Relationship between assays of glycemia in diabetic subjects with advanced chronic kidney disease

BACKGROUND

Relative to hemoglobin A(1c) (HbA(1c)), glycated albumin (GA) more accurately reflects recent glycemic control in diabetic patients on hemodialysis and peritoneal dialysis. These assays have yet to be compared in patients with advanced chronic kidney disease (CKD).

METHODS

HbA(1c) and GA were simultaneously measured in 303 diabetic subjects: 70 with CKD prior to dialysis (CKD-stage 4), 184 with CKD after transplantation (TXP-stage 3) and 49 non-nephropathy controls.

RESULTS

Mean estimated GFR was 76, 46 and 26 ml/min in controls, TXP-3 and CKD-4 cases, respectively. Mean (SD) HbA(1c) (%) and GA (%) concentrations were 7.30 (1.40) and 16.8 (4.9) in controls, 7.28 (1.66) and 21.5 (6.4) in CKD-4 cases, and 7.21 (1.62) and 21.2 (5.5) in TXP-3 cases, respectively. The GA:HbA(1c) ratio differed significantly between non-nephropathy controls and both groups of CKD patients (both p < 0.001), but not between CKD-4 and TXP-3 cases (p = 0.92). The glucose:HbA(1c) ratio was inversely associated with GFR in all 254 nephropathy cases (r = -0.13; p = 0.04), while glucose:GA did not vary significantly based upon GFR (r = -0.08; p = 0.24).

CONCLUSIONS

The relationship between glycated albumin and HbA(1c) is influenced by the presence of reduced GFR in diabetic patients with CKD. The accuracy of the HbA(1c) assay in diabetic subjects with severe nephropathy requires further investigation, although HbA(1c) performs relatively well with milder CKD.

Reliability of the arterial to end-tidal carbon dioxide gradient in mechanically ventilated patients with multisystem trauma

The accuracy and reliability of the relationship between arterial and end-tidal carbon dioxide (PETCO2 and PaCO2), expressed as the gradient, P(a-ET)CO2, was assessed with 171 comparisons in nine mechanically ventilated trauma patients. The P(a-ET)CO2 was 14 +/- 11 mm Hg. (mean +/- standard deviation.) The positive correlation between PaCO2 (44 +/- 10 mm Hg) and PETCO2 (30 +/- 10 mm Hg) for the study population (reflected by r = 0.64, p = 0.001; but r2 = 0.41) indicated statistical significance, but only 40% of the changes reflected a linear relationship. Seventy-eight percent of individual patients had significant correlations of PaCO2 and PETCO2 (p < 0.02 to p < 0.001). Changes in PETCO2 erroneously predicted the PaCO2 changes in 27% of comparisons with 15% false decreases and 12% false increases. Trends in P(a - ET)CO2 magnitude are not reliable, and concordant direction changes in PETCO2 and PaCO2 are not assured.

Outcomes of repeat cytoreductive surgery with hyperthermic intraperitoneal chemotherapy for the treatment of peritoneal surface malignancy

BACKGROUND

Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) has improved the survival of patients with peritoneal surface malignancy. On recurrence, a repeat CRS/HIPEC is a treatment option.

STUDY DESIGN

A retrospective analysis of 868 CRS/HIPEC procedures was performed. Type of primary, functional status, completion of resection, hospitalization, morbidity, mortality, and survival were reviewed.

RESULTS

Sixty-two patients (7.7%) underwent a second CRS/HIPEC, including 33 patients with appendiceal primaries, 8 ovarian, 7 mesotheliomas, 4 colon cancers, and 10 various malignancies. Median follow-up was 60.8 months. Median overall survival in months was 85.3 for appendiceal cancer, 52.9 for mesothelioma, 60.1 for ovarian, and 137.4 for colon cancer. R1 resection was achieved in 43.5% after both procedures. Median survival after the second cytoreduction was 52.1 months for appendiceal cancer, 21.8 for mesothelioma, 53.9 for ovarian, and 55.7 for colon cancer. Median survival was 55.7 months for R1 resection, 20.3 months for R2a resection, and 15.5 months for R2b-R2c. Median ICU and hospital stay was 1 and 7.5 days, respectively. The 30-day morbidity after the second CRS/HIPEC was 48.4% and mortality was 3.2%. In multivariate analysis, the R status of the second CRS/HIPEC (p = 0.013) and the interval between the 2 procedures (p = 0.009) were significant in predicting improved survival.

CONCLUSIONS

In experienced tertiary centers and for selected patients, a repeat CRS/HIPEC procedure has morbidity and mortality similar to the initial cytoreduction. Survival depends primarily on the completion of the repeat cytoreduction and favorable biology of the tumor.

Peritoneal surface disease from colorectal cancer: comparison with the hepatic metastases surgical paradigm in optimally resected patients

BACKGROUND

Surgical resection is the treatment of choice for colorectal hepatic metastases (HM). In contrast, metastatic disease to the peritoneum is treated with systemic therapy. We examined our experience with cytoreductive surgery (CS) and intraperitoneal hyperthermic chemotherapy (IPHC) for peritoneal surface disease (PSD) compared with liver resection for HM.

METHODS

A review of prospective databases of colorectal cancer patients undergoing surgery for metastatic disease to the peritoneum or liver (1992-2005) was carried out.

RESULTS

One hundred and twenty-one patients underwent CS + IPHC and 101 patients underwent hepatic resection with median follow-up of 86 and 56 months, respectively. Fifty-five (45%) patients in the IPHC group had complete resection of all gross tumor. Ninety-five (94%) of the HM patients had negative surgical margins. Comparison of the R0/R1 PSD and margin-negative HM group demonstrated significant differences in age, performance status, and preoperative chemotherapy. The 1-, 3-, and 5-year overall survival for the R0/R1 PSD patients was 91, 48, and 26%; while it was 87, 59, and 34% for the HM patients (P = 0.32). Perioperative morbidity was 42% versus 34% (P = 0.38) and mortality was 5.5% versus 4.2% (P = 0.71) between the PSD and HM patients, respectively.

CONCLUSION

R0/R1 resection during CS + IPHC compared with margin-negative hepatic resection demonstrated no significant difference in overall survival and for select patients should be considered a viable treatment option. Further studies to improve the resectability of PSD patients and define the role of neoadjuvant and adjuvant drug strategies are needed.

Survival and quality of life following cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy for peritoneal carcinomatosis of colonic origin

BACKGROUND

Peritoneal carcinomatosis of colonic origin (PCC) is a life-threatening diagnosis. Cytoreductive surgery (CS) with hyperthermic intraperitoneal chemotherapy (HIPEC) offers patients the prospect of long-term survival with alleviation of symptoms.

METHODS

Patients underwent HIPEC for PCC and completed questionnaires preoperatively (T1) and after surgery at 3 (T2), 6 (T3), and 12 (T4) months. Questionnaires included the Functional Assessment of Cancer Therapy-Colon (FACT-C), Brief Pain Inventory (BPI), SF-36 Medical Outcomes Study Survey (SF-36), Center for Epidemiologic Studies-Depression Scale (CES-D), and the ECOG Performance Status Rating.

RESULTS

A total of 62 patients were assessed before surgery. Median overall survival was 18 months, with 71.3 ± 6.3% survival at 1 year. Emotional well-being (P = .0007) improved after HIPEC. Social/family well-being (P = .065) and the colon subscale (P = .061) of the FACT worsened at T2, but recovered by T3. One-third to one-half of patients reported depressive symptoms over the course of the study. Pain scores increased above BL at T2, but decreased below BL at T3 and T4.

CONCLUSIONS

Emotional well being is improved after CS + HIPEC despite complications that may affect short-term recovery. Most patients remaining in the study recover to preoperative levels of functioning between 3 and 6 months after surgery. For some, survival can be attained without major decrement in QOL at 1 year. QOL concerns must be a key component in the evaluation for patients with PCC for CS and HIPEC.

Monitoring health outcomes following cytoreductive surgery plus intraperitoneal hyperthermic chemotherapy for peritoneal carcinomatosis

BACKGROUND

Cytoreductive surgery with intraperitoneal hyperthermic chemotherapy for peritoneal carcinomitosis (PC) is an aggressive treatment designed to alleviate symptoms and prolong life. It is associated with physical and psychological morbidity. The purpose of this study was to monitor health outcomes related to treatment.

METHODS

Patients completed a questionnaire before and after surgery at 3, 6 and 12 months. The questionnaire consisted of basic demographic items as well as the Functional Assessment of Cancer Therapy-Colon Scale (FACT-C), SF-36 Medical Outcomes Study Health Survey, Center for Epidemiologic Studies-Depression Scale (CES-D), Brief Pain Inventory-Short Form, and ECOG Performance Status Rating. Time trends were assessed with mixed models (SAS PROC MIXED) so as to use all data and to account for missing data.

RESULTS

Ninety-six patients (49% females, 9% African Americans) of an average age of 52.9 (SD = 12.5) years were assessed before surgery. PC originated in primary lesions of the appendix (n = 36); colon/rectum (n = 24); mesothelium (n = 9); ovary (n = 5); stomach (n = 4); and miscellaneous (n = 18). Quality of life (QOL) and pain scores improved from baseline to 12 months. Physical functioning changed over the 12-month study period with improvement recorded at 6 months. The percentage of patients reporting significant depressive symptom at each time point was; baseline = 32%; 3 months = 19%; 6 & 12 months = 24%.

CONCLUSIONS

Acceptable QOL, return of functional status, and reduced pain can be attained between 3 and 6 months following treatment although some deficits in general health remain. Depressive symptoms are common and should be monitored.

Cellular basis of diabetic nephropathy: II. The transforming growth factor-beta system and diabetic nephropathy lesions in type 1 diabetes

Transforming growth factor-beta (TGF-beta) may be critical in the development of diabetic nephropathy (DN), and genetic predisposition is an important determinant of DN risk. We evaluated mRNA expression levels of TGF-beta system components in cultured skin fibroblasts (SFs) from type 1 diabetic patients with fast versus slow development of DN. A total of 125 long-standing type 1 diabetic patients were ranked by renal mesangial expansion score (MES) based on renal biopsy findings and diabetes duration. Patients in the highest quintile of MES who were also microalbuminuric or proteinuric (n = 16) were classified as "fast-track" for DN, while those in the lowest quintile who were also normoalbuminuric (n = 23) were classsified as "slow-track" for DN. Twenty-five normal subjects served as control subjects. SFs were cultured in medium with 25 mmol/l glucose for 36 h. SF mRNA expression levels for TGF-beta1, TGF-beta type II receptor (TGF-beta RII), thrombospondin-1, and latent TGF-beta binding protein-1 (LTBP-1) were measured by real-time RT-PCR. LTBP-1 mRNA expression was reduced in slow-track (0.99 +/- 0.38) versus fast-track patients (1.65 +/- 0.52, P = 0.001) and control subjects (1.41 +/- 0.7, P = 0.025). mRNA levels for TGF-beta1, TGF-beta RII, and thrombospondin-1 were similar in the three groups. Reduced LTBP-1 mRNA expression in SFs from slow-track patients may reflect genetically determined DN protection and suggests that LTBP-1 may be involved in the pathogenesis of DN through the regulation of TGF-beta activity.

Cytoreductive surgery with intraperitoneal hyperthermic chemotherapy for malignant peritoneal mesothelioma: mitomycin versus cisplatin

BACKGROUND

Malignant peritoneal mesothelioma (MPM) is a rare, rapidly fatal disease. Because traditional treatments offer little benefit, there has been increasing interest in cytoreductive surgery (CS) with intraperitoneal hyperthermic chemotherapy (IPHC). The most efficacious chemotherapy regimen is not established. Herein we report clinical outcomes of MPM patients treated with CS and IPHC and contrast results using two chemoperfusates: mitomycin and cisplatin.

METHODS

Thirty-four patients were treated for MPM. Following CS, 19 patients underwent IPHC with mitomycin and 15 received cisplatin. Overall survival, disease-free survival, and progression-free survival were compared between the two groups.

RESULTS

Overall survival was 56 and 17% at 3 and 5 years, with median survival of 40.8 months. Those perfused with cisplatin were more likely to be alive at 1, 2, and 3 years (P < 0.05, 0.05, and 0.04, respectively). Median survival for mitomycin and cisplatin was 10.8 and 40.8 months, respectively (P = 0.22). Median disease-free survival and progression-free survival were 10.3 and 9.1 months, respectively. There was a trend toward improved disease-free and progression-free survival using cisplatin.

CONCLUSIONS

CS with IPHC is a promising modality for patients with MPM, and clinical outcomes appear to be improved using cisplatin. We recommend using high-dose intraperitoneal cisplatin following cytoreductive surgery when treating malignant peritoneal mesothelioma.

Renal function and blood pressure are altered in adolescents born preterm

BACKGROUND

Preterm birth increases the risk of hypertension and kidney disease. However, it is unclear when changes in blood pressure (BP) and renal function become apparent and what role obesity and sex play. We hypothesized adolescents born preterm have higher BP and worse kidney function compared to term in an obesity- and sex-dependent manner.

METHODS

Cross-sectional analysis of 14-year-olds born preterm with very low birth weight (n = 96) compared to term (n = 43). We used generalized linear models to estimate the associations among preterm birth and BP, estimated glomerular filtration rate (eGFR), and ln (x) urinary albumin-to-creatinine ratio (ACR), stratified by overweight/obesity (OWO, body mass index (BMI) ≥ 85th percentile) and sex.

RESULTS

Compared to term, preterm-born adolescents had higher systolic blood pressure (SBP) and diastolic blood pressure (DBP) (adjusted β (aβ) 3.5 mmHg, 95% CI - 0.1 to 7.2 and 3.6 mmHg, 95% CI 0.1 to 7.0), lower eGFR (β - 8.2 mL/min/1.73 m², 95% CI - 15.9 to - 0.4), and higher ACR (aβ 0.34, 95% CI - 0.04 to 0.72). OWO modified the preterm-term difference in DBP (BMI < 85th percentile aβ 5.0 mmHg, 95% CI 0.7 to 9.2 vs. OWO 0.2 mmHg, 95% CI - 5.3 to 5.6) and ACR (OWO aβ 0.72, 95% CI 0.15 to 1.29 vs. BMI < 85th percentile 0.17, 95% CI - 0.31 to 0.65). Sex modified the preterm-term ACR difference (female aβ 0.52, 95% CI 0.001 to 1.04 vs. male 0.18, 95% CI - 0.36 to 0.72).

CONCLUSIONS

Prematurity was associated with higher BP and reduced renal function that were detectable in adolescence. OWO and sex may modify the strength of these relationships.

Serial Audiometry in a Clinical Trial of AIED Treatment

OBJECTIVE

We analyzed pure-tone and speech audiometric results from a prospective trial of anti-inflammatory treatment of subjects with active autoimmune inner ear disease (AIED). We sought to characterize the pattern and size of the treatment effect as reflected in clinical audiometry and to identify audiometric predictors of response to steroid treatment of AIED.

SUBJECTS

Adult participants demonstrated clinically established criteria for AIED (n = 116). Eligibility required audiometric evidence of active AIED as indicated by idiopathic sensorineural hearing loss with threshold elevations within 3 months of enrollment.

METHODS

We evaluated audiometric changes after 4 weeks of treatment with pharmacologic doses (60 mg/day) of prednisone. We examined the relationship between audiometric pure-tone thresholds at baseline and changes in word intelligibility score (WIS) using parametric and nonparametric analyses. Magnitudes of change were assessed using independent or paired t-tests. Separate analyses were performed on subgroups that did or did not show improved WIS score with steroid treatment.

RESULTS

Overall mean pure-tone averages improved from baseline to closeout of prednisone treatment in better hearing ears from 52.4 to 48.3 dB (p < .0001). Mean WIS improved in the better ear from 71.4% to 78.1% (p < .0001). Of pure-tone measures, only the six-tone average showed significant correlation with both the absolute improvements in WIS and with the percentage change in WIS after treatment. Individual frequencies at baseline showed no significant relationship with changes in WIS score after treatment. In 69 (59.5%) of 116 subjects, WIS improved (range, 2-80%) in the better ear. In these subjects, the baseline pure-tone thresholds and pure-tone averages correlated significantly and positively with improvement in WIS.

CONCLUSIONS

Steroid treatment in AIED-mediated hearing loss produce variable but significant hearing gains. Neither a focal, cochleotopic region of greatest vulnerability to AIED nor frequency-specific amenability to treatment were evident. We did observe that analysis of predictors and the degree of treatment effect vary with different approaches to measuring change in the WIS. Depending on the approach adopted, the size of the treatment effect may be greatest across intermediate hearing levels at baseline. These observations offer an audiometric database that may enable greater precision in judging clinically meaningful parameters for future studies of AIED treatment and other interventions for sensorineural hearing loss.

Tumour inhibitory plants. Amides of Piper novae-hollandiae (Piperaceae)

A new amide, Δαβ-dihydropiperine (I), has been isolated from the wood of Piper novae-hollandiae and synthesized. Two amides, N-isobutyl-trans- 2,trans-4-octadienamide and 3,4-methylenedioxycinnamoylpiperidide, previously unreported from natural sources but known from synthesis, were present as were five amides already established as plant constituents, namely, N-isobutyl-trans-2,trans-4-decadienamide, fagaramide, piperlonguminine, piperine, and an isomer of piperine, probably chavicine, as well as the essential oil, dillapiole. Δαβ-and Δβγ-Dihydro-piperlonguminine, (VIII) and (IX), and Δβγ-dihydropiperine (III) were also synthesized.

Survival and health outcomes after cytoreductive surgery with intraperitoneal hyperthermic chemotherapy for disseminated peritoneal cancer of appendiceal origin

BACKGROUND

Cytoreductive surgery with intraperitoneal hyperthermic chemotherapy for peritoneal carcinomatosis of appendiceal origin can alleviate symptoms and prolong survival. This aggressive therapy may impair patient quality of life (QOL). The purpose of this study was to monitor health outcomes before and after treatment.

METHODS

Patients underwent cytoreductive surgery and intraperitoneal hyperthermic chemotherapy for peritoneal cancer. Patients completed questionnaires consisting of demographic information and the Functional Assessment of Cancer Therapy, the SF-36 Medical Outcomes Study survey, the Center for Epidemiologic Studies-Depression Scale, and the ECOG Performance Status Rating before (T1) and after surgery at 3 (T2), 6 (T3), 12 (T4), and 24 (T5) months. Time trends were assessed with the mixed model (SAS PROC MIXED) to allow use of all the observed data as well as to account for missing data.

RESULTS

Fifty-eight patients (50% female) with a mean age 52.4 years (SD 12.6; range, 28-80) were assessed before surgery. Overall survival at 1 year was 78.7%. Emotional well-being improved over the study period, while physical well-being and physical functioning declined at T2 and then improved to near baseline levels at T3 and T4. Percentage of patients with depressive symptoms was as follows: T1 = 24%, T2 = 30%, T3 = 24%, and T4 = 33%. QOL scores improved over time.

CONCLUSIONS

Although complications can affect short-term recovery, survival in appendix cancer patients with peritoneal cancer is good and for some can be achieved without major decrements in QOL at 1 year. Depressive symptoms and some physical limitations remain in surviving patients.

Birth cohort evidence of population influences on blood pressure in the United States, 1887-1994

PURPOSE

Mean blood pressure (BP) has declined in the U.S. for several decades. It is unknown to what extent this decline was due to treatment of persons with recognized high BP or to population-wide influences on BP. Treatment would shift only the highest values lower, whereas, population-wide influences on BP would shift the entire distribution downward.

METHODS

We examined changes in the distributions of systolic and diastolic BP (SBP, DBP) across birth cohorts born between 1887 and 1975 in 52,646 individuals examined in the National Health (and Nutrition) Examination Surveys between 1960 and 1994. The BP distributions were estimated as functions of age and birth-year to examine changes between birth cohorts. We postulated that the age-adjusted 10th, 50th and 90th percentiles of SBP and DBP had decreased in more recent versus earlier birth cohorts.

RESULTS

The series of birth cohorts exhibited successively lower SBP and DBP at low, middle and high percentiles. In general, the 10th percentile of SBP decreased approximately 1.19 mmHg per decade of birth-year, whereas the 50th percentile decreased 2.40 mmHg per decade, and the 90th percentile decreased 4.62 mmHg per decade. A similar pattern of results was seen for DBP.

CONCLUSIONS

The entire distribution of both SBP and DBP shifted downward. The downward shifts at the 50th percentile and below unequivocally demonstrate a strong prevention effect in the U.S. population during the period 1887 through 1975. This epidemiologic analysis indicates that population-wide influences can alter favorably the distribution of BP throughout the whole population.

Clinical trials of an intravenous oxygenator in patients with adult respiratory distress syndrome

In patients with severe adult respiratory distress syndrome, mechanical ventilation may not be able to ensure gas exchange sufficient to sustain life. We report the use of an intravenous oxygenator (IVOX) in five patients who were suffering from severe adult respiratory distress syndrome as a result of aspiration, fat embolism, or pneumonia. IVOX was used in an attempt to provide supplemental transfer of CO2 and O2 and thereby reduce O2 toxicity and barotrauma. All patients were tracheally intubated, sedated, and chemically paralyzed and had a PaO2 < 60 mmHg when the lungs were ventilated with an FIO2 = 1.0 and a positive end expiratory pressure of > or = 5 cmH2O. The right common femoral vein was located surgically, and the patient was systemically anticoagulated with heparin. A hollow introducer tube was inserted into the right common femoral vein, and the furled IVOX was passed into the inferior vena cava and advanced until the tip was in the lower portion of the superior vena cava. IVOX use ranged from 2 h to 4 days. In this group of patients, IVOX gas exchange ranged from 21 to 87 ml x min-1 of CO2 and from 28 to 85 ml x min-1 of O2. One of the five patients survived and was discharged from the hospital. The IVOX transferred up to 28% of metabolic gas-exchange requirements. One patient with a small vena cava showed signs of caval obstruction. Three other patients demonstrated signs of a septic syndrome after the device was inserted.(ABSTRACT TRUNCATED AT 250 WORDS)

Single-Injection Adductor Canal Block With Multiple Adjuvants Provides Equivalent Analgesia When Compared With Continuous Adductor Canal Blockade for Primary Total Knee Arthroplasty: A Double-Blinded, Randomized, Controlled, Equivalency Trial

BACKGROUND

Peripheral nerve blockade is used to provide analgesia for patients undergoing total knee arthroplasty. This study compared a single-injection adductor canal block (SACB) with adjuvants to continuous adductor canal blockade (CACB). The hypothesis was that the 2 groups would have equivalent analgesia at 30 hours after neural blockade.

METHODS

This was a double-blinded, randomized, controlled, equivalency trial. Sixty patients were randomized to either the SACB group (20 mL of 0.25% bupivacaine, 1.67 mcg/mL of clonidine, 2 mg of dexamethasone, 150 mcg of buprenorphine, and 2.5 mcg/mL of epinephrine) or the CACB group (20 mL 0.25% of bupivacaine injection with 2.5 mcg/mL of epinephrine followed by an 8 mL/h infusion of 0.125% bupivacaine continued through postoperative day 2). The primary outcome was movement pain scores at 30 hours using the numeric rating scale (NRS). The secondary outcomes included serial postoperative NRS pain scores (rest and movement every 6 hours), opioid consumption, time to first opioid administration, ability to straight leg raise, patient satisfaction, length of stay, and the incidence of nausea/vomiting.

RESULTS

An intention-to-treat analysis included 59 patients. The NRS pain scores with movement were equivalent at 30 hours (SACB 5.5 ± 2.8 vs CACB 5.7 ± 2.9 [mean NRS ± standard deviation]; mean difference 0.2 [-1.5 to 1.0 {90% confidence interval}]). All NRS pain scores were equivalent until 42 hours (rest) and 48 hours (rest and movement) with the CACB group having lower pain scores. Other secondary outcomes were not statistically different.

CONCLUSION

An SACB provides equivalent analgesia for up to 36 hours after block placement when compared with a CACB for patients undergoing total knee arthroplasty, though a CACB was favored at 42 hours and beyond.

Quality-of-Life Evaluation After Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy

BACKGROUND

Cytoreductive surgery (CS) with hyperthermic intraperitoneal chemotherapy (HIPEC) for peritoneal metastases can alleviate symptoms and prolong survival at the expense of morbidity and quality of life (QoL). This study aimed to monitor QoL and outcomes before and after HIPEC.

METHODS

A prospective QoL trial of patients who underwent HIPEC for peritoneal metastases from 2000 to 2015 was conducted. The patients completed the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36), the Functional Assessment of Cancer Therapy + Colon Subscale (FACT-C), the Brief Pain Inventory, the Center for Epidemiologic Studies Depression scale, and the Eastern Cooperative Oncology Group (ECOG) performance status at baseline, then 3, 6, 12, and 24 months after HIPEC. The trial outcome index (TOI) was analyzed. Proportional hazards modeled the effect of baseline QoL on survival.

RESULTS

The 598 patients (53.8 % female) in the study had a mean age of 53.3 years. The overall 1-year survival rate was 76.8 %, and the median survival period was 2.9 years. The findings showed a minor morbidity rate of 29.3 %, a major morbidity rate of 21.7 %, and a 30-day mortality rate of 3.5 %. The BPI (p < 0.0001) and worst pain (p = 0.004) increased at 3 months but returned to baseline at 6 months. After CS + HIPEC, FACT-C emotional well-being, SF-36 mental component score, and emotional health improved (all p < 0.001). Higher baseline FACT-General (hazard ratio [HR], 0.92; 95 % confidence interval [CI], 0.09-0.96), FACT-C (HR, 0.73; 95 % CI 0.65-0.83), physical well-being (HR, 0.71; 95 % CI 0.64-0.78), TOI (HR, 0.87; 95 % CI 0.84-0.91), and SF-36 vitality (HR, 0.88; 95 % CI 0.83-0.92) were associated with improved survival (all p < 0.001). Higher baseline BPI (HR, 1.1; 95 % CI 1.05-1.14; p < 0.0001), worst pain (HR, 1.06; 95 % CI 1.01-1.10; p = 0.01), and ECOG (HR, 1.74; 95 % CI 1.50-2.01; p < 0.0001) were associated with worse survival.

CONCLUSIONS

Although HIPEC is associated with morbidity and detriments to QoL, recovery with good overall QoL typically occurs at or before 6 months. Baseline QoL is associated with morbidity, mortality, and survival after HIPEC.

Clinical significance of a NAD(P)H: quinone oxidoreductase 1 polymorphism in patients with disseminated peritoneal cancer receiving intraperitoneal hyperthermic chemotherapy with mitomycin C

Recent data indicate that NAD(P)H: quinone oxidoreductase 1 (NQO1) is important in the activation of mitomycin C. A polymorphism in human NQO1 (609C>T) is associated with diminished NQO1 activity. The purpose of our study was to determine the effect of the 609C>T polymorphism on tumor NQO1 activity and overall survival in patients with disseminated peritoneal cancer receiving intraperitoneal mitomycin C therapy. Patients with disseminated peritoneal cancer of gastrointestinal or other origin were eligible. Following aggressive surgical debulking, patients were administered a 2-h heated (40.5 degrees C) intraperitoneal perfusion with mitomycin C. NQO1 activity was determined in tumor tissue obtained during surgery and patients were genotyped for the NQO1 C609T polymorphism using a polymerase chain reaction-based method. The major response variable monitored during the trial was overall survival. Of the 117 patients genotyped for the NQO1 609C>T polymorphism, 67% were wild-type (WT), 31% were heterozygous (HE), and 2% were homozygous mutant (HM). In tumor tissue, the mean NQO1 activities from WT (n = 14) and HE (n = 5) patients were 794 +/- 603 and 70 +/- 133.1 nmol/min/mg protein respectively (P = 0.006). Significant differences in survival between WT versus HE/HM genotypes were noted in optimally debulked patients (R0/R1) (43.6+ months, median not yet reached versus 23 months respectively, P = 0.037) and in patients with peritoneal carcinomatosis of colonic origin (18.2 versus 11.5 months respectively, P = 0.050). These data indicate that the NQO1 609C>T polymorphism results in significantly reduced tumor NQO1 activity and reduced survival in subsets of patients receiving intraperitoneal hyperthermic mitomycin C therapy.

Tumour inhibitory plants. The alkaloids of Bruguiera sexangula and Bruguiera exaristata (Rhizophoraceae)

Tropine and tropine esters of acetic, propionic (a new natural ester), n-butyric (a new natural ester), isobutyric, α-methylbutyric or isovaleric, and benzoic acids have been identified in crude alkaloid mixtures from the bark of B. sexangula and B. exaristata. The major component of the mixtures from both species was a new alkaloid, brugine, (+)-tropine 1,2-dithiolan-3-carboxylate.

Stability of arterial to end-tidal carbon dioxide gradients during postoperative cardiorespiratory support

The changes in the arterial to end-tidal carbon dioxide gradient. P(a-ET)CO2, were studied in postoperative cardiac surgery patients from the time of admission to the intensive care unit, during changing cardiorespiratory support, up to the time of tracheal extubation. Individual factors evaluated for their effects on P(a-ET)CO2 included rate of mechanical ventilation, infusion of vasoactive agents (nitroglycerin, nitroprusside, dopamine, dobutamine, and metariminol), and associated changes in haemodynamic pathophysiology (cardiac index, pulmonary artery pressure, pulmonary vascular resistance index, systemic vascular resistance index, and pulmonary capillary wedge pressure). After approval by the Clinical Investigation Committee, 59 patients, age 63 +/- 9 (41 to 75) yr, were studied and 382 individual gradient determinations made. Mean P(a-ET)CO2 was 5.47 +/- 5.21 mmHg, with the mean PaCO2, 36.51 +/- 5.89 mmHg and mean ETCO2, 31.04 +/- 6.44 mmHg. For the population as a whole, the correlation between PaCO2 and ETCO2 determined by regression analysis was maintained (R = 0.644, P less than 0.001). Comparison of the individual and population correlation coefficients by Student's t test showed no significant difference, but a normal population distribution of the gradients (P less than 0.05). None of the variables assessed could be determined to influence P(a-ET)CO2 significantly. For many of the individual patients, however, the relationship between PaCO2 and ETCO2 did not maintain a significant correlation throughout the study period. In the postoperative cardiac surgery patient population P(a-ET)CO2 follows a normal distribution and PaCO2 and ETCO2 maintain a statistically significant correlation. However, when evaluating individual patients, this relationship has wide variability.

Multiple Factors Affect Renal Dietitians’ Use of the NKF-K/DOQI Adult Nutrition Guidelines

OBJECTIVE

We investigated the components of the National Kidney Foundation-Kidney Disease Outcomes Quality Initiative Nutrition Guidelines that are implemented by renal dietitians and the types of resources and support available to assist in implementing these guidelines.

DESIGN AND PARTICIPANTS

A 49-item survey was mailed to 1694 dietitians in the United States. who were members of the National Kidney Foundation Council on Renal Nutrition in June 2003. The survey included sections on clinical practice, tools available to perform nutrition assessments, daily activities of the dietitian, and demographic and professional questions.

RESULTS

Of the 1694 surveys mailed, 951 were returned (56% response rate); 848 were useable (89%). The primary employer was for-profit dialysis units (67%) and the mean (+/- SD) number of patients per dietitian was 104.9 +/- 48.3. Virtually all of the dietitians were aware of the nutrition guidelines (97%); 58% read all of the guidelines, whereas only 41% read some of the guidelines. Ninety-two percent of respondents implemented at least one guideline in their clinical practice; 72% and 55% had implemented 5 and 10 guidelines, respectively; but only 5% implemented all of the guidelines. Several barriers to implementation included lack of tools such as computers, calipers, and food models (57%); inadequate time including high dietitian-to-patient ratios (40%); and lack of administrative support from the dialysis unit (29%).

CONCLUSIONS

There are multiple barriers that prevent the adequate assessment of the nutritional status of dialysis patients. Only after these resources are provided will it be possible to determine the impact of the nutrition guidelines on patient outcomes.

Cost analysis of the History, ECG, Age, Risk factors, and initial Troponin (HEART) Pathway randomized control trial

INTRODUCTION

The HEART Pathway is a diagnostic protocol designed to identify low-risk patients presenting to the emergency department with chest pain that are safe for early discharge. This protocol has been shown to significantly decrease health care resource utilization compared with usual care. However, the impact of the HEART Pathway on the cost of care has yet to be reported.

METHODS AND RESULTS

We performed a cost analysis of patients enrolled in the HEART Pathway trial, which randomized participants to either usual care or the HEART Pathway protocol. For low-risk patients, the HEART Pathway recommended early discharge from the emergency department without further testing. We compared index visit cost, cost at 30 days, and cardiac-related health care cost at 30 days between the 2 treatment arms. Costs for each patient included facility and professional costs. Cost at 30 days included total inpatient and outpatient costs, including the index encounter, regardless of etiology. Cardiac-related health care cost at 30 days included the index encounter and costs adjudicated to be cardiac-related within that period. Two hundred seventy of the 282 patients enrolled in the trial had cost data available for analysis. There was a significant reduction in cost for the HEART Pathway group at 30 days (median cost savings of $216 per individual), which was most evident in low-risk (Thrombolysis In Myocardial Infarction score of 0-1) patients (median savings of $253 per patient) and driven primarily by lower cardiac diagnostic costs in the HEART Pathway group.

CONCLUSIONS

Using the HEART Pathway as a decision aid for patients with undifferentiated chest pain resulted in significant cost savings.

Ethnic variation in the correlation between random serum glucose concentration and glycated haemoglobin

AIMS

To determine if the relationship between serum glucose concentration and glycated haemoglobin is different between African-Americans and whites.

METHODS

Retrospective cross-sectional study comparing the association between glycated haemoglobin and serum glucose levels, based upon ethnicity. Two databases were evaluated: (i) 4215 African-American and 6359 white outpatients who had simultaneous glycated haemoglobin, random serum glucose and creatinine concentration measurements between 2000 and 2007 at the North Carolina Baptist Hospital and (ii) 1021 white and 312 African-American Diabetes Heart Study (DHS) participants.

RESULTS

In North Carolina Baptist Hospital clinic attendees, a given glycated haemoglobin was associated with higher serum glucose concentrations in African-Americans compared with whites. In a multivariate model with glycated haemoglobin as the outcome variable, racial differences remained significant after adjustment for serum glucose, age, gender and kidney function. For individuals with a serum glucose between 5.6 and 8.3 mmol/l, the glucose : glycated haemoglobin ratio was 1.03 +/- 0.16 mmol/l/% in white individuals and 0.99 +/- 0.17 mmol/l/% in African-Americans (P < 0.0001). For a glycated haemoglobin value of 7.0%, there was a 0.98-mmol/l difference in predicted serum glucose concentration in 50-year-old African-American men, relative to white. Results were replicated in the DHS, where in a best-fit linear model, after adjustment for glucose, African-American race was a significant predictor of glycated haemoglobin (P < 0.0001).

CONCLUSIONS

African-Americans have higher glycated haemoglobin values at given serum glucose concentrations relative to whites. This finding may contribute to the observed difference in glycated haemoglobin values reported between these race groups.

Clinical, histopathologic, and radiographic indicators of malignancy in head and neck paragangliomas

OBJECTIVE: The goal of this study is to review our series of head and neck paragangliomas to identify factors that may help in predicting malignancy.

STUDY DESIGN: Case series with chart review.

SETTING: Academic medical center.

SUBJECTS AND METHODS: Subjects with head and neck paragangliomas at our institution from 1976 to current were reviewed. In addition to statistical comparisons of epidemiologic factors, pathologic and radiographic characteristics were reviewed.

RESULTS: Of the 84 subjects, there were seven malignant paragangliomas (8%). Age was found to be significantly different between the benign and malignant subgroups, with an average age of 54 ± 16 and 40 ± 12 years, respectively ( P = 0.02). Pain was a presenting complaint in five patients with benign disease (6%), and five of the seven malignant patients (71%) presented with pain, showing a significant association between pain and disease type ( P <0.0001). The odds ratio for a patient with pain having a malignant tumor was 36 (95% CI: 5.5–234). Enlarging neck mass was noted in all cases of malignant disease, but only in 31 percent of cases of benign disease ( P < 0.0001). In a secondary analysis of carotid body tumors alone, enlarging neck mass was not found to be significant between benign and malignant disease ( P = 0.14). However, pain continued to be significantly different, with 67 percent of malignant lesions demonstrating pain, compared with only 11 percent of benign lesions ( P = 0.01). CONCLUSION: This study suggests that pain, a rapidly enlarging neck mass, and younger age are predictive factors of underlying malignancy, which should prompt one to consider an aggressive diagnostic and management approach.

Predictors of success after embryo transfer: experience from a single provider

OBJECTIVE

Our goal was to examine the variables present at the time of embryo transfer and to determine their effects on the clinical pregnancy rate.

STUDY DESIGN

All fresh and frozen embryo transfers during a 3-year period in a university-based in vitro fertilization program were examined. Female age, previous in vitro fertilization attempt, diagnosis, embryo number and quality, transfer technique, and presence of a clinical pregnancy were recorded for each couple. Logistic regression analyses were performed both univariately and multivariately to determine the association between a clinical pregnancy and the independent variables.

RESULTS

All transfers during the study period were included in the analysis. The four primary diagnoses were pelvic or tubal disease, male factor infertility, unexplained infertility, and endometriosis. The 46 frozen embryo transfers had a clinical pregnancy rate similar to that among the 159 fresh embryo transfers and were therefore included in the analysis. One variable was found to significantly affect the outcome, the number of high-grade embryos placed. The presence of a previous failed embryo transfer tended to lower the success rate for future attempts; however, this result did not reach statistical significance. The catheter type and the transfer difficulty did not affect outcome.

CONCLUSION

The two most important variables for predicting a clinical pregnancy are a first-time transfer and the number of high-grade embryos placed. Neither the type of embryo transfer catheter used nor the diagnosis affected outcome. In this small sample difficult embryo transfers did not diminish the chance for a successful outcome.

Hyperbaric nitrous oxide as a sole anesthetic agent in humans

Nitrous oxide (N2O) has been used to produce analgesia and anesthesia for more than 100 yr. However, because of its high MAC value (1.04), general anesthesia with N2O can usually be attained only in a hyperbaric environment. Because of the sparsity of documentation for human physiologic responses to hyperbaric N2O, we studied eight male volunteers at 2 ATA (1520 mm Hg) anesthetized with N2O only for periods of 2-4 h. N2O partial pressures ranged from 836 to 1368 mm Hg. The anesthetic state was associated with tachypnea, tachycardia, increases in systemic blood pressure, mydriasis, diaphoresis, and at times, clonus and opisthotonus. A stable level of physiologic activity was difficult to maintain.