Impact of comorbidities on perioperative outcomes for carcinoma of oral cavity

INTRODUCTION

Surgical management of oral cavity carcinoma involves composite resection with reconstruction. Comorbidities increase the risk of perioperative complications. Objective stratification is important for uneventful recovery. The Charlson Comorbidity Index and the Washington University Head and Neck Comorbidity Index were used to assess perioperative morbidity and mortality.

MATERIALS AND METHODS

This was a prospective study of 531 patients with head and neck squamous cell carcinoma who were treated between January 2014 and December 2017. Patients' comorbidity scores on the Charlson Comorbidity Index and Washington University Head and Neck Comorbidity Index were recorded.

RESULTS

The median age of the cohort was 49 years. Median Charlson Comorbidity Index score was 3 and Washington University Head and Neck Comorbidity Index was 0. There were five mortalities with a Charlson Comorbidity Index score of 4 or more. Fifteen patients had either infection, leak or postoperative bleeding. A Charlson Comorbidity Index of 4 or more was associated with higher event rate and poor overall survival (p=0.001).

CONCLUSION

Higher Charlson Comorbidity Index score is associated with increased incidence of peri-operative morbidity and mortality, while the Washington University Head and Neck Comorbidity Index is a poor predictor of the same.

Venetoclax, bendamustine, and rituximab in patients with relapsed or refractory NHL: a phase Ib dose-finding study

Background

Venetoclax is a selective, potent inhibitor of the anti-apoptotic B-cell leukemia/lymphoma-2 protein approved for treatment of chronic lymphocytic leukemia. We conducted a dose-finding study of venetoclax in combination with bendamustine-rituximab (BR) in patients with relapsed/refractory non-Hodgkin's lymphoma (NHL).

Patients and methods

BR was given for six cycles at standard doses. Intermittent and continuous oral venetoclax administration was explored at 50-1200 mg daily doses. Co-primary objectives included safety, pharmacokinetics (PKs), maximum-tolerated dose (MTD), and recommended phase II dose (RP2D); secondary objective was preliminary efficacy.

Results

Sixty patients were enrolled: 32 with follicular lymphoma, 22 with diffuse large B-cell lymphoma, and 6 with marginal zone lymphoma. Nausea (70%), neutropenia (68%), diarrhea (55%), and thrombocytopenia (52%) were the most frequent adverse events (AEs). Most common grade 3/4 AEs were neutropenia (60%) and lymphopenia (38%). Serious AEs were reported in 24 patients; the most frequent were febrile neutropenia and disease progression (8% each). Five patients died from either disease progression (n = 4) or respiratory failure (n = 1). MTD was not reached; RP2D for venetoclax-BR combination was established as 800 mg daily continuously. Venetoclax PK exposure with and without BR was comparable. For all patients, overall response rate was 65%. Median duration of overall response, overall survival, and progression-free survival was 38.3 months [95% confidence interval (CI) 10.4-NR], not yet reached, and 10.7 months (95% CI 4.3-21.0), respectively.

Conclusions

This study established the safety profile of venetoclax in combination with BR, and results demonstrated tolerability and preliminary efficacy of the combination. Additional follow-up is needed to better determine the future role of BR plus venetoclax in the treatment of relapsed/refractory B-cell NHL.

Trial registered

Clinicaltrials.gov, NCT01594229.

Comparing the cost of essential nutrients from different food sources in the American diet using NHANES 2011-2014

Background

One reason that some Americans do not meet nutrient needs from healthy eating patterns is cost. Food cost affects how people eat, and healthy diets tend to be more expensive. Cost is also important for diet sustainability. Sustainable eating patterns must be both nutritionally adequate and affordable. The objective of this study was to compare the cost of obtaining shortfall nutrients from different food groups to help identify cost-effective ways Americans can move towards healthy and sustainable eating patterns.

Methods

This analysis used dietary intake data from the National Health and Nutrition Examination Survey from 2011 to 2012 and 2013–2014 (n = 5876 children 2–18 years and n = 9953 adults 19–99 years). Americans’ nutrient intake from food categories in “What We Eat in America” and the 2015–2020 Dietary Guidelines for Americans was determined using the Food and Nutrient Database for Dietary Studies. Food cost and the cost of nutrients were obtained from Center for Nutrition Promotion and Policy food cost database 2001–2002 and 2003–2004 (adjusted for inflation).

Results

The daily mean cost of food was $4.74 ± 0.06 for children and $6.43 ± 0.06 for adults. “Protein foods” and “mixed dishes” were the two most expensive food categories (43–45% of daily food costs), while “grains,” “fruits,” and “vegetables” combined accounted for ~ 18% of the daily cost, and “milk and dairy” accounted for 6–12% of total daily food costs in both adults and children. “Milk and dairy” were the least expensive dietary sources of calcium and vitamin D in the American diet, while “grains” were the least expensive sources of iron and magnesium, and “protein foods” were the least expensive sources of choline. “Fruits” and “vegetables” were the least expensive sources of potassium and vitamin C, respectively, and “snacks and sweets” were the least expensive sources of vitamin E.

Conclusion

“Milk and dairy” were inexpensive sources of three of the four nutrients of public health concern (calcium, vitamin D, and potassium), while “grains” were the least expensive source of fiber. The results of this work reinforce the importance of consuming a variety of nutrient-rich foods for cost-effective, sustainable eating patterns.

Intake of 100% Fruit Juice Is Associated with Improved Diet Quality of Adults: NHANES 2013-2016 Analysis

Fruit intake is generally associated with better diet quality and overall health. This report examined the effect of 100% fruit juice (considered a part of total fruit servings) and its replacement with whole fruits equivalents on nutrient intake and diet quality. National Health and Nutrition Examination Survey 2013-2016 data (24-h dietary recall) from adults 19+ years (n = 10,112) were used to assess the diet quality and nutrient intakes and to isocalorically replace with 100% fruit juice intakes whole fruit equivalents in a modeling analysis. About 15.6% adults were 100% fruit juice consumers. Consumers had higher diet quality (10% higher Healthy Eating Index, HEI 2015 score), and higher intakes of energy, calcium, magnesium, potassium, vitamin C and vitamin D than non-consumers. Consumption of 100% fruit juice was also associated with lower risk of being overweight/obese (-22%) and having metabolic syndrome (-27%). Replacing 100% fruit juice with whole fruits equivalents did not affect nutrient intake except for a modest increase (+6.4%) in dietary fiber. Results show that 100% fruit juice intake was associated with better diet quality and higher nutrient intake. Replacement of 100% fruit juice intake with whole fruits equivalents had no significant effect on nutrients except for dietary fiber.

Harmonically Confined Particles with Long-Range Repulsive Interactions

We study an interacting system of N classical particles on a line at thermal equilibrium. The particles are confined by a harmonic trap and repel each other via pairwise interaction potential that behaves as a power law ∝∑[under i≠j][over N]|x_{i}-x_{j}|^{-k} (with k>-2) of their mutual distance. This is a generalization of the well-known cases of the one-component plasma (k=-1), Dyson's log gas (k→0^{+}), and the Calogero-Moser model (k=2). Because of the competition between harmonic confinement and pairwise repulsion, the particles spread over a finite region of space for all k>-2. We compute exactly the average density profile for large N for all k>-2 and show that while it is independent of temperature for sufficiently low temperature, it has a rich and nontrivial dependence on k with distinct behavior for -2<k<1, k>1 and k=1.

Caffeine Intake and Demographic Characteristics of Shift Workers: A Cross-sectional Analysis Using NHANES 2005–2010 Data (P14-001-19)

Objectives

Caffeine is the most widely consumed stimulant in the world and sociodemographic factors including occupation are associated with its intake. Non-standard work schedules are required in various occupations, and it is difficult to adapt to them. Shift work is associated with poor sleep, inadequate diet and numerous adverse health effects. We assessed whether caffeine intake differs in individuals working various shifts since it is assumed shift workers use more caffeine to cope with fatigue and disrupted circadian rhythms.

Methods

The 24-h dietary recall data collected in NHANES 2005–2010 datasets (employed adults age 19–70 years, n = 8500) were used to estimate individual usual caffeine intake from caffeine-containing foods and beverages. Daily patterns of work were self-reported as: regular daytime shift; evening shift; night shift; rotating shift; or “other”. Regression analyses assessed associations of shift work with caffeine intake after adjustment for age, gender, ethnicity, smoking status, work hours, energy intake, and alcohol intake, all known to be associated with caffeine intake.

Results

Approximately 73.5% of employed adults were day shift workers and 26.5% were non-day shift workers. Day shift workers were more likely to be non-Hispanic white and of higher economic status compared to other shift workers. Mean 24-hour caffeine intake of day shift workers (204 ± 5 mg) was similar (P > 0.2) to that of evening, night, and rotating shift workers (209 ± 23, 184 ± 18, and 199 ± 15 mg, respectively). Regardless of work schedule, individuals consumed the most caffeine during morning hours. Evening and night shift workers consumed less caffeine during their work hours (76.8 ± 8.8 and 98.4 ± 18.5 mg, respectively) and more during non-work hours (131 ± 24 and 84.9 ± 9.5 mg, respectively) compared to day shift workers (157 ± 4 and 49.7 ± 3.4 mg during work hours and non-work hours, respectively; P < 0.01 for both).

Conclusions

Unexpectedly, daily caffeine intake was similar across different types of shift workers after adjustment for age, gender, ethnicity, smoking, economic status and other factors.

Opinions or assertions contained herein are private views of the authors and not to be construed as official or reflecting views of the Army or DoD.

Funding Sources

DMRP/MRMC.

Comparing the Cost of Essential Nutrients from Different Food Sources in the American Diet (OR20-04-19)

Objectives

The cost of food, along with several other factors, influences how people eat and is an important facet of sustainability. Sustainable eating patterns are both nutritionally adequate and affordable. The objective of this study was to compare the cost to the consumer of obtaining shortfall nutrients from different food groups: milk and dairy, protein foods, mixed dishes, grains, snacks & sweets, fruits, and vegetables.

Methods

This analysis used dietary intake data from the National Health and Nutrition Examination Survey from 2011–2012 and 2013–2014 (n = 5876 children age 2–18 years and 9953 adults age 19–99 years). Americans’ nutrient intake from food categories in “What We Eat in America” and the 2015–2020 Dietary Guidelines for Americans was determined using the Food and Nutrient Database for Dietary Studies. Food cost and the cost of nutrients were obtained from Center for Nutrition Promotion and Policy food cost database 2001–2002 and 2003–2004 and adjusted for inflation.

Results

The daily mean cost of food was $4.74 ± 0.06 for children and $6.43 ± 0.06 for adults. “Protein foods” and “mixed dishes” were the two most expensive food categories (43–45% of daily food costs), and “milk and dairy” accounted for 6–12% of total daily food costs in both adults and children. “Milk and dairy” were also the least expensive dietary sources of calcium and vitamin D in the American diet. “Protein foods” and “grains” were the main dietary sources of choline, and “protein foods” were also the least expensive sources of choline. “Grains” were the least expensive sources of iron and magnesium, while “fruits” and “vegetables” were the least expensive sources of potassium and vitamin C, respectively. “Snacks & sweets” were the least expensive sources of vitamin E. Although “milk and dairy” were not the least costly sources of potassium, magnesium and vitamin A, they were the second least expensive.

Conclusions

In addition to contributing essential nutrients to the American diet, “milk and dairy” are also inexpensive sources for several of these nutrients, including three of the four “nutrients of public health concern” (calcium, vitamin D, and potassium), indicating that dairy foods can be part of sustainable eating patterns.

Funding Sources

National Dairy Council.

Sodium and Potassium in the American Diet: Important Food Sources from NHANES 2015–2016 (P18-045-19)

Objectives

This analysis used data from the 2015–2016 National Health and Nutrition Examination Survey (NHANES) to identify major food sources of sodium, potassium, or both in the American diet.

Methods

Twenty-four-hour dietary recall data (n = 7817) from the dietary component of the 2015–2016 NHANES was used. Data was analyzed separately for children age 2–18 years and for adults age 19 + years using day one sample weights. Percent sodium and potassium contributions from 48 food subgroups of “What We Eat in America” were determined using SAS (PROC SURVEYREG) and the ratio method.

Results

The top five food sources of sodium for children 2–18 years of age were: mixed dishes – sandwiches (8.9%), mixed dishes – pizza (8.4%), cured meat/poultry (6.7%), mixed dishes – grain based (6.2%), and poultry (6.0%). Major food sources of potassium for children were milk (11.7%), fruits (7.1%), white potatoes (5.6%), mixed dishes – sandwiches (5.2%), and 100% fruit juices (4.8%). In adults, the top five sources of sodium were mixed dishes – sandwiches (7.5%), cured meat/poultry (7.0%), mixed dishes – Mexican (6.1%), poultry (5.5%), and breads, rolls, tortillas (5.4%). Major food sources of potassium for adults were coffee and tea (8.1%), vegetables, excluding potatoes (7.9%), fruits (6.2%), white potatoes (6.1%), and milk (4.9%). Milk was a minor source of sodium for children (2.6%) and in adults (1.2%). While previous research shows cheese as a source of sodium in the U.S. diet, cheese as consumed was not one of the top 5 sources of sodium for adults or children. However, it is a component of several of the mixed dishes identified in this analysis.

Conclusions

In children, sandwiches was a top food source of both sodium and potassium. There were no other overlaps in sources of sodium and potassium. Mixed dishes were top food sources of sodium in the diets of both children and adults, while milk, fruits, and potatoes were top food sources of potassium for both groups. This information could be used to help Americans move closer to Dietary Guidelines for Americans recommendations for both sodium and potassium.

Funding Sources

National Dairy Council.

Exploring organizational support for the provision of structured self-management education for people with Type 2 diabetes: findings from a qualitative study

AIM

To explore the organizational context in which Type 2 diabetes structured group education is provided.

METHODS

Four Clinical Commissioning Groups in England providing Type 2 diabetes structured self-management education participated in a qualitative study exploring the context for provision of that education. Using UK National Diabetes Audit returns, two Clinical Commissioning Groups were selected that had non-attendance rates of ≤25%, and two that had non-attendance rates of ≥50%. Between May 2016 and August 2017, 20 interviews were conducted with Clinical Commissioning Group staff including: commissioners, healthcare professionals, managers, general practitioners and diabetes educators. Data gathering was prolonged as it proved challenging to engage with healthcare staff as a result of frequent local restructuring and service disruption.

RESULTS

Local audits revealed discrepancies in basic data such as referral and attendance numbers compared with national audit data. There was a commonality in the themes identified from interviews: diabetes education was rarely embedded in service structure; where education uptake was poor, a lack of central support to delivery teams was noticeable; and where education uptake was positive, delivery teams were actively engaged, sometimes relying on enthusiastic individuals. Both situations put the local sustainability of diabetes education at risk.

CONCLUSIONS

There appears to be a link between attendance rates and organizational issues, therefore, when considering how to increase attendance rates, the state of the diabetes education infrastructure should be reviewed. Good uptake of diabetes education can be too reliant on the enthusiastic commitment of small teams or individuals delivering the education.

Do Americans Get Enough Nutrients from Food? Assessing Nutrient Adequacy with NHANES 2013–2016 (P18-040-19)

Objectives

Following dietary recommendations should ensure adequate consumption of essential nutrients, including key nutrients that tend to be underconsumed. The objective of this analysis was to determine if Americans are meeting nutrient needs, especially for shortfall nutrients, as defined by the Dietary Guidelines for Americans, by assessing average food intakes with data from the National Health and Nutrition Examination Survey (NHANES) from 2013–2016.

Methods

Twenty-four-hour dietary recall data from children age 2–18 years (n = 5670) and adults age 19–99 years (n = 10,112) participating in NHANES 2013–2014 and 2015–2016 were analyzed using day one sample weights. Usual intake of nutrients was determined using the National Cancer Institute method with two dietary recalls. The percentage of population with inadequate (intake below the Estimated Average Requirement) or sufficient (intakes above the Adequate Intake, AI) intake of shortfall nutrients was determined using the cut-point method. With iron, the probability method was used instead.

Results

Nearly half of the population does not consume adequate calcium (47.4 ± 1.8% children; 44.5 ± 1.1% adults). Even more of the population does not consume enough vitamin D (93.7 ± 0.8% children; 94.8 ± 0.5% adults). Non-Hispanic black children and adults had higher rates of inadequate calcium and vitamin D consumption than other ethnic groups. Large proportions of the population also do not consume enough magnesium (36.2 ± 1.4% children; 53.3 ± 1.2% adults), vitamin A (23.8 ± 2.0% children; 45.5 ± 1.1% adults), vitamin C (22.6 ± 1.6% children; 48.3 ± 1.3% adults) or vitamin E (67.2 ± 1.3% children; 79.0 ± 1.3% adults). Approximately 2.95 ± 0.47% children and 6.02 ± 0.30% adults had inadequate iron intake. Only a small proportion of children and adults consumed more dietary fiber and potassium than the AI for their age groups. Additionally, 20.0 ± 1.1% children and 8.31 ± 0.73% adults had choline intake above the AI.

Conclusions

Large percentages of American children and adults do not meet recommendations for underconsumed “nutrients of public health concern” or shortfall nutrients. Encouraging children and adults to consume nutrient-rich foods, such as dairy, fruits and vegetables, can help close these gaps.

Funding Sources

National Dairy Council.

Disrupted radial and tibial microarchitecture in patients with monoclonal gammopathy of undetermined significance

Patients with monoclonal gammopathy of undetermined significance (MGUS) had abnormalities in volumetric BMD (vBMD), microarchitecture, and stiffness at both the radius and tibia by high-resolution peripheral quantitative CT compared to matched controls. This is the first report demonstrating that patients with MGUS have microarchitectural deficits at multiple skeletal sites.

INTRODUCTION

Fracture risk is elevated in patients with monoclonal gammopathy of undetermined significance (MGUS). However, the pathogenesis of bone disease in these patients is poorly understood. Prior work using high-resolution peripheral CT (HRpQCT) demonstrated abnormal microarchitecture at the radius, with predominantly cortical abnormalities. We hypothesized that patients with MGUS have abnormal microarchitecture at both radius and tibia compared to controls, reflecting global skeletal effects of the disease.

METHODS

This case-control study enrolled 36 subjects; patients with MGUS (n = 12) were matched 1:2 by age, sex, and race to controls (n = 24). Areal BMD (aBMD) was measured by DXA, vBMD, and microarchitecture by HRpQCT, and whole bone stiffness by finite element analysis. Serum was drawn for markers of bone metabolism and inflammation.

RESULTS

By DXA, MGUS patients had lower aBMD at the lumbar spine, femoral neck, and 1/3 radius. Markers of bone metabolism and inflammation did not differ. By HRpQCT at the radius, MGUS patients had lower total, trabecular and cortical density, lower trabecular number, and greater trabecular separation and heterogeneity. At the tibia, MGUS patients had lower total and trabecular density, lower trabecular number, greater separation and heterogeneity, and lower whole bone stiffness.

CONCLUSIONS

Patients with MGUS had lower vBMD, cortical, and trabecular abnormalities at the radius compared to matched controls. At the tibia, trabecular abnormalities predominated. These results suggest that in addition to previously described cortical deficits, deterioration of trabecular bone may contribute to a generalized skeletal fragility in patients with MGUS.