Imaging skeletal muscle volume, density, and FDG uptake before and after induction therapy for non-small cell lung cancer

AIM

To assess whether changes in body composition could be assessed serially using conventional thoracic computed tomography (CT) and positron-emission tomography (PET)/CT imaging in patients receiving induction chemotherapy for non-small cell lung cancer (NSCLC).

MATERIALS AND METHODS

CT-based skeletal muscle volume and density were measured retrospectively from thoracic and lumbar segment CT images from 88 patients with newly diagnosed and untreated NSCLC before and after induction chemotherapy. Skeletal muscle 2-[¹⁸F]-fluoro-2-deoxy-d-glucose (FDG) uptake was measured from PET/CT images from a subset of patients (n=42). Comparisons of each metric before and after induction chemotherapy were conducted using the non-parametric Wilcoxon signed-rank test for paired data. The association between clinical factors and percentage change in muscle volume was examined using univariate linear regression models, with adjustment for baseline muscle volume.

RESULTS

Following induction chemotherapy, thoracic (-3.3%, p=0.0005) and lumbar (-2.6%, p=0.0101) skeletal muscle volume were reduced (adiposity remained unchanged). The proportion of skeletal muscle with a density <0 HU increased (7.9%, p<0.0001), reflecting a decrease in skeletal muscle density and skeletal muscle FDG uptake increased (10.4-31%, p<0.05). No imaging biomarkers were correlated with overall survival.

CONCLUSION

Changes in body composition can be measured from routine thoracic imaging. During chemotherapy skeletal muscle volume and metabolism are altered; however, there was no impact on survival in this retrospective series, and further validation in prospective, well-controlled studies are required.

Heterogeneous Recognition of beta 2-glycoprotein I by Antibodies from Antiphospholipid Syndrome Patients

Beta 2-glycoprotein I plays a pivotal role in the binding of antiphospholipid antibodies to phospholipid in patients with antiphospholipid syndrome. In this study the nature of the epitopes on beta 2-glycoprotein I (β2-GPI) recognised by sera from antiphospholipid syndrome (APS) patients (n = 15) was investigated and compared to rabbit polyclonal and mouse monoclonal anti-β2-GPI antibodies. β2-GPI was only recognised when bound to a high affinity binding support. The antigenic epitope on β2-GPI recognised by all APS patients was also dependent on disulphide bond integrity. Digestion of β2-GPI with elastase rapidly destroyed the epitope(s) on β2-GPI recognised by antibodies in 91% of APS patients. The main cleavage occurred at tryptophan316-lysine317 in the fifth domain. Digestion with staphylococcal V8 protease resulted in a 50% reduction in antibody binding in 81% of patients and the cleavage sites mainly involved the first domain of the molecule. There was considerable variability in the recognition of six different species of β2-GPI by serum from APS patients. The epitopes on β2-GPI bound by APS sera appear conformationally determined in all patients but are quite heterogeneous in the regions of β2-GPI that are recognised.

Portal hypertension and chylous ascites complicating acute pancreatitis: the therapeutic value of portal vein stenting

Chylous ascites as a consequence of acute pancreatitis is very rare. We present an unusual case of a 73-year-old man who developed refractory chylous ascites one month after an acute severe episode of gallstone pancreatitis, associated with portal hypertension. He was successfully treated with portal vein stenting, which has remained patent to date.

Spontaneous Perforation of the UPJ: A Case Report and Review of the Literature

Spontaneous rupture of the ureter is an uncommon condition defined by non-traumatic extravasation of urine. Causative factors leading to rupture include urinary calculi, malignancies, instrumentation or trauma. Ureteral rupture can lead to numerous complications, including abscess formation, urinomas, and urosepsis. Minimal literature is available regarding spontaneous ureteral perforation, especially at the ureteropelvic junction. We present a rare case of spontaneous perforation of the ureter at the ureteropelvic junction caused by an undiagnosed non-compliant bladder. This case illustrates a previously undescribed cause of spontaneous ureteral perforation and the importance of prompt identification and treatment.

Steep discounting of delayed monetary and food rewards in obesity: a meta-analysis

BACKGROUND

An increasing number of studies have investigated delay discounting (DD) in relation to obesity, but with mixed findings. This meta-analysis synthesized the literature on the relationship between monetary and food DD and obesity, with three objectives: (1) to characterize the relationship between DD and obesity in both case-control comparisons and continuous designs; (2) to examine potential moderators, including case-control v. continuous design, money v. food rewards, sample sex distribution, and sample age (18 years); and (3) to evaluate publication bias.

METHOD

From 134 candidate articles, 39 independent investigations yielded 29 case-control and 30 continuous comparisons (total n = 10 278). Random-effects meta-analysis was conducted using Cohen's d as the effect size. Publication bias was evaluated using fail-safe N, Begg-Mazumdar and Egger tests, meta-regression of publication year and effect size, and imputation of missing studies.

RESULTS

The primary analysis revealed a medium effect size across studies that was highly statistically significant (d = 0.43, p < 10-14). None of the moderators examined yielded statistically significant differences, although notably larger effect sizes were found for studies with case-control designs, food rewards and child/adolescent samples. Limited evidence of publication bias was present, although the Begg-Mazumdar test and meta-regression suggested a slightly diminishing effect size over time.

CONCLUSIONS

Steep DD of food and money appears to be a robust feature of obesity that is relatively consistent across the DD assessment methodologies and study designs examined. These findings are discussed in the context of research on DD in drug addiction, the neural bases of DD in obesity, and potential clinical applications.

Are Atrial Fibrillation Guidelines Altering Management? A Community Based Study

Background and Aims: We wanted to determine the prevalence of atrial fibrillation (AF) in a community based cross sectional study in greater Glasgow and how current anti thrombotic management compares to published guidelines. Methods: 1466 patients with AF were identified in General Practices in our community and 1008 consented to take part. Their demographic details and medical history were recorded. Results: 1466 patients (mean age 73.4; 55% female) with AF were identified, in our community, giving a prevalence of 1%. 53% of patients were on warfarin therapy. Of those not receiving warfarin, only one third had a putative contra-indication. The proportion of AF patients on warfarin increased with increasing stroke risk, and over the period of the study. Conclusions: Prevalence of AF was in keeping with previous estimates. The proportion of patients with AF receiving warfarin therapy appears to be increasing. In the moderate risk group, there was a tendency to use more warfarin in the younger age groups compared to the elderly. It was in the moderate and low risk groups that there was still evidence of deviation from published guidelines.

Routine screening of Indigenous cancer patients' unmet support needs: a qualitative study of patient and clinician attitudes

Background

Indigenous Australians have poorer cancer outcomes in terms of incidence mortality and survival compared with non-Indigenous Australians. The factors contributing to this disparity are complex. Identifying and addressing the psychosocial factors and support needs of Indigenous cancer patients may help reduce this disparity. The Supportive Care Needs Assessment Tool for Indigenous People (SCNAT-IP) is a validated 26-item questionnaire developed to assess their unmet supportive care needs. This qualitative study reports on patient and clinician attitudes towards feasibility and acceptability of SCNAT-IP in routine care.

Methods

Forty-four in-depth semi-structured interviews were conducted with 10 clinical staff and 34 Indigenous cancer patients with heterogeneous tumours. Participants were recruited from four geographically diverse Australian cancer clinics. Transcripts were imported into qualitative analysis software (NVivo 10 Software), coded and thematic analysis performed.

Results

Indigenous patients (mean age 54.4 years) found the SCNAT-IP beneficial and easy to understand and they felt valued and heard. Clinical staff reported multiple benefits of using the SCNAT-IP. They particularly appreciated its comprehensive and systematic nature as well as the associated opportunities for early intervention. Some staff described improvements in team communication, while both staff and patients reported that new referrals to support services were directly triggered by completion of the SCNAT-IP. There were also inter-cultural benefits, with a positive and bi-directional exchange of information and cultural knowledge reported when using the SCNAT-IP. Although staff identified some potential barriers to using the SCNAT-IP, including the time required, the response format and comprehension difficulties amongst some participants with low English fluency, these were outweighed by the benefits. Some areas for scaled improvement were also identified by staff.

Conclusions

Staff and patients found the SCNAT-IP to be an acceptable tool and supported universal screening for Indigenous cancer patients. The SCNAT-IP has the potential to help reduce the inequalities in cancer care experienced by Indigenous Australians by identifying and subsequently addressing their unmet support needs. Further research is needed to explore the validity of the SCNAT-IP for Indigenous people from other nations.

12: THE OVERUSE OF STRESS ULCER PROPHYLAXIS ON ADMISSION AND DISCHARGE AT A TERTIARY CARE TEACHING HOSPITAL: AN OBSERVATIONAL STUDY

Purpose of Study

Studies have linked the use of anti-secretory agents to nosocomial complications including Clostridium difficile–induced pseudomembranous colitis and hospital acquired pneumonia. Although there are comprehensive evidence-based guidelines for the initiation of stress ulcer prophylaxis, there are no universally accepted approaches. This has caused nationwide disorganization in current practice, which has led to their overuse. While many studies have shown the pervasiveness of stress ulcer prophylaxis overuse in the hospital setting, none have demonstrated its effect on the community through the improper discharge of patients on these medications.

Methods Used

A retrospective review of patient data at a major teaching hospital in New York City was performed. During a 2 month study period, adult non-intensive care patients were randomly selected to determine the incidence of inappropriate initiation of stress ulcer prophylaxis on admission, as compared to the incidence of appropriate use. A follow-up assessment was then completed to determine the incidence of patients that were inappropriately discharged on these medications.

Summary of Results

A total of 100 randomly selected patients throughout the inpatient medicine service were analyzed. The results showed a high rate of inappropriate initiation and discharge of patients on anti-secretory agents. The study showed a 50% (n=50) incidence of overall stress ulcer prophylaxis use. Of the patients on stress ulcer prophylaxis, a 76% (n=38) incidence of inappropriate use was found. Of the patients inappropriately on stress ulcer prophylaxis, there was a 53% (n=19) incidence of inappropriate discharge home on these medications.

Conclusions

This study highlights the continued inappropriate initiation and discharge of patients on anti-secretory agents, despite mounting evidence and advisories against this practice. The use of an electronic medical record could provide an additional resource to improve quality of care. Electronic prescriptions allow for prompts that ask for a clinical indication during the prescription process. The advent of this technology may yield even more promising improvements in clinical practice, and its implementation is the current focus of a continuing study.

Aging implications on fresh muscle traits of Certified Angus Beef steaks

Vacuum-packaged Certified Angus Beef (CAB) subprimals ( = 72) that included the longissimus thoracis (LT), longissimus lumborum (LL), gluteus medius (GM), and infraspinatus (IF) muscles were purchased from a major beef packing facility. Subprimals were allocated to 1 of 3 aging periods (14, 28, or 42 d) and aged at 2°C. After aging, 5 steaks were cut from each subprimal and assigned to pH, water-holding capacity, Warner-Bratzler shear force (WBSF), cooked color, cooking yield, cooking loss, and sensory panel analysis. Infraspinatus steaks were more tender ( < 0.05) than all other steaks, and subprimals aged 14 d had greater ( < 0.05) WBSF values than the other 2 aging periods, regardless of muscle. Water-holding capacity and cook yield were greater ( < 0.05) for LL and LT than IF and GM steaks, whereas purge loss was greater ( < 0.05) for IF and GM than LL and LT steaks. Throughout the aging periods, pH declined for all muscle groups, with IF steaks having the greatest ( < 0.05) pH values among all muscles. Among IF steaks, sensory evaluations of all attributes did not ( ≥ 0.26) differ across aging periods; yet among LT steaks, consumers rated those aged 14 d greater ( < 0.05) in overall impression than LT steaks aged 28 and 42 d. Among LT steaks, those aged 14 d received greater ( < 0.05) flavor ratings than LT steaks subjected to longer aging periods, and LT steaks aged 14 d received the greatest ( < 0.05) overall impression, with consumers giving greater ( < 0.05) overall impression scores to LT steaks aged 42 d over those aged 28 d. Aging period had no effect ( ≥ 0.017) on consumer ratings for flavor, tenderness, juiciness, or overall impression of LL steaks. Among GM steaks, consumers rated steaks aged 14 and 28 d more ( < 0.05) flavorful than those aged 42 d, and consumer ratings for overall impression were greater ( < 0.05) for GM steaks aged 28 d than for GM steaks aged 42 d; however, consumers failed ( = 0.035) to note differences in tenderness scores of GM steaks in response to aging period. Furthermore, consumers indicated a greater ( < 0.05) likelihood to purchase LT steaks aged 14 d over LT steaks aged 28 d, LL steaks aged 42 d over LL steaks aged 14 d, and GM steaks aged 14 and 28 d over GM steaks aged 42 d. These results indicate that consumers struggled to identify steak flavor attributes and suggest that the benefit of aging for premium beef products does not offer a tremendous sensory advantage to the consumer.

Common and unique associated factors for medically unexplained chronic widespread pain and chronic fatigue

OBJECTIVE

Chronic widespread pain and chronic fatigue share common associated factors but these associations may be explained by the presence of concurrent depression and anxiety.

METHODS

We mailed questionnaires to a randomly selected sample of people in the UK to identify participants with chronic widespread pain (ACR 1990 definition) and those with chronic fatigue. The questionnaire assessed sociodemographic factors, health status, healthcare use, childhood factors, adult attachment, and psychological stress including anxiety and depression. To identify persons with unexplained chronic widespread pain or unexplained chronic fatigue; we examined participant's medical records to exclude medical illness that might cause these symptoms.

RESULTS

Of 1443 participants (58.0% response rate) medical records of 990 were examined. 9.4% (N=93) had unexplained chronic widespread pain and 12.6% (N=125) had unexplained chronic fatigue. Marital status, childhood psychological abuse, recent threatening experiences and other somatic symptoms were commonly associated with both widespread pain and fatigue. No common effect was found for few years of education and current medical illnesses (more strongly associated with chronic widespread pain) or recent illness in a close relative, neuroticism, depression and anxiety scores (more strongly associated with chronic fatigue). Putative associated factors with a common effect were associated with unexplained chronic widespread pain or unexplained chronic fatigue only when there was concurrent anxiety and/or depression.

DISCUSSION

This study suggests that the associated factors for chronic widespread pain and chronic fatigue need to be studied in conjunction with concurrent depression/anxiety. Clinicians should be aware of the importance of concurrent anxiety or depression.