Potential Futility Research Articles

Flow cytometric expression of Bcl-2, Mcl-1, and their ratios correlates with primary and secondary cytogenetic changes and their combinations in multiple myeloma.

Response to BH3 mimetics in multiple myeloma (MM) correlates with CCND1-rearrangement or expression of anti-apoptotic molecules, particularly Bcl-2 and Mcl-1. Our study investigates the relationship between cytogenetic abnormalities (CGAs) and intracellular Bcl-2 and Mcl-1 expression in myeloma plasma cells(MPCs) using flow cytometry (FCM). We measured median fluorescence intensity (MFI) of Bcl-2 and Mcl-1 in 163 bone marrow samples (143 MM, 20 controls) across various cell types. Both Bcl-2MFI and Mcl-1MFI were significantly higher in MPCs compared to other cells, with Bcl-2 MFI exceeding Mcl-1 MFI in MPCs. Bcl-2 expression peaked in CCND1-rearranged cases, while Mcl-1 expression was highest in cases with 1q21 gain/amplification. Notably, 65-74% of cases with other CGAs exhibited moderate to strong Bcl-2 or Mcl-1 expression, indicating potential utility of BH3 mimetics in this group, while 25% showed dim to absent expression of one or both markers, suggesting potential futility in these patients. Our study highlights FCM's potential for rapid Bcl-2 and Mcl-1 quantification, surpassing traditional methods. We propose that direct measurement of Bcl-2 and Mcl-1 expression in PCs by FCM, combined with cytogenetic characterization, could improve therapeutic decision-making regarding the use of BH3 mimetics in MM, potentially enhancing outcomes and overcoming resistance.

High Seroprevalence of Hepatitis C Virus Among Cisgender Women Who Exchange Sex in the Seattle, Washington Area.

Injection drug use (IDU) is a risk factor for hepatitis C virus (HCV) acquisition and occurs disproportionately among women who exchange sex (WES). However, little is known about HCV epidemiology in this population. We estimated HCV seroprevalence, identified correlates of HCV seropositivity, and characterized social networks by HCV serostatus and IDU history among WES in the Seattle, Washington, area. This was a secondary analysis of data from the 2016 National HIV Behavioral Surveillance survey in the Seattle, Washington area, a cross-sectional survey that used respondent-driven sampling (RDS) to enroll WES for money or drugs (N = 291). All participants were offered rapid HCV-antibody testing. We estimated HCV seropositivity and used log regression methods to estimate crude and adjusted prevalence ratios (PRs) for correlates of HCV seropositivity among WES. Using RDS recruitment chain data, we computed homophily indices to estimate the extent to which participants were likely to recruit another participant with the same HCV serostatus and IDU history. In the study sample of WES in the Seattle, Washington area, 79% reported lifetime IDU and 60% were HCV seropositive. HCV seropositivity was strongly associated with ever injecting drugs (PRadj: 7.7 [3.3, 18.0]). The RDS homophily scores for HCV seropositivity (0.07) and ever injecting drugs (0.02) suggested that participants did not tend to recruit others with the same characteristics beyond what would be expected by chance. Among this sample of WES in Seattle, Washington area, HCV seroprevalence was high and strongly associated with a history of IDU. The high burden of HCV among WES suggests this marginalized group would benefit from additional harm reduction services and targeted HCV treatment campaigns to reduce forward transmission. We saw little evidence of preferential recruitment among WES who were HCV seropositive or reported a history of IDU, suggesting the potential futility of peer-based referrals for HCV treatment.

Navigating parental requests: considering the relational potential standard in paediatric end-of-life care in the paediatric intensive care unit

Families and clinicians approaching a child’s death in the paediatric intensive care unit (PICU) frequently encounter questions surrounding medical decision-making at the end of life (EOL), including defining what is...

An anthropology of impossible futures

This guest editorial explores the intricate relationship between anthropology and the concept of impossible futures, focusing on the global push towards electric vehicles (EVs) and the lithium energy assemblage. Drawing inspiration from a lecture by palaeobiologist Mark Williams, a member of the Anthropocene Working Group (AWG), the author reflects on the Anthropocene epoch and the human‐caused transformations of the earth. It examines the European Green Deal's impact on the automotive industry, the global struggle for lithium and the paradoxes of green technology investments. It questions the feasibility of the envisioned future, emphasizing the contradictions within global capitalism and the potential futility of climate change mitigation efforts. The author calls for a reorientation in anthropological research, focusing on novel forms of unity, solidarity, justice and interspecies bonds in the face of seemingly impossible conditions. It concludes with a contemplation of anthropology's role in translating and understanding social life in the context of unattainable futures without losing sight of the discipline's contested past and inherent hope.

The Self-Anti-Censorship Nature of Encryption: On the Prevalence of Anamorphic Cryptography

As part of the responses to the ongoing crypto wars, the notion of Anamorphic Encryption was put forth. The notion allows private communication in spite of a dictator who is engaged in an extreme form of surveillance and or censorship, where it asks for all private keys and knows and may even dictate all messages. The original work pointed out efficient ways to use two known schemes in the anamorphic mode, bypassing the draconian censorship and hiding information from the all-powerful dictator. A question left open was whether these examples are outlier results or whether anamorphic mode is pervasive in existing systems. Here we answer the above question: we develop new techniques, expand the notion, and show that the notion of Anamorphic Cryptography is, in fact, very much prevalent. We first refine the notion of Anamorphic Encryption with respect to the nature of covert communication. Specifically, we distinguish Single-Receiver Encryption for many to one communication, and Multiple-Receiver Encryption for many to many communication within the group of conspiring users. We then show that Anamorphic Encryption can be embedded in the randomness used in the encryption, and we give families of constructions that can be applied to numerous ciphers. In total the families cover classical encryption schemes, some of which in actual use. Among our examples is an anamorphic channel with much higher capacity than the regular channel. In sum, the work shows the very large extent of the potential futility of control and censorship over the use of strong encryption by the dictator (typical for and even stronger than governments engaging in the ongoing crypto-wars): While such limitations obviously hurt utility which encryption typically brings to safety in computing systems, they essentially, are not helping the dictator. While the actual implications of what we show here and what it means in practice require further policy and legal analyses and perspectives, the technical aspects regarding the issues are clearly showing the futility of the war against Cryptography.

Selection Liver Transplantation and Bridge Therapeutic Modalities in Acute Liver Failure

Introduction: Acute liver failure (ALF) is a condition that can rapidly progress to multiorgan failure. Therefore, different extracorporeal liver support systems have been developed to function as a bridge to transplantation or spontaneous survival. Conversely, the shortage of organs demands a rigorous selection process to determine whom should receive transplantation and several prognostic models have been proposed to identify the patients who would benefit the most from liver transplantation (LT). Objectives: A review of the main selection criteria used for LT in ALF is carried out, focusing mostly on the new proposed prognostic markers, and aiming to identify poor prognosis criteria associated with futility in LT. Extracorporeal liver support systems (ECLS) were also reviewed, including an analysis of their impact on the survival of patients with ALF. Methods: MEDLINE and PubMed databases were searched between 16th October 2021 and 5th December 2021. The inclusion criteria were: adult patients; patients with acute liver injury (ALI) or ALF; observational studies; clinical studies; case series; case-control studies; systematic reviews; meta-analysis. Discussion: King’s College criteria (KCC) have been widely used and despite good specificity, have low sensitivity. Several markers have been used to improve prognostic accuracy, but the results are not sufficiently clear. Patient age, ABO incompatibility, and poor-quality grafting were potential factors that could indicate potential futility in LT. ECLS have a positive influence in clinical and laboratory parameters; however, there is no clear evidence of improvement in survival. Conclusion: ALF is a heterogeneous syndrome, which brings into question of the studies carried out to evaluate prognostic criteria to select patients for LT. It also narrows down the studies performed to evaluate the impact of ECLS on survival.

Injection drug use infective endocarditis: clinical features and therapeutic challanges

Abstract Introduction Injection drug use (IDU) is a known risk factor for infective endocarditis (IE) and is associated with frequent recurrences, but its prognostic impact is still debated. Moreover, the potential futility of surgery in this population is an unsolved matter. Purpose We aimed to determine the clinical characteristics, the therapeutic strategy, and the prognostic impact of injection drug use IE (IDUIE). Method We retrospectively included in the analysis 454 consecutive episodes of definite active IE admitted in a single surgical centre from January 2012 to December 2020; 14 out of them where a subsequent infective episode of the same patient. Results IDUIE cases were 63 (13.8%), without significant proportional differences over time. IDUIE patients were significantly younger (43.95±10.12 vs 67.84±13.33, p 0.00) and presented fewer comorbidities (p<0.001). They were admitted with a first episode of IE only in 60.3% of cases vs 92.8% of non-IDU (p<0.001). Embolism was present at admission in a higher percentage (60.3 vs 38.4%, p<0.001). IDUIE was more frequently associated with spondylodiscitis (15.9 vs 7.4%, p=0.026). The infection was less frequently left-sided than in non-IDU patients (57.1 vs 97.2%, p<0.001) and was more often polimicrobic (12.7 vs 4.9%, p=0.015). Most patients were positive for Staphylococcus aureus (54.0 vs 12.8%, p<0.001), while Streptococci were significantly less frequent in patients with IDUIE (11 vs 25%, p=0.015). The proportion of patients undergoing surgery was similar among the two groups (85.5 vs 78.8%, NS). IDUIE patients treated medically for absence of surgical indication had a better survival than patients undergoing surgery for complicated IE (p<0.001). IDUIE was associated with a higher proportion of relapse during follow-up (28.3 vs 3.3%, p<0.001). It was not associated with higher mortality (Figure 1) but was an independent predictor of mortality in multivariable analysis including age (HR per unit 1.048, 95% CI 1.038–1.063, p=0.00) and drug abuse (HR 3.2, 95% CI 1.8–5.6, p=0.00; Figure 2). Among IDUIE patients, we did not find predictors of futility of surgery, not even multiple relapses. Conclusions IDUIE represents a considerable proportion of overall cases of IE, mainly affecting young people. Staphylococcus aureus is the most common microbiologic agent. IDUIE is not associated with higher mortality but drug abuse is an independent predictor of mortality. Considering that patient with uncomplicated IE treated medically have a better prognosis, we should reserve surgery to patients with a strict indication for it. On the other hand, since there are no predictors of futility of surgery, all patients with a complicated IE should undergo surgery without delay. The main determinant of prognosis in these patients is not IE but drug abuse itself. For this reason, increased focus on addiction treatment following hospital discharge is mandatory to improve long term prognosis. Funding Acknowledgement Type of funding sources: None.

Infective endocarditis in intravenous drug abusers: clinical challenges emerging from a single-centre experience

BackgroundIntravenous drug abuse (IDA) is a known risk factor for infective endocarditis (IE) and is associated with frequent relapses, but its prognostic impact is still debated. The potential futility of surgery in this population is a further issue under discussion. We aimed to describe the clinical characteristics, the therapeutic strategy, and the prognosis associated with IDA in IE.MethodsWe retrospectively analysed 440 patients admitted to a single surgical centre for definite active IE from January 2012 to December 2020.ResultsPatients reporting IDA (N = 54; 12.2%) were significantly younger (p < 0.001) and presented fewer comorbidities (p < 0.001). IDA was associated with a higher proportion of relapses (27.8 vs. 3.3%, p < 0.001) and, at multivariable analysis, was an independent predictor of long-term mortality (HR 2.3, 95%CI 1.1–4.7, p = 0.015). We did not register multiple relapses in non-IDA patients. Among IDA patients, we observed 1 relapse after discharge in 9 patients, 2 relapses in 5 patients and 3 relapses in 1 patient. In IDA patients, neither clinical and laboratory variables nor the occurrence of even multiple relapses emerged as indicators of an adverse risk–benefit ratio of surgery in patients with surgical indication.ConclusionsIE secondary to IDA affects younger patients than those with IE not associated with IDA. Probably due to this difference, IE secondary to IDA is not associated with significantly higher mortality, whereas the negative, long-term prognostic impact of IDA emerges in multivariate analysis. Considering the good prognosis of patients with uncomplicated IE treated medically, surgery should be reserved to patients with a strict- guidelines-based indication. However, since there are no clear predictors of an unfavourable risk–benefit ratio of surgery in patients with surgical indication, all patients with a complicated IE should be operated, irrespective of a history of IDA.

Cumulative impact of mitral annular calcifications and thoracic aortic calcifications on 1-year mortality after TAVI

Mitral Annular Calcifications (MAC) and Thoracic Aortic Calcifications (TAC) represent 2 well-established predictors of mortality after TAVI; they could be combined to enhance the prediction of outcome after TAVI and improve patient selection. To evaluate the cumulative prognostic value of MAC and TAC in patients with aortic stenosis, treated with TAVI on 1-year all-cause and cardiovascular (CV) mortalities. Between 2010 and 2014, 1382 TAVI patients were included, in 4 high volume french centers. High MAC was defined as ≥ 2 cm 3 and high TAC was defined as > 3.6 cm 3 (boundary of third tertile). Three groups were considered; 1: low MAC and low TAC, 2: high MAC or high TAC, and 3: high MAC and high TAC. Outcomes were all-cause and CV deaths. Kaplan Meier graphs, PLogRank test and multivariable Cox analysis were used to assess the prognostic value of MAC and TAC: Model 1 adjusted for EUROSCORE, Model 2 for age, gender, atrial fibrillation, coronary artery disease, left ventricle ejection fraction, mean aortic gradient, renal function, peripheral vascular disease, history of stroke, chronic obstructive pulmonary disease, and vascular access. Groups 1, 2 and 3 comprised 839 (60.7%), 492(35.6%), and 51(3.7%) patients respectively. At 1-year post TAVI, 25 patients were lost to follow-up and 230(16.6%) died, of whom 164(11.9%) from CV causes. Fig. 1 displays all-cause and CV deaths according to the 3 groups (PLogRank = 0.005 for both). In model 1, group 3 had an excess risk compared to group 1: HR 2.21 CI(1.27–3.85), p = 0.005, and HR 2.29 CI(1.19–4.42), p = 0.013 for all-cause and CV mortality, respectively. Similar results were found in model 2: HR 2.06 CI(1.18–3.60), p = 0.01, and HR 2.14 CI(1.10–4.16), p = 0.025 for all-cause and CV mortality, respectively. A cumulative impact of MAC and TAC on post-TAVI mortality is demonstrated. A special attention for potential futility should be payed to patients with a high MAC/TAC burden.

Incidence, underlying conditions, and outcomes of patients receiving acute renal replacement therapies in tertiary cardiac intensive care units: An analysis from the Critical Care Cardiology Trials Network Registry

The prevalence of renal disease in cardiac intensive care units (CICUs) is increasing, but little is known about the utilization, concurrent therapies, and outcomes of patients requiring acute renal replacement therapy (RRT) in this specialized environment. In the Critical Care Cardiology Trials Network, 16 centers submitted data on CICU admissions including acute RRT (defined as continuous renal replacement therapy and/or acute intermittent dialysis). Among 2,985 admissions, 178 (6.0%; interhospital range 1.0%-16.0%) received acute RRT. Patients receiving RRT, versus not, were more commonly admitted for cardiogenic shock (15.7% vs 4.2%, P < .01), cardiac arrest (9.6% vs 3.7%, P < .01), and acute general medical diagnoses (10.7% vs 5.8%, P < .01), whereas acute coronary syndromes (16.9% vs 32.1%, P < .01) were less frequent. Variables independently associated with acute RRT included diabetes, heart failure, liver disease, severe valvular disease, shock, cardiac arrest, hypertension, and younger age. In patients receiving acute RRT, versus not, advanced therapies including mechanical ventilation (55.6% vs 18.0%), vasoactive support (73.0% vs 35.2%), invasive hemodynamic monitoring (59.6% vs 29.2%), and mechanical circulatory support (27.5% vs 8.4%) were more common. Acute RRT was associated with higher in-hospital mortality (42.1% vs 9.3%, adjusted odds ratio 3.74, 95% CI, 2.52-5.53) and longer median length of stay (10.0 vs 5.3 days, P < .01). In conclusion, acute RRT in contemporary CICUs was associated with the provision of other advanced therapies and lower survival. These data underscore the risks associated with the provision of renal support in patients with primary cardiovascular problems and the need to develop standardized indications and potential futility measures in this specialized population.

How many older adults receive drugs of questionable clinical benefit near the end of life? A cohort study

Background: The high burden of disease-oriented drugs among older adults with limited life expectancy raises important questions about the potential futility of care. Aim: To describe the use of drugs of questionable clinical benefit during the last 3 months of life of older adults who died from life-limiting conditions. Design: Longitudinal, retrospective cohort study of decedents. Death certificate data were linked to administrative and healthcare registries with national coverage in Sweden. Setting: Older adults (≥75 years) who died from conditions potentially amenable to palliative care between 1 January and 31 December 2015 in Sweden. We identified drugs of questionable clinical benefit from a set of consensus-based criteria. Results: A total of 58,415 decedents were included (mean age, 87.0 years). During their last 3 months of life, they received on average 8.9 different drugs. Overall, 32.0% of older adults continued and 14.0% initiated at least one drug of questionable clinical benefit (e.g. statins, calcium supplements, vitamin D, bisphosphonates, antidementia drugs). These proportions were highest among younger individuals (i.e. aged 75–84 years), among people who died from organ failure and among those with a large number of coexisting chronic conditions. Excluding people who died from acute and potentially unpredictable fatal events had little influence on the results. Conclusion: A substantial share of older persons with life-limiting diseases receive drugs of questionable clinical benefit during their last months of life. Adequate training, guidance and resources are needed to rationalize and deprescribe drug treatments for older adults near the end of life.

Author response: Evolving use of seizure medications after intracerebral hemorrhage: A multicenter study

We thank Srinivasan et al. for the interest in our article.1 We agree that the use of levetiracetam is rational and stated so in the last paragraph of the article.1 Separately, Srinivasan et al. state that clinicians “appreciate the futility of using prophylactic” seizure medications. It is not clear how best to reconcile the rational and common use of levetiracetam with the potential futility of this approach. Definitive clinical trials are needed to determine whether prophylactic seizure medications alter patient outcomes and the occurrence of seizures in high-risk patients.

Potential uselessness and futility of left atrial appendage occlusion and patent foramen ovale closure in cardioembolic stroke.

: International guidelines indicate that interventional closure of left atrial appendage and patent foramen ovale may be considered in selected patients for stroke prevention. These procedures appear, however, from the published literature, at high risk of uselessness and futility in the single case, if not even capable to induce harm and adverse events. In fact, all reported systematic reviews and meta-analyses have not shown in a convincing manner the superiority of these procedures in stroke prevention, taking into account the occurrence of possible complications also, as compared with alternative medical treatment. On the basis of these considerations, it becomes very difficult to define always and unequivocally how adequate and complete was the information when given to each single candidate patient before the procedure by the Heart Team, the left atrial appendage occlusion Team or patent foramen ovale closure Team, potentially involved in conflict of interest. Before indicating these procedures, a complete diagnostic work-up should then be planned for each single patient to identify and treat not only one, but all concomitant risk factors and potential different cardioembolic sources. It could also be suggested to have, for each single candidate patient, a second independent opinion from physicians not involved in the procedure and possibly not operating in the same institution. This prudential approach could reduce in each single case the risk of uselessness, futility and even potential harm and adverse events of those procedures.

THU-328 - Evaluation of potential futility in alcoholic hepatitis – multicentre study

THU-328 - Evaluation of potential futility in alcoholic hepatitis – multicentre study

Poe Ballantine and the Gothic Frontier

ABSTRACTThis article situates Ballantine’s Love and Terror on the Howling Plains of Nowhere in terms of its creative engagement with gothic history, where the domestic narrative of the “memoir” and the monstrosity of Steven Haataja’s death are closely complementary. Ballantine’s book has a keen conceptual interest in the issue of origins: Where does the (textual) “self” begin, and how can history be understood without proper knowledge of true origins? This article examines other forms of beginnings in American literature (Twain, Hawthorne, Rip van Winkle) to advocate the value of Ballantine’s work as a significant contribution to American gothic history, one founded not on secure origins but on the repudiation of history. Ballantine’s memoir is a metafictional examination of this problem, where the failure of enlightenment discourses of law and medicine is understood as an anxious expression of the potential futility of the errand into the wilderness.

The Beast with the Broken Lance: Humanism and Posthumanism in Tennyson’s Idylls of the King

In Epic, poem frames Tennyson's 1842 Morte d'Arthur, fictional poet Everard Hall justifies burning his twelve-book Arthurian epic by invoking another extinct, prehistoric creature: Why take style of heroic times? For nature brings not back Mastodon, Nor we times; and why should any Remodel models? (11. 35-38). (1) The poet is, of course, an avatar for Tennyson himself, and analogy he makes between those heroic times and the tells us a few important things about Idylls of King, twelve-book opus would evolve out of Morte d'Arthur over course of several decades. It tells us first Tennyson worried about genre, about anachronism of writing an Arthurian epic for a Victorian public--an anxiety still plagued him in 1858, when he wrote a letter urging his publishers to disabuse your own minds and of others, as far as you can, of fancy I am about an Epic of King Arthur. I should be crazed to attempt such a thing in heart of 19th cenmry. (2) But it also tells us, more compellingly, he worried about Mastodon, and what it represents metonymically--about potential futility of writing in a genre asserts an anthropocentric cosmology when paleontology, evolutionary theory, and other scientific discourses were busy revealing just how far universe extended beyond scope of human. Arthurian legend assumes a Christian time-scale, beginning with Creation and ending with Last Day; is always present, and prehistory--with which Idylls begins--is simply chaotic time before Arthur's reign. As John D. Rosenberg points out, however, Idylls was written during a period when ... geology and then evolution pushed back origins of things from imagined instant of Creation to unimaginably remote beginnings; and imminent Last Day opened out upon eonian cycles of days without end. (3) The reference suggests Tennyson less anxious about anachronism of poem's style than about obsolescence of its worldview. Why should he remodel an of universe when a new model looms so monstrously large? The interlineal juxtaposition between capital-M Mastodon and lower-case implies an even more pointed and destabilizing question: Why write in a form celebrates human achievement when discoveries like have rendered human so seemingly insignificant? And yet, Tennyson did not end up burning his twelve-book epic; he completed it, and completed it with a capstone, moreover, suggests this tension between cosmological models--and by extension, models of Man--was something dynamized his poetic project rather than endangering it. In 1891, half a dozen years after Idylls published in its final, twelve-book form, poet added one last line to epilogue recalls--without quite resolving--the vs. Mastodon conflict he expressed in 1842. Feeling, as his son reports, that perhaps he had not made humanity of King sufficiently clear, (4) Tennyson inserted a new formulation to describe Arthur once and for all: Ideal closed in man (To Queen, 1. 38). What is ideal manhood, what is real man, and how might relationship between two of them constitute a clear picture of King's humanity--or humanity in general? The rest of poem furnishes several possible answers: in a moral sense, Arthur is figure of ideal manhood because he is one of unyielding principle surrounded by so many figures--both within and outside Round Table--of criminality and corruption; in a more dualistic sense, poem suggests enclosure is happening within Arthur, with ideal manhood of his immortal soul trapped within real man of his body. And yet, appeal occurs right before Tennyson's final addition juxtaposes not with body, but with Sense: Accept this old imperfect tale, poet enjoins queen, New-old, and shadowing Sense at war with Soul (11. …

Clinical Course of acute‐on‐chronic liver failure syndrome and effects on prognosis

Acute-on-chronic liver failure (ACLF) is characterized by acute decompensation (AD) of cirrhosis, organ failure(s), and high 28-day mortality. We investigated whether assessments of patients at specific time points predicted their need for liver transplantation (LT) or the potential futility of their care. We assessed clinical courses of 388 patients who had ACLF at enrollment, from February through September 2011, or during early (28-day) follow-up of the prospective multicenter European Chronic Liver Failure (CLIF) ACLF in Cirrhosis study. We assessed ACLF grades at different time points to define disease resolution, improvement, worsening, or steady or fluctuating course. ACLF resolved or improved in 49.2%, had a steady or fluctuating course in 30.4%, and worsened in 20.4%. The 28-day transplant-free mortality was low-to-moderate (6%-18%) in patients with nonsevere early course (final no ACLF or ACLF-1) and high-to-very high (42%-92%) in those with severe early course (final ACLF-2 or -3) independently of initial grades. Independent predictors of course severity were CLIF Consortium ACLF score (CLIF-C ACLFs) and presence of liver failure (total bilirubin ≥12 mg/dL) at ACLF diagnosis. Eighty-one percent had their final ACLF grade at 1 week, resulting in accurate prediction of short- (28-day) and mid-term (90-day) mortality by ACLF grade at 3-7 days. Among patients that underwent early LT, 75% survived for at least 1 year. Among patients with ≥4 organ failures, or CLIF-C ACLFs >64 at days 3-7 days, and did not undergo LT, mortality was 100% by 28 days. Assessment of ACLF patients at 3-7 days of the syndrome provides a tool to define the emergency of LT and a rational basis for intensive care discontinuation owing to futility.

P1123 RESPONSE-GUIDED THERAPY WITH BOCEPREVIR PLUS PEGINTERFERON ALFA-2a (40KD) AND RIBAVIRIN IN TREATMENT-NAIVE PATIENTS INFECTED WITH HCV GENOTYPE 1: INTERIM RESULTS FROM THE TriCo STUDY

with pegylated interferon a-2a and ribavirin (PR) in patients infected with chronic HCV. Futility rules may prevent unnecessary prolongation of therapy, minimising adverse effects and limiting resistance emergence. We explored potential futility rules for patients treated with faldaprevir. Methods: In STARTVerso1 and -2, treatment-naive patients infected with HCV genotype-1 were randomised to 48 weeks (W) of PR plus: placebo for 24W (Arm 1); faldaprevir 120mg QD for 12W or 24W (Arm 2); or faldaprevir 240mg QD for 12W (Arm 3). Patients in Arms 2 and 3 stopped all treatment at W24 on achievement of early treatment success (HCVRNA 100 or >1,000 IU/mL at week 4 or 12 have high probabilities of predicting treatment failure; NPVs are similar using the W4 or W12 time point.

Trends in the cost of the futile cancer care near the end of life.

126 Background: Aggressive cancer care near the end of life may not only represent a quality-of-care issue, but also a futility issue. Under the constraint of health resources, it is of interest to know the cost trends of futile treatment for cancer patients near the end of their life. Methods: The definition of potential medical futility for cancer patients near the end of their life was developed based on the RAND/UCLA Appropriateness Method. Nine experts or academics from medical, political, social, or legal fields built a consensus that treatment after 7 days in the intensive care unit following a cardiopulmonary resuscitation for cancer patients who died within 3 months is probably futile. Based on this definition, we used death registry and Taiwan’s National Health Insurance claim data from 2000-2001 and 2009-2010 respectively to estimate the cost of potential futile treatment for cancer patients near the end of their life in 2001 and 2010. Results: The percentage of cancer patients receiving potentially futile treatment near the end of their life reduced from 2.68% in 2001 (883/32,993) to 1.58% in 2010 (649/41,046). The cost of potentially futile cancer care also decreased from $283 million NTD (New Taiwan Dollar) in 2001 to $255 million NTD in 2010 (1USD=30NTD). Nevertheless, the per capita cost of potentially futile cancer care slightly increased from $320 thousand NTD to $393 thousand NTD. Conclusions: Although the cost of potentially futile cancer care for patients near the end of life is not huge in Taiwan, its trend of decrease may indicate that supportive but not aggressive cancer care is more and more prevailing and acceptable by patients, their family, as well as health care providers.

Evaluation of Prescribing Medications for Terminal Cancer Patients near Death: Essential or Futile

PurposeThe purpose of this study is to evaluate the prescription of essential or futile medications for terminal cancer patients during their final admission.Materials and MethodsWe conducted a retrospective review of the medical charts of terminally ill cancer patients admitted to the Hemato-oncology Department of two teaching hospitals from March 1, 2007 to December 31, 2009. Essential medications were based on the drugs listed by the International Association for Hospice and Palliative Care, while futile medications were defined when short-term benefit to patients with respect to survival, quality of life, or symptom control was not anticipated.ResultsA total of 196 patients were included. Among essential medications, strong opioids were the most frequently prescribed drugs during the last admission (62.2% fentanyl, 44.3% morphine), followed by megestrol (46.0%), and metoclopramide (37.2%); 51% of gastric protectors were prescribed with potential futility. Anti-hypertensive and antiglycemic agents were administered to those who experienced arterial blood pressure below 90 mm Hg (47.3%) or presented with a single measurement of fasting glucose below 50 mg/dL (10.7%), respectively. Statins were prescribed to 6.1% (12/196) of patients, and 75% of those prescriptions were regarded as futile.ConclusionOur data suggest that effective prescription of essential medications and withdrawal from futile medications should be actively reconciled for improvement of a patient's end-of-life care.