adult↗

PubMed2002

Prognostic significance of p53, Ki-67, VEGF and Glut-1 in resected stage I adenocarcinoma of the lung.

OBJECTIVES: The purpose of this study was to evaluate the prognostic significance of various biological factors in patients with resected stage I adenocarcinoma. METHODS: We immunohistochemically examined 47 specimens of surgically resected adenocarcinomas to evaluate the expression of the biological markers p53, Ki-67, vascular endothelial growth factor (VEGF) and glucose transporter-1 (Glut-1). Angiogenesis grade and tumor vessel invasion was also investigated. Actuarial survival was analyzed by the Kaplan-Meier method. Clinical variables and biological markers were analyzed using the Cox's proportional hazards model for multivariate analysis to identify independent prognostic factors. RESULTS: The overall survival rate for the whole series was 85.1% at 3 years and 71.9% at 5 years, with a median survival time of 73 months. Differentiation, Ki-67, Glut-1, VEGF, tumor vessel invasion and microvessel density (MVD) were significant prognostic factors by univariate analysis, with Glut-1 expression the most important prognostic factor for survival (P<0.0001). After multivariate analysis, only Glut-1 expression remained as a prognostic factor for survival. CONCLUSION: Glut-1 expression can be a predictor for prognosis in patients with resected stage I adenocarcinoma of the lung.

Adenocarcinoma↗

PubMed1997

Prognostic factors and evaluation of mycosis fungoides and Sézary syndrome.

BACKGROUND: Staging evaluations of patients with mycosis fungoides (MF) and Sézary syndrome (SS) are performed to individualize therapy and to predict survival. OBJECTIVE: Our purpose was to determine the prognostic factors in patients with MF and SS. METHODS: A retrospective study of 101 patients was performed. For inclusion in the study, patients had to have been evaluated for MF or SS within 6 months of the initial definitive histologic diagnosis. The evaluation included physical examination, chest radiograph, peripheral blood smear, lymph node biopsy, bone marrow biopsy, gallium 67 scan, liver-spleen scan and computed tomography (CT) of the chest, abdomen, and pelvis. RESULTS: The type of skin disease present at initial diagnosis was a good prognostic indicator of survival and clinical outcome. Univariate adverse prognostic features included hepatosplenomegaly or adenopathy by CT scan, abnormal liver-spleen scan, abnormal gallium scan, adenopathy, and peripheral blood, bone marrow, and lymph node involvement. Independent prognostic factors in multivariate analysis were the type of skin involvement as well as peripheral blood and visceral involvement. CONCLUSION: Our study confirms previous reports that type of skin and peripheral blood and visceral involvement are important prognostic factors in patients with MF or SS. Our results support the finding that patients with T1 stage disease have an excellent survival outlook and clinical outcome.

Bone Marrow↗

PubMed2006

[Prognostic factor and prediction tables for clinically localized prostate cancer].

INTRODUCTION AND OBJECTIVES: To identify the independent prognostic factors of prostate cancer and to develop a table for predicting the probabilities of not-localised prostate cancer occurrence, thus permitting to restrict the radical prostatectomy indication to those patients who have greater probabilities of being cured by the procedure. METHODS: 1293 patients with clinically localised prostate cancer, with histories of neither hormone therapy nor prostate radiation therapy, in whom radical prostatectomy was performed during the period 1990-2003, were retrospectively evaluated. In order to analyse the prognostic factors, logistic regression was carried out by studying all the potential confusion and interaction factors, and by introducing the independent variables in a forward fashion with the following criteria: BCON(0.0001) LCON(0.00001) ITER(50) POUT(0.1). The prognostic variables were categorised, and the prediction table of the not-localised prostate cancer probability was developed from them. RESULTS: Clinical stage, prostatic specific antigen and Gleason's "grade" were identified as prognostic factors, taking into account that the higher they are, the higher the probability of not-localised prostate cancer occurrence. Logistic regression enabled us to develop a table to predict the probability of not-localised prostate cancer in which, taking a 50% probability as the cutoff point, a 26.13% sensitivity and a 94.65% specificity are obtained. The pathological examination of the prostate and the lymphadenectomy showed that, globally, 70% of the tumours were localised. CONCLUSIONS: Application of tables to predicting the probability of having not-localised prostate cancer offers the possibility of improving the prognostic accuracy of the so-called "risk groups", and enables to issue a therapeutic indication better adjusted to the actual status of the disease.

Adult↗

PubMed2003

Prognostication and intensive care unit outcome: the evolving role of scoring systems.

Prognostic scoring systems remain important in clinical practice. They enable us to characterize our patient populations with robust measures for predicted mortality. This allows us to audit our own experience in the context of institutional quality control measures and facilitates, albeit imperfectly, comparisons across units and patient populations. Practically, they provide an objective means to characterize case-mix and this helps to quantify resource needs when negotiating with hospital administrators for funding. Prognostic scores also help to stratify patient populations for research purposes. To be used accurately and effectively, one must have a good understanding of the limitations that are intrinsic to these prognostic systems. It is important to understand the details of their derivation and validation. The population of patients that is used to develop the models may not be relevant to your patient population. The model may have been derived several years before and may no longer reflect current practice patterns and treatment. These models may become obsolete over time. As with all scoring systems, there are potential problems with misclassification and more serious, systematic error, in data collection. One needs to rigorously adhere to guidelines about how these data are to be collected and processed; the persons who collect the data require regular updates and ongoing training. In their current form, the systems should not be used to prognosticate in individual patients, nor should they be used to define medical futility. The prognostic models should be viewed as being in evolution. Many patient and ICU characteristics that seem to have an important impact on mortality have yet to be incorporated into any of the current models. As an example, these may include the genetic characteristics of the patients and the ICU's organizational structure and process of care [51, 52]. Because the organ dysfunction measures are able to be obtained daily they give a much more complete understanding of the patient's entire ICU course as opposed to the initial 24-hour period. Daily scores also help to capture the intensity of resource use and may help us gain a better understanding of what is truly ICU-acquired organ dysfunction. These measures may also be used for research to better characterize the natural history and course of a certain disease group or population. Also, they may be used in innovative ways to predict ICU mortality and post-ICU long-term morbidity. These current and developing applications will help us to further understand the link between ICU severity of illness and long-term morbidity as we move beyond survival as the sole measure of ICU outcome.

APACHE↗

PubMed2003

[Prognostic value of serum levels of tumor necrosis factor-alpha in patients with heart failure].

INTRODUCTION AND OBJECTIVE: Tumor necrosis factor-alpha is an inflammatory cytokine which rises in heart failure and has prognostic value in severe cases. Its value is less established in moderate cases. Our aim was to determine its prognostic value in cases from a community hospital. PATIENTS: We studied 50 patients, average age 59.5 12.3 years, with dilated cardiomyopathy (72% non-ischemic) and moderate heart failure (59% functional class II). METHODS: Patients were evaluated with an echocardiogram and cardiopulmonary treadmill stress test (Naughton), muscular strength measurements (hand dynamometer), blood tumor necrosis factor levels, and an average follow-up of 17.5 9 months (range, 1-29 months). All causes of mortality, cardiac transplantation, and readmissions for heart failure were recorded. RESULTS: Twenty-three patients experienced events. These patients were older (63 +/- 12.7 vs 55.7 +/- 11.4 years; p = 0.042), had a lower peak VO2 (13.7 +/- 3.9 vs 16 +/- 3.3 ml/kg/min; p = 0.035), and higher peak VE/VCO2 and factor levels [41.9 +/- 10.6 vs 33.2 +/- 5.7; p = 0.001 and 4.3 (3.1-7.9) vs 3.3 (2.4-4.3) pg/ml; p = 0.021, respectively]. In the Cox model, the only variable with independent prognostic value was peak VE/VCO2 [HR 1.13 (1.07-1.19); p < 0.001]. The best cutoff point was 34.5 (sensitivity, 86.4%; specificity, 58.3%; p = 0.0007). The cytokine had no independent prognostic value. CONCLUSIONS: Our patients with events were older, had a lower peak VO2, and higher peak VE/VCO2 and serum tumor necrosis factor levels. However, only peak VE/VCO2 had independent prognostic value.

Body Mass Index↗