Type 2 Diabetes Prevention Focused on Normalization of Glycemia: A Two-Year Pilot Study

The purpose of this study is to assess the effects of an alternative approach to type 2 diabetes prevention. Ninety-six patients with prediabetes (age 52 (10) years; 80% female; BMI 39.2 (7.1) kg/m2) received a continuous remote care intervention focused on reducing hyperglycemia through carbohydrate restricted nutrition therapy for two years in a single arm, prospective, longitudinal pilot study. Two-year retention was 75% (72 of 96 participants). Fifty-one percent of participants (49 of 96) met carbohydrate restriction goals as assessed by blood beta-hydroxybutyrate concentrations for more than one-third of reported measurements. Estimated cumulative incidence of normoglycemia (HbA1c <5.7% without medication) and type 2 diabetes (HbA1c ≥6.5% or <6.5% with medication other than metformin) at two years were 52.3% and 3%, respectively. Prevalence of metabolic syndrome, class II or greater obesity, and suspected hepatic steatosis significantly decreased at two years. These results demonstrate the potential utility of an alternate approach to type 2 diabetes prevention, carbohydrate restricted nutrition therapy delivered through a continuous remote care model, for normalization of glycemia and improvement in related comorbidities.

American Brachytherapy Society Task Group Report: Use of androgen deprivation therapy with prostate brachytherapy-A systematic literature review

PURPOSE

Prostate brachytherapy (PB) has well-documented excellent long-term outcomes in all risk groups. There are significant uncertainties regarding the role of androgen deprivation therapy (ADT) with brachytherapy. The purpose of this report was to review systemically the published literature and summarize present knowledge regarding the impact of ADT on biochemical progression-free survival (bPFS), cause-specific survival (CSS), and overall survival (OS).

METHODS AND MATERIALS

A literature search was conducted in Medline and Embase covering the years 1996-2016. Selected were articles with >100 patients, minimum followup 3 years, defined risk stratification, and directly examining the role and impact of ADT on bPFS, CSS, and OS. The studies were grouped to reflect disease risk stratification. We also reviewed the impact of ADT on OS, cardiovascular morbidity, mortality, and on-going brachytherapy randomized controlled trials (RCTs).

RESULTS

Fifty-two selected studies (43,303 patients) were included in this review; 7 high-dose rate and 45 low-dose rate; 25 studies were multi-institutional and 27 single institution (retrospective review or prospective data collection) and 2 were RCTs. The studies were heterogeneous in patient population, risk categories, risk factors, followup time, and treatment administered, including ADT administration and duration (median, 3-12 months);71% of the studies reported a lack of benefit, whereas 28% showed improvement in bPFS with addition of ADT to PB. The lack of benefit was seen in low-risk and favorable intermediate-risk (IR) disease and most high-dose rate studies. A bPFS benefit of up to 15% was seen with ADT use in patients with suboptimal dosimetry, those with multiple adverse risk factors (unfavorable IR [uIR]), and most high-risk (HR) studies. Four studies reported very small benefit to CSS (2%). None of the studies showed OS advantage; however, three studies reported an absolute 5-20% OS detriment with ADT. Literature suggests that OS detriment is more likely in older patients or those with pre-existing cardiovascular disease. Four RCTs with an adequate number of patients and well-defined risk stratification are in progress. One RCT will answer the question regarding the role of ADT with PB in favorable IR patients and the other three RCTs will focus on optimal duration of ADT in the uIR and favorable HR population.

CONCLUSIONS

Patients treated with brachytherapy have excellent long-term disease outcomes. Existing evidence shows no benefit of adding ADT to PB in low-risk and favorable IR patients. UIR and HR patients and those with suboptimal dosimetry may have up to 15% improvement in bPFS with addition of 3-12 months of ADT, with uncertain impact on CSS and a potential detriment on OS. To minimize morbidity, one should exercise caution in prescribing ADT together with PB, in particular to older men and those with existing cardiovascular disease. Due to the retrospective nature of this evidence, significant selection, and treatment bias, no definitive conclusions are possible. RCT is urgently needed to define the potential role and optimal duration of ADT in uIR and favorable HR disease.

A review of the evidence on the effectiveness of children's vision screening

Screening programmes enable health conditions to be identified so that effective interventions can be offered. The aim of this review was to determine: (1) the effectiveness of children's vision screening programmes; (2) at what age children should attend vision screening; and (3) what form vision screening programmes should take to be most effective. A literature review on the effectiveness of vision screening programmes in children aged 0-16 years was undertaken. Eligible studies/reviews were identified through clinical databases, hand searches and consultation with expert reviewers. The methodological quality of papers was rated using National Health and Medical Research Council (NHMRC) guidelines. Screening of children 18 months to 5 years, and subsequent early treatment, led to improved visual outcomes. The benefit was primarily through treatment of amblyopia, with improved visual acuity of the amblyopic eye. However, the overall quality of the evidence was low. The implication of improved visual acuity (e.g. any potential impact on quality of life) was not considered. Without consideration of 'quality of life' values, such as loss of vision in one eye or possibility of future bilateral vision loss, the cost-effectiveness of screening is questionable. Screening and treating children with uncorrected refractive error can improve educational outcomes. Evidence suggested that screening occur in the preschool years. Orthoptists were favoured as screening personnel; however, nurses could achieve high sensitivity and specificity with appropriate training. Further research is required to assess the effectiveness of neonatal screening. Most studies suggested that children's vision screening was beneficial, although programme components varied widely (e.g. tests used, screening personnel and age at testing). Research is required to clearly define any improvements to quality of life and any related economic benefits resulting from childhood vision screening. The evidence could be used to guide optimization of existing programmes.

Population-based study of biochemical and survival outcomes after permanent 125I brachytherapy for low- and intermediate-risk prostate cancer

OBJECTIVES

To analyze the biochemical and survival outcomes after permanent low-dose-rate prostate brachytherapy in a large, consecutive, population-based cohort of patients.

METHODS

A total of 1006 consecutive implants were performed from July 20, 1998 to October 23, 2003 for men with low-risk and "low-tier" intermediate-risk prostate cancer. The prescribed minimal peripheral dose was 144 Gy, using 0.33 mCi (125)I sources and a preplan technique with a strong posterior-peripheral dose bias. Most patients (65%) had received 6 months of androgen deprivation therapy. Supplemental external beam radiotherapy was not used. The prognostic features, dose metrics, and follow-up data were prospectively collected. Kaplan-Meier and Cox regression analyses were used to assess the factors associated with freedom from biochemical recurrence and survival.

RESULTS

The median patient age at treatment was 66 years. The median follow-up was 54 months for biochemical outcomes and 66 months for survival. The actuarial freedom from biochemical recurrence rate was 95.6% +/- 1.6% at 5 years and 94.0% +/- 2.2% at 7 years. On multivariate analysis, the pretreatment prostate-specific antigen level (P = .03) and androgen deprivation therapy use (P = .04) were predictive of the freedom from biochemical recurrence. The actuarial rates of distant metastasis and disease-specific death at 5 years were both <1%. The overall survival rate at 5 years was 95.2% +/- 1.4% and was 93.4% +/- 1.8% at 7 years. On multivariate analysis, only age was predictive of overall survival (P = .011).

CONCLUSIONS

When consistently planned and delivered, low-dose-rate brachytherapy, without supplemental external beam radiotherapy or intraoperative planning, can produce cancer-specific outcomes for men with low- and "low-tier" intermediate-risk prostate cancer at least equal to that produced by dose-escalated external beam radiotherapy or surgical prostatectomy.

Rural environments reduce the genetic influence on adolescent substance use and rule-breaking behavior

BACKGROUND

There is increasing evidence that certain environmental factors can modify genetic effects. This is an important area of investigation as such work will help to guide the development of new intervention programs. In this paper, we address whether rural environments moderate the genetic influence on adolescent substance use and rule-breaking behavior (i.e. externalizing psychopathology).

METHOD

Over 1200 Minnesotan 17-year-old twins were classified as either urban or rural. Externalizing behavior was operationalized as the use and abuse of alcohol and drugs along with symptoms of conduct, oppositional defiant, and antisocial personality disorders. Biometric factor modeling estimated whether the relative contribution of genetic and shared environmental factors varied from urban to rural settings.

RESULTS

Residency effects reached statistical significance in the male sample only. In urban environments, externalizing behavior was substantially influenced by genetic factors, but in rural environments, shared environmental factors became more influential. This was apparent at both the individual-variable and factor levels.

CONCLUSIONS

These findings suggest a gene-environment interaction in the development of male adolescents' problem behaviors, including substance use. The results fit within an expanding literature demonstrating both the contextual nature of the heritability statistic and how certain environments may constrain the expression of genetic tendencies.

Adjuvant axillary radiotherapy for breast cancer: Is CT planning with nodal contouring better than traditional planning?

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Background: Historically, adjuvant radiotherapy planning for breast cancer has been based on clinical mark-up then subsequently bony landmarks. The objective of this study is to investigate whether individualized CT-based nodal contour guided planning of axillary fields in breast cancer improves nodal coverage and minimizes dose to normal tissues. There have been no previous studies addressing this issue. Methods: Thirty 4-field radiotherapy plans were selected as ‘traditional’ plans: 15 without nodal contours (traditional field placement) and 15 with radiation oncologists’ nodal contours. The following structures were contoured on each patient CT, regardless of previously contoured structures: level I, level II/III, supraclavicular(SCV)/infraclavicular(ICV) lymph nodes, ipsilateral brachial plexus and lung. Dose volume histograms (DVHs) of the listed contoured structures were obtained for the 30 original plans. All 30 patients were then re-planned with the same anterior dose prescription as the original plan (4000cGy/16 fractions (#) or 4500cGy/25#) but adjusted depth of midplane dose prescription based on nodal depth; MLC blocking was adjusted to the ‘study’ nodal contours. DVHs of the contoured structures for the new nodal-based plans were compared with the DVHs of the original plans, using two-tailed paired t-tests. Results: Volume receiving 90% dose (V90) was significantly improved for SCV nodes: original plan 84.67% vs nodal plan 95.76%(p=0.0005). V90 were similar for level I and level II/III nodes, but hot spots in these nodal groups were significantly hotter in the original vs nodal plan: mean hot spot for level I 120.8% vs 116.3%(p=0.0008), mean hot spot for level II/III 118.1% vs 113.2% (p=0.000003). Dose to 90% of the brachial plexus (D90) was significantly higher in the original vs nodal plan: 79.92% vs 40.92%(p=0.0028). V20 lung were not significantly different. Mean total body dose was significantly higher in the original vs nodal plan 831.8cGy vs 677.7cGy (p=0.0015). Conclusions: CT-based nodal contour guided planning significantly improves coverage of the nodes, particularly supraclavicular nodes, while markedly reducing the dose to critical normal structures, such as brachial plexus.

No significant financial relationships to disclose.

Preferences for sexual information resources in patients treated for early-stage prostate cancer with either radical prostatectomy or brachytherapy

OBJECTIVE

To identify the preferences for sexual information resources of patients before and after definitive treatment for early-stage prostate cancer with either radical prostatectomy (RP) or brachytherapy.

PATIENTS AND METHODS

Two hundred patients (mean age 64 years) treated with either RP or brachytherapy were recruited from radiation oncology (100) and urology (100) outpatient clinics. Patients completed a survey questionnaire to identify the types of information used, preferred sources of information, knowledge of treatments for erectile dysfunction (ED), effect of sexual function on the treatment decision, and the International Index of Erectile Function (IIEF) to assess their current level of sexual function.

RESULTS

Urologists were identified as the main source of sexual information. Written information, Internet access and videos were identified as preferred sources of information before and after treatment. The effects of treatment on sexual function had no apparent significant influence on the men's definitive treatment choice. Compared with patients in the brachytherapy group, patients in the RP group reported having significantly higher levels of sexual desire (P < 0.001) after treatment, but otherwise the erectile domains of the groups were remarkably similar. Two-thirds of patients wanted more information on the effects of treatment on sexual function, and on available treatments for ED.

CONCLUSIONS

These results support the need for physicians to offer patients access to information on the effect of treatment for early-stage prostate cancer on erectile function before and after treatment.

Adequacy of pain assessment and pain relief and correlation of patient satisfaction in 68 ED fast-track patients

INTRODUCTION

The new standards of the joint commission on accreditation of healthcare organizations specify the patient's right to appropriate assessment and management of pain. With this impetus, we looked at our own practice to see how well we assess and manage patients with pain.

METHODS

Patients who presented with minor nonemergent pain were interviewed on arrival, and then again before discharge, with use of a structured questionnaire. A total of 68 completed pain surveys were analyzed.

RESULTS

With use of a visual analog scale, patients rated their pain on arrival and at discharge; they also rated pain they were willing to accept when it was time for discharge. Sixty percent of the patients went home with more pain than they were willing to accept. Fifty-one percent of the patients were offered something for pain, and only half of them said the pain relief was adequate. The median time from arrival to administration of pain medication was 104 minutes. Surprisingly, the median patient satisfaction rating for overall care was "very good."

DISCUSSION

This survey revealed that acute pain conditions are underevaluated and undertreated in one fast-track setting, suggesting that ED staff need more education about the management of acute pain. It also showed that relying on patient satisfaction surveys as surrogate markers for how well we manage pain is erroneous.

Timing of postoperative adjustment in adjustable suture strabismus surgery

PURPOSE

The use of adjustable sutures in strabismus surgery has increased the rate of surgical success. Little data are available on the optimum timing for postoperative adjustment after strabismus surgery. We wanted to compare 2 common practices of adjustable suture technique after strabismus surgery.

METHODS

Two comparable groups of 40 patients each, who had strabismus surgery with adjustable suture technique, were prospectively studied. Group A had early adjustment the same day of the surgery about 6 hours after the operation, and group B had late adjustment the next day about 24 hours after the operation. Subjective scoring tables were used to evaluate the pain felt by the patient before, during, and after the adjustment and any difficulties of the adjustment process. Requirements of postoperative pain medications and final alignment 6 weeks after surgery were also compared.

RESULTS

Despite adequate statistical power, no significant differences were found between the groups regarding pain before, during, and after adjustment, difficulties performing the adjustment, and final alignment after 6 weeks (P > .05). Both adjustment schedules were equally associated with mild to moderate pain before, during, and after the adjustment. In the first 24 hours after surgery, no overall difference in the use of pain medications was found. Nausea and vomiting in the first 24 postoperative hours were more common in the early adjustment group (P = .02).

CONCLUSION

The surgeon can feel free to choose the timing for postoperative adjustment. However, when performing an early adjustment, the surgeon should be especially prepared to control nausea and vomiting.

Development of an ED teaching program aimed at reducing prehospital delays for patients with chest pain

OBJECTIVE

Delays in providing thrombolytic agents to patients with chest pain occur mainly in the prehospital arena. To reduce prehospital delay in treating patients with chest pain, we created a discharge teaching video that emphasized calling 911 in the event of a possible heart attack and a written action plan to be posted near the telephone. We also gave patients their EKG readings to bring with them on their next visit to the emergency department.

SETTING AND SAMPLE

All patients with chest pain admitted to the Chest Pain Observation Unit at Baystate Medical Center, Springfield, Mass, were eligible for this teaching effort. We tracked 127 nonconsecutive patients from January 1997 to May 1997. Of these patients, 108 were included in the study.

RESULTS

We interviewed 102 patients (94%) 3 days after they were discharged from the Chest Pain Observation Unit. Within this group, 92% were able to describe what a heart attack might feel like, and 81.4% said they would call 911 or go to the hospital if they had symptoms of a heart attack. If they thought that their symptoms might be indigestion, 69% said they would take an antacid, then go to the hospital if they did not feel better. Fifty-one percent remembered what to do with their EKG readings, and 60.7% knew how to take their nitroglycerin correctly.

CONCLUSION

We concluded that patients understood the message they were given and retained some of the material 3 days after discharge from the Chest Pain Observation Unit. The follow-up telephone calls revealed areas for improvement in the discharge teaching tools.

Gross anatomic evidence of partitioning in the human fibularis longus and brevis muscles

Evidence from a variety of studies suggests that many mammalian muscles are partitioned with respect to their architecture and innervation. Each of these specific muscle subvolumes is innervated by an individual muscle nerve branch, contains motor unit territories with a unique array of physiological attributes and has been known as a neuromuscular compartment or segment. This gross anatomic study investigated for evidence of neuromuscular segmentation in human fibularis (peroneus) longus and brevis muscles. Forty-three legs (24 left, 19 right) from embalmed adult cadavers were dissected. Any architectural segment within these muscles were identified. The specific innervation patterns of these muscles were also described. The fibularis longus muscle was consistently found to have connective tissue partitions that separated it into four parts: anterior superficial, anterior deep, posterior superficial, and posterior deep. The innervation pattern of this muscle was consistent with the segments defined by the connective tissue partitions. There were consistently four primary motor branches, each supplying a specific portion of the fibularis longus muscle. While a typical branching pattern was recognized, there was some variability as to the order of these branches as they originated. The fibularis brevis muscle was consistently found to have a central connective tissue partition that separated it into two portions: anterior and posterior. In 91% of the fibularis brevis muscles, there were two primary motor branches, one for each of the two segments of the muscle. In the other 9%, only one primary motor branch supplying the muscle could be identified.