The Impact of Combined Radiation and Chemotherapy on Outcome in Uterine Clear Cell Carcinoma Compared with Chemotherapy Alone

AIMS

To investigate the impact of pelvic radiation on survival in patients with uterine clear cell carcinoma (UCC) who received adjuvant chemotherapy.

MATERIALS AND METHODS

Patients with stage I-IV UCC who had undergone surgery and chemotherapy were identified from the Surveillance, Epidemiology, and End Results (SEER) programm 2000-2009. Patients were divided into those who received only chemotherapy and those who received both chemotherapy and radiation therapy. Kaplan-Meier curves and Cox regression models were used for analysis.

RESULTS

Of the 317 patients included, 195 (62%) were in the chemotherapy only group and 122 (38%) were in the chemotherapy and radiation therapy group. Pelvic radiation was associated with significant improvement in overall survival (median 88 versus 25 months, 5 year survival: 58% versus 33%, P<0.001) in the chemotherapy and radiation therapy group compared with the chemotherapy only group for the entire cohort. On subset analysis, chemotherapy and radiation therapy was associated with improved overall survival in late stage disease (III-IV) (5 year 54% versus 22%, P<0.001) compared with the chemotherapy only group, whereas in stage I-II UCC, there was no difference in overall survival between the chemotherapy and radiotherapy group and the chemotherapy only group (5 year 65% versus 67%, P=0.69). In multivariable analysis, pelvic radiation was associated with improved survival in patients with late stage disease (hazard ratio 0.57, 95% confidence interval 0.35-0.94, P=0.03) but not for early stage disease (hazard ratio 0.81, 95% confidence interval 0.33-2.0, P=0.65). Other significant predictors were advanced stage, positive cytology and extensive lymphadenectomy.

CONCLUSIONS

Radiation was associated with significant improvement in survival in advanced stage UCC, but not in early stage UCC. These data support the beneficial role of radiation therapy in UCC, especially in patients with advanced stage disease.

The risk of overall mortality in patients with Type 2 diabetes receiving different combinations of sulfonylureas and metformin: a retrospective analysis

AIMS

Sulfonylureas have been shown to increase mortality when used in combination with metformin. This may not be a class effect of sulfonylureas, but rather secondary to differences in properties inherent to the individual sulfonylureas (hypoglycaemic risk, sulfonylurea receptor selectivity and effects on myocardial ischemic preconditioning). The purpose of this study was to assess the risk of overall mortality in patients with Type 2 diabetes treated with different combinations of sulfonylureas and metformin.

METHODS

A retrospective cohort study was conducted using an academic health center enterprise-wide electronic health record system to identify 7320 patients with Type 2 diabetes (3768 initiators of glyburide (glibenclamide) and metformin, 2277 initiators of glipizide and metformin and 1275 initiators of glimepiride and metformin), ≥ 18 years of age and not on insulin or a non-insulin injectable at baseline. The patients were followed for mortality by documentation in the electronic health record and Social Security Death Index. Multivariable Cox models with propensity analysis were used to compare cohorts.

RESULTS

No statistically significant difference in overall mortality risk was observed among the different combinations of sulfonylureas and metformin: glimepiride and metformin vs. glipizide and metformin (HR 1.03; 95% CI 0.89-1.20), glimepiride and metformin vs. glyburide (glibenclamide) and metformin (HR 1.08; 95% CI 0.90-1.30), or with glipizide and metformin vs. glyburide (glibenclamide) and metformin (HR 1.05; 95% CI 0.95-1.15).

CONCLUSIONS

Our results did not identify an increased mortality risk among the different combinations of sulfonylureas and metformin, suggesting that overall mortality is not substantially influenced by the choice of sulfonylurea.

Bladder pain syndrome/interstitial cystitis in twin sisters

PURPOSE

We determined the genetic contribution of and associated factors for bladder pain syndrome using an identical twin model.

MATERIALS AND METHODS

Multiple questionnaires were administered to adult identical twin sister pairs. The O'Leary-Sant Interstitial Cystitis Symptom and Problem Index was administered to identify individuals at risk for bladder pain syndrome. Potential associated factors were modeled against the bladder pain syndrome score with the twin pair as a random effect of the factor on the bladder pain syndrome score. Variables that showed a significant relationship with the bladder pain syndrome score were entered into a multivariable model.

RESULTS

In this study 246 identical twin sister pairs (total 492) participated with a mean age (± SD) of 40.3 ± 17 years. Of these women 45 (9%) were identified as having a moderate or high risk of bladder pain syndrome (index score greater than 13). There were 5 twin sets (2%) in which both twins met the criteria. Correlation of bladder pain syndrome scores within twin pairs was estimated at 0.35, suggesting a genetic contribution to bladder pain syndrome. Multivariable analysis revealed that increasing age (estimate 0.46 [95% CI 0.2, 0.7]), irritable bowel syndrome (1.8 [0.6, 3.7]), physical abuse (2.5 [0.5, 4.1]), frequent headaches (1.6 [0.6, 2.8]), multiple drug allergies (1.5 [0.5, 2.7]) and number of self-reported urinary tract infections in the last year (8.2 [4.7, 10.9]) were significantly associated with bladder pain syndrome.

CONCLUSIONS

Bladder pain syndrome scores within twin pairs were moderately correlated, implying some genetic component. Increasing age, irritable bowel syndrome, frequent headaches, drug allergies, self-reported urinary tract infections and physical abuse were factors associated with higher bladder pain syndrome scores.

Diagnostic characteristics of late-night salivary cortisol using liquid chromatography-tandem mass spectrometry

OBJECTIVE

The objective of the study was to describe the diagnostic performance of a commercially available late-night salivary cortisol (NSC) assay using liquid chromatography tandem mass spectrometry.

METHODS

We retrospectively identified 90 patients who had one or more NSC determinations: 52 patients in whom Cushing syndrome (CS) was excluded or could not be confirmed [group 1 (G1)] and 38 patients in whom CS was confirmed [group 2 (G2)]. Eighteen healthy volunteers served as controls.

RESULTS

Baseline demographics in all groups were similar with regards to age, ethnicity, gender, and body mass index. NSC levels [median (range)] were higher in G2, 381 (64-13,500) ng/dl [10.51 (1.77-372.46) nmol/liter], compared with controls, 19.3 (2.1-416) ng/dl [0.53 (0.06-11.48) nmol/liter], and G1, 26 (4-176) ng/dl [0.72 (0.11-4.86) nmol/liter, P < 0.001]. The highest combined sensitivity (92%) and specificity (92%) was achieved at a cut point of 107 ng/dl (2.95 nmol/liter). Two or more NSCs were done in 32 of 52 G1 and 31 of 38 G2 patients. In G1 eight of 32 (25%) had at least one elevated [>100 ng/dl (2.76 nmol/liter)] NSC including two in whom both NSCs were elevated. In contrast, four of 31 (13%) in G2 had at least one normal NSC including one with four of five normal NSC values. None of the patients with CS had a NSC less than 60 ng/dl (<1.66 nmol/liter). Comparing G1 and G2, obtaining more than one saliva sample did not improve the diagnostic accuracy of NSC measurement (P = 0.64).

CONCLUSION

The liquid chromatography tandem mass spectrometry assay to measure NSC is a simple and reliable test to screen patients suspected to have CS. Clinicians should be aware of appropriate cutoff values for proper interpretation of NSC and use additional tests when necessary.

Desktop telemedicine in vascular surgery: some preliminary findings

OBJECTIVE

Surgical specialists have generally underutilized telemedicine technologies. This report describes the use of real-time interactive-video telemedicine to augment the care of vascular surgical patients in underserved rural areas within our region.

MATERIALS AND METHODS

The telemedicine system at Fletcher-Allen Health Care (FAHC) and the University of Vermont in Burlington utilizes desktop video conferencing technology with terrestrial transmission at 384 kbps. The current system was initiated in January 1996, and there are at present 18 external sites and multiple locations at FAHC, including the vascular laboratory, angiography suites, operating rooms, and the home of one vascular surgeon. During the first 12 months of operation, the vascular surgeons were asked to complete a questionnaire to evaluate the technology and its usefulness in clinical care. The use of the telemedicine system by the vascular surgeons was monitored by the questionnaires, phone bills, and a special "no charge" billing code. Telemedicine events were classified as clinical or educational.

RESULTS

In the 26 months since implementation, 107 events have taken place, including both clinical and educational uses. There were 103 clinical uses by three vascular surgeons, including five emergency uses. A joint Vermont-Maine vascular educational conference has taken place four times. Overall, use by vascular surgery represented 14.2% of all telemedicine events in the first year or 30.9% of all clinical events during that time period. Use of telemedicine was reported to have improved patient care in 96% of the cases. Eighty percent of the telemedicine uses in the first year saved patient travel. There were no diagnostic errors, as determined by in-person clinical follow-up, attributable to the telemedicine system use.

CONCLUSIONS

Use of a real-time video telemedicine has great potential for vascular surgeons, but cost-effectiveness studies may be needed prior to its widespread adoption.