Final Results of a Prospective Evaluation of the Predictive Value of Interim Positron Emission Tomography in Patients With Diffuse Large B-Cell Lymphoma Treated With R-CHOP-14 (SAKK 38/07)

PURPOSE Our main objective was to prospectively determine the prognostic value of [(18)F]fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT) after two cycles of rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone given every 14 days (R-CHOP-14) under standardized treatment and PET evaluation criteria. PATIENTS AND METHODS Patients with any stage of diffuse large B-cell lymphoma were treated with six cycles of R-CHOP-14 followed by two cycles of rituximab. PET/CT examinations were performed at baseline, after two cycles (and after four cycles if the patient was PET-positive after two cycles), and at the end of treatment. PET/CT examinations were evaluated locally and by central review. The primary end point was event-free survival at 2 years (2-year EFS). RESULTS Median age of the 138 evaluable patients was 58.5 years with a WHO performance status of 0, 1, or 2 in 56%, 36%, or 8% of the patients, respectively. By local assessment, 83 PET/CT scans (60%) were reported as positive and 55 (40%) as negative after two cycles of R-CHOP-14. Two-year EFS was significantly shorter for PET-positive compared with PET-negative patients (48% v 74%; P = .004). Overall survival at 2 years was not significantly different, with 88% for PET-positive versus 91% for PET-negative patients (P = .46). By using central review and the Deauville criteria, 2-year EFS was 41% versus 76% (P < .001) for patients who had interim PET/CT scans after two cycles of R-CHOP-14 and 24% versus 72% (P < .001) for patients who had PET/CT scans at the end of treatment. CONCLUSION Our results confirmed that an interim PET/CT scan has limited prognostic value in patients with diffuse large B-cell lymphoma homogeneously treated with six cycles of R-CHOP-14 in a large prospective trial. At this point, interim PET/CT scanning is not ready for clinical use to guide treatment decisions in individual patients.

Diagnostic value of immunoassays for heparin-induced thrombocytopenia: a systematic review and meta-analysis.

Immunoassays are essential in the workup of patients with suspected heparin-induced thrombocytopenia. However, the diagnostic accuracy is uncertain with regard to different classes of assays, antibody specificities, thresholds, test variations, and manufacturers. We aimed to assess diagnostic accuracy measures of available immunoassays and to explore sources of heterogeneity. We performed comprehensive literature searches and applied strict inclusion criteria. Finally, 49 publications comprising 128 test evaluations in 15 199 patients were included in the analysis. Methodological quality according to the revised tool for quality assessment of diagnostic accuracy studies was moderate. Diagnostic accuracy measures were calculated with the unified model (comprising a bivariate random-effects model and a hierarchical summary receiver operating characteristics model). Important differences were observed between classes of immunoassays, type of antibody specificity, thresholds, application of confirmation step, and manufacturers. Combination of high sensitivity (>95%) and high specificity (>90%) was found in 5 tests only: polyspecific enzyme-linked immunosorbent assay (ELISA) with intermediate threshold (Genetic Testing Institute, Asserachrom), particle gel immunoassay, lateral flow immunoassay, polyspecific chemiluminescent immunoassay (CLIA) with a high threshold, and immunoglobulin G (IgG)-specific CLIA with low threshold. Borderline results (sensitivity, 99.6%; specificity, 89.9%) were observed for IgG-specific Genetic Testing Institute-ELISA with low threshold. Diagnostic accuracy appears to be inadequate in tests with high thresholds (ELISA; IgG-specific CLIA), combination of IgG specificity and intermediate thresholds (ELISA, CLIA), high-dose heparin confirmation step (ELISA), and particle immunofiltration assay. When making treatment decisions, clinicians should be a aware of diagnostic characteristics of the tests used and it is recommended they estimate posttest probabilities according to likelihood ratios as well as pretest probabilities using clinical scoring tools.

Incremental Value of the CRUSADE, ACUITY, and HAS-BLED Risk Scores for the Prediction of Hemorrhagic Events After Coronary Stent Implantation in Patients Undergoing Long or Short Duration of Dual Antiplatelet Therapy

BACKGROUND Multiple scores have been proposed to stratify bleeding risk, but their value to guide dual antiplatelet therapy duration has never been appraised. We compared the performance of the CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the ACC/AHA Guidelines), ACUITY (Acute Catheterization and Urgent Intervention Triage Strategy), and HAS-BLED (Hypertension, Abnormal Renal/Liver Function, Stroke, Bleeding History or Predisposition, Labile INR, Elderly, Drugs/Alcohol Concomitantly) scores in 1946 patients recruited in the Prolonging Dual Antiplatelet Treatment After Grading Stent-Induced Intimal Hyperplasia Study (PRODIGY) and assessed hemorrhagic and ischemic events in the 24- and 6-month dual antiplatelet therapy groups. METHODS AND RESULTS Bleeding score performance was assessed with a Cox regression model and C statistics. Discriminative and reclassification power was assessed with net reclassification improvement and integrated discrimination improvement. The C statistic was similar between the CRUSADE score (area under the curve 0.71) and ACUITY (area under the curve 0.68), and higher than HAS-BLED (area under the curve 0.63). CRUSADE, but not ACUITY, improved reclassification (net reclassification index 0.39, P=0.005) and discrimination (integrated discrimination improvement index 0.0083, P=0.021) of major bleeding compared with HAS-BLED. Major bleeding and transfusions were higher in the 24- versus 6-month dual antiplatelet therapy groups in patients with a CRUSADE score >40 (hazard ratio for bleeding 2.69, P=0.035; hazard ratio for transfusions 4.65, P=0.009) but not in those with CRUSADE score ≤40 (hazard ratio for bleeding 1.50, P=0.25; hazard ratio for transfusions 1.37, P=0.44), with positive interaction (Pint=0.05 and Pint=0.01, respectively). The number of patients with high CRUSADE scores needed to treat for harm for major bleeding and transfusion were 17 and 15, respectively, with 24-month rather than 6-month dual antiplatelet therapy; corresponding figures in the overall population were 67 and 71, respectively. CONCLUSIONS Our analysis suggests that the CRUSADE score predicts major bleeding similarly to ACUITY and better than HAS BLED in an all-comer population with percutaneous coronary intervention and potentially identifies patients at higher risk of hemorrhagic complications when treated with a long-term dual antiplatelet therapy regimen. CLINICAL TRIAL REGISTRATION URL: http://clinicaltrials.gov. Unique identifier: NCT00611286.

Decomposing speed of information processing in elementary cognitive tasks

Many studies obtained reliable individual differences in speed of information processing (SIP) as measured by elementary cognitive tasks (ECTs). ECTs usually employ response times (RT) as measure of SIP, but different ECTs target different cognitive processes (e.g., simple or choice reaction, inhibition). Here we used modified versions of the Hick and the Eriksen Flanker task to examine whether these tasks assess dissociable or common aspects of SIP. In both tasks, task complexity was systematically varied across three levels. RT data were collected from 135 participants. Applying fixed-links modeling, RT variance increasing with task complexity was separated from RT variance unchanging across conditions. For each task, these aspects of variance were represented by two independent latent variables. The two latent variables representing RT variance not varying with complexity of the two tasks were virtually identical (r = .83). The latent variables representing increasing complexity in the two tasks were also highly correlated (r = .72) but clearly dissociable. Thus, RT measures contain both task-unspecific, person-related aspects of SIP as well as task-specific aspects indicating the cognitive processes manipulated with the respective task. Separating these aspects of SIP facilitates the interpretation of individual differences in RT.

Legal Change and the Social Value of Lawsuits

This paper integrates the literatures on the social value of lawsuits, the evolution of the law, and judicial preferences to evaluate the hypothesis that the law evolves toward efficiency. The setting is a simple accident model with costly litigation where the efficient law minimizes the sum of accident plus litigation costs. In the steady state equilibrium, the distribution of legal rules is not necessarily efficient but instead depends on a combination of selective litigation, judicial bias, and precedent.

A Note on the Social versus Private Value of Suits when Care is Bilateral

This paper re-examines the social versus private value of lawsuits when both injurers and victims can take care. The basic conclusions of that literature remain valid in this context: the private and social values generally differ, and there is no necessary relationship between them, meaning that there may be either too many or too few suits. Introducing the possibility of victim care does, however, alter the calculation of the deterrent effect of lawsuits. In particular, because allowing suits tends to reduce the incentives for victims to invest in precaution, the social value of prohibiting suits increases in direct relation to the productivity of victim care in lowering accident risk.

The diagnostic value of a 12-lead electrocardiogram in patients with cardiac tamponade due to a malignant pericardial effusion

Background. Cardiac tamponade can occur when a large amount of fluid, gas, singly or in combination, accumulating within the pericardium, compresses the heart causing circulatory compromise. Although previous investigators have found the 12-lead ECG to have a poor predictive value in diagnosing cardiac tamponade, very few studies have evaluated it as a follow up tool for ruling in or ruling out tamponade in patients with previously diagnosed malignant pericardial effusions. ^ Methods. 127 patients with malignant pericardial effusions at the MD Anderson Cancer Center were included in this retrospective study. While 83 of these patients had a cardiac tamponade diagnosed by echocardiographic criteria (Gold standard), 44 did not. We computed the sensitivity (Se), specificity (Sp), positive (PPV) and negative predictive values (NPV) for individual and combinations of ECG abnormalities. Individual ECG abnormalities were also entered singly into a univariate logistic regression model to predict tamponade. ^ Results. For patients with effusions of all sizes, electrical alternans had a Se, Sp, PPV and NPV of 22.61%, 97.61%, 95% and 39.25% respectively. These parameters for low voltage complexes were 55.95%, 74.44%, 81.03%, 46.37% respectively. The presence of all three ECG abnormalities had a Se = 8.33%, Sp = 100%, PPV = 100% and NPV = 35.83% while the presence of at least one of the three ECG abnormalities had a Se = 89.28%, Sp = 46.51%, PPV = 76.53%, NPV = 68.96%. For patients with effusions of all sizes electrical alternans had an OR of 12.28 (1.58–95.17, p = 0.016), while the presence of at least one ECG abnormality had an OR of 7.25 (2.9–18.1, p = 0.000) in predicting tamponade. ^ Conclusions. Although individual ECG abnormalities had low sensitivities, specificities, NPVs and PPVs with the exception of electrical alternans, the presence of at least one of the three ECG abnormalities had a high sensitivity in diagnosing cardiac tamponade. This could point to its potential use as a screening test with a correspondingly high NPV to rule out a diagnosis of tamponade in patients with malignant pericardial effusions. This could save expensive echocardiographic assessments in patients with previously diagnosed pericardial effusions. ^

A framework for demonstrating the value of human services

Tanto profesionales como quienes tienen a su cargo diferentes servicios están de acuerdo en que la evaluación es importante. Sin embargo, los orientadores rara vez evalúan su trabajo de manera de hallar una relación causal entre los servicios que los usuarios reciben y los cambios a los que acceden. Se ha desarrollado un marco teórico para evaluar los cambios en los conocimientos, habilidades, actitudes y creencias del usuario y examinar el impacto que dichos cambios han hecho en su vida y en la sociedad en la que se desenvuelve. El marco incluye también un sistema de seguimiento de las intervenciones realizadas y de los recursos necesarios para poder implementar exitosamente estas acciones. Ha sido empleado en diversas situaciones orientadoras, establecimientos educativos y acciones de orientación vocacional, con el objeto de proporcionar evidencia de que el servicio brindado realmente produce un impacto sobre la vida del usuario.

A framework for demonstrating the value of human services

Tanto profesionales como quienes tienen a su cargo diferentes servicios están de acuerdo en que la evaluación es importante. Sin embargo, los orientadores rara vez evalúan su trabajo de manera de hallar una relación causal entre los servicios que los usuarios reciben y los cambios a los que acceden. Se ha desarrollado un marco teórico para evaluar los cambios en los conocimientos, habilidades, actitudes y creencias del usuario y examinar el impacto que dichos cambios han hecho en su vida y en la sociedad en la que se desenvuelve. El marco incluye también un sistema de seguimiento de las intervenciones realizadas y de los recursos necesarios para poder implementar exitosamente estas acciones. Ha sido empleado en diversas situaciones orientadoras, establecimientos educativos y acciones de orientación vocacional, con el objeto de proporcionar evidencia de que el servicio brindado realmente produce un impacto sobre la vida del usuario.

Distribution models for mountain plant species: The value of elevation

The climatic conditions of mountain habitats are greatly influenced by topography. Large differences in microclimate occur with small changes in elevation, and this complex interaction is an important determinant of mountain plant distributions. In spite of this, elevation is not often considered as a relevant predictor in species distribution models (SDMs) for mountain plants. Here, we evaluated the importance of including elevation as a predictor in SDMs for mountain plant species. We generated two sets of SDMs for each of 73 plant species that occur in the Pacific Northwest of North America; one set of models included elevation as a predictor variable and the other set did not. AUC scores indicated that omitting elevation as a predictor resulted in a negligible reduction of model performance. However, further analysis revealed that the omission of elevation resulted in large over-predictions of species' niche breadths-this effect was most pronounced for species that occupy the highest elevations. In addition, the inclusion of elevation as a predictor constrained the effects of other predictors that superficially affected the outcome of the models generated without elevation. Our results demonstrate that the inclusion of elevation as a predictor variable improves the quality of SDMs for high-elevation plant species. Because of the negligible AUC score penalty for over-predicting niche breadth, our results support the notion that AUC scores alone should not be used as a measure of model quality. More generally, our results illustrate the importance of selecting biologically relevant predictor variables when constructing SDMs.

A framework for demonstrating the value of human services

Tanto profesionales como quienes tienen a su cargo diferentes servicios están de acuerdo en que la evaluación es importante. Sin embargo, los orientadores rara vez evalúan su trabajo de manera de hallar una relación causal entre los servicios que los usuarios reciben y los cambios a los que acceden. Se ha desarrollado un marco teórico para evaluar los cambios en los conocimientos, habilidades, actitudes y creencias del usuario y examinar el impacto que dichos cambios han hecho en su vida y en la sociedad en la que se desenvuelve. El marco incluye también un sistema de seguimiento de las intervenciones realizadas y de los recursos necesarios para poder implementar exitosamente estas acciones. Ha sido empleado en diversas situaciones orientadoras, establecimientos educativos y acciones de orientación vocacional, con el objeto de proporcionar evidencia de que el servicio brindado realmente produce un impacto sobre la vida del usuario.