Weight loss and quality of life in patients surviving 2 years after gastric cancer resection

BACKGROUND

Malnutrition is common in patients undergoing gastric cancer resection, leading to weight loss, although little is known about how this impacts on health-related quality of life (HRQL). This study aimed to explore the association between HRQL and weight loss in patients 2 years after curative gastric cancer resection.

METHODS

Consecutive patients undergoing curative gastric cancer resection and surviving at least 2 years without disease recurrence were recruited. Patients completed the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30) and the specific module for gastric cancer (STO22) before and 2 years postoperatively and associations between HRQL scores and patients with and without ≥ 10% body weight loss (BWL) were examined.

RESULTS

A total of 76 patients were included, of whom 51 (67%) had BWL ≥10%. At 2 years postoperatively, BWL ≥10% was associated with deterioration of all functional aspects of quality of life, with persistent pain (21.6%), diarrhoea (13.7%) and nausea/vomiting (13.7%). By contrast, none of the patients with BWL <10% experienced severe nausea/vomiting, pain or diarrhoea.

CONCLUSIONS

Disabling symptoms occurred more frequently in patients with ≥10% BWL than in those with <10% BWL, with a relevant negative impact on HRQL. A cause-effect relationship between weight loss and postoperative outcome remains unsolved.

Prevalence of diabetes, prediabetes, and stress hyperglycemia: insulin therapy and metabolic control in patients on total parenteral nutrition (prospective multicenter study)

OBJECTIVE

The prevalence of carbohydrate metabolism disorders in patients who receive total parenteral nutrition (TPN) is not well known. These disorders can affect the treatment, metabolic control, and prognosis of affected patients. The aims of this study were to determine the prevalence in noncritically ill patients on TPN of diabetes, prediabetes, and stress hyperglycemia; the factors affecting hyperglycemia during TPN; and the insulin therapy provided and the metabolic control achieved.

METHODS

We undertook a prospective multicenter study involving 19 Spanish hospitals. Noncritically ill patients who were prescribed TPN were included, and data were collected on demographic, clinical, and laboratory variables (glycated hemoglobin, C-reactive protein [CRP], capillary blood glucose) as well as insulin treatment.

RESULTS

The study included 605 patients. Before initiation of TPN, the prevalence of known diabetes was 17.4%, unknown diabetes 4.3%, stress hyperglycemia 7.1%, and prediabetes 27.8%. During TPN therapy, 50.9% of patients had at least one capillary blood glucose of >180 mg/dL. Predisposing factors were age, levels of CRP and glycated hemoglobin, the presence of diabetes, infectious complications, the number of grams of carbohydrates infused, and the administration of glucose-elevating drugs. Most (71.6%) patients were treated with insulin. The mean capillary blood glucose levels during TPN were: known diabetes (178.6 ± 46.5 mg/dL), unknown diabetes (173.9 ± 51.9), prediabetes (136.0 ± 25.4), stress hyperglycemia (146.0 ± 29.3), and normal (123.2 ± 19.9) (P<.001).

CONCLUSION

The prevalence of carbohydrate metabolism disorders is very high in noncritically ill patients on TPN. These disorders affect insulin treatment and the degree of metabolic control achieved.

Efficacy of treatment for hyperglycemic crisis in elderly diabetic patients in a day hospital

Background

The purpose of this prospective cohort study was to compare the costs of day hospital (DH) care for hyperglycemic crisis in elderly diabetic patients with those of conventional hospitalization (CH). Secondary objectives were to compare these two clinical scenarios in terms of glycemic control, number of emergency and outpatient visits, readmissions, hypoglycemic episodes, and nosocomial morbidity.

Methods

The study population comprised diabetic patients aged >74 years consecutively admitted to a tertiary teaching hospital in Spain for hyperglycemic crisis (sustained hyperglycemia [>300 mg/dL] for at least 3 days with or without ketosis). The patients were assigned to DH or CH care according to time of admission and were followed for 6 months after discharge. Exclusion criteria were ketoacidosis, hyperosmolar crisis, hemodynamic instability, severe intercurrent illness, social deprivation, or Katz index >D.

Results

Sixty-four diabetic patients on DH care and 36 on CH care were included, with no differences in baseline characteristics. The average cost per patient was 1,345.1±793.6 € in the DH group and 2,212.4±982.5 € in the CH group (P<0.001). There were no differences in number of subjects with mild hypoglycemia during follow-up (45.3% DH versus 33.3% CH, P=0.24), nor in the percentage of patients achieving a glycated hemoglobin (HbA_1c) <8% (67.2% DH versus 58.3% CH, P=0.375). Readmissions for hyperglycemic crisis and pressure ulcer rates were significantly higher in the CH group.

Conclusion

DH care for hyperglycemic crises is more cost-effective than CH care, with a net saving of 1,418.4 € per case, lower number of readmissions and pressure ulcer rates, and similar short-term glycemic control and hypoglycemia rates.

Role of A1c in the postpartum screening of women with gestational diabetes

OBJECTIVE

This study aimed to determine whether A1c detects a different prediabetes prevalence in women with a history of gestational diabetes mellitus (GDM) compared to those diagnosed with oral glucose tolerance test (OGTT) and the influence of haemoglobin concentrations on A1c levels.

DESIGN AND PATIENTS

We evaluated carbohydrate metabolism status by performing OGTT and A1c tests in 141 postpartum women with prior GDM in the first year post-delivery.

RESULTS

The overall prevalence of prediabetes was 41.8%. Prevalence of isolated A1c 5.7-6.4%, impaired glucose tolerance (IGT) and impaired fasting glucose (IFG) was 10.6%, 7.1%, and 9.2%, respectively. Isolated A1c 5.7-6.4% was associated with Caucasian origin (66.7% versus 32.6%, p = 0.02) and with higher LDL cholesterol concentrations (123 ± 28.4 mg/dl versus 101.6 ± 19.2 mg/dl, p = 0.037) compared with patients diagnosed by OGTT (IFG or IGT). Women with postpartum anaemia had similar A1c levels to those with normal haemoglobin concentrations (5.5% ± 0.6% versus 5.4% ± 0.4%, p = 0.237).

CONCLUSIONS

Use of A1c in postpartum screening of women with GDM detected an additional 10.6% of patients with prediabetes and a more adverse lipid profile. Haemoglobin concentrations did not influence A1c values.

Estimated glucose disposal rate in assessment of the metabolic syndrome and microvascular complications in patients with type 1 diabetes

OBJECTIVE

The objective of the study was to quantify insulin resistance in type 1 diabetes patients by estimated glucose disposal rate (eGDR), according to the presence or absence of the metabolic syndrome, and its relationship with chronic complications.

DESIGN

This was a cross-sectional study in 91 patients with type 1 immune-mediated diabetes managed at an outpatient endocrinology clinic. All participants were Caucasians aged 18 yr or older with type 1 diabetes duration of more than 6 months who had completed the study protocol.

RESULTS

Twenty-nine patients met metabolic syndrome criteria, yielding a prevalence of 31.9%. Although no differences in insulin requirements were found between diabetic patients with and without metabolic syndrome, lower eGDR levels, indicating greater insulin resistance, were observed in metabolic syndrome patients compared with those without (6.19 +/- 1.5 mg/kg(-1) x min(-1) vs. 9.93 +/- 1.6 mg/kg(-1) x min(-1)) (P < 0.001). An eGDR level less than 8.77 mg/kg(-1) x min(-1) showed 100% sensitivity and 85.2% specificity for metabolic syndrome diagnosis. All patients with diabetes complications had eGDR values below 8.16 mg/kg(-1) x min(-1). eGDR level was significantly lower in patients with diabetic retinopathy (5.97 +/- 1.2 mg/kg(-1) x min(-1)), diabetic neuropathy (5.06 +/- 0.4 mg/kg(-1) x min(-1)), or diabetic nephropathy (5.79 +/- 1.5 mg/kg(-1) x min(-1)) compared with those without (9.38 +/- 2.0 mg/kg(-1) x min(-1), P < 0.001; 9.26 +/- 2.0 mg/kg(-1) x min(-1), P < 0.001; and 9.19 +/- 2.2 mg/kg(-1) x min(-1), P < 0.001).

CONCLUSIONS

Insulin resistance is common in type 1 diabetes patients and is associated with microvascular complications. eGDR, as an insulin resistance marker, provides more useful information than other classical variables such as insulin requirements.

Risk factors for transient vocal cord palsy after thyroidectomy

Background

Transient recurrent laryngeal nerve palsy affects to 5–10 per cent of patients after extracapsular thyroidectomy. This prospective study assessed the impact of surgical injury and extralaryngeal branching of the inferior laryngeal nerve (ILN) on vocal cord dysfunction (VCD).

Methods

Total thyroidectomy or lobectomy was performed in 188 patients, with 302 ILNs at risk. The anatomy of the ILN and degree of injury to the nerve, based on the Laryngeal Nerve Injury Score (LNIS), were recorded. Fibreoptic laryngoscopy was performed a mean(s.d.) of 10·6(4·1) days after thyroidectomy.

Results

Some 37·4 per cent of ILNs showed extralaryngeal branching. In all, 10·9 per cent of patients developed VCD; 4·3 per cent had paresis and 6·6 per cent paralysis. All paretic and all but one paralytic cords recovered fully after 61(17) days. VCD was more frequently associated with branched than non-branched ILNs (15·8 versus 8·1 per cent; P = 0·022). Injuries were more common in branched nerves (mean(s.e.m.) total LNIS 0·94(0·08) versus 0·51(0·05); P &lt; 0·001). Branched nerves were more likely to be associated with VCD (odds ratio 2·2 (95 per cent confidence interval 1·1 to 4·5)).

Conclusion

Branched ILNs suffer more surgical injuries and are twice as likely to be associated with VCD.

[The influence of clinical presentation and metabolic control of insulin dependent diabetes in the evolution of residual insulin secretion. A prospective study at five years]

BACKGROUND

To study the influence of clinical, metabolic and immunological parameters during the first years of the evolution of insulin-dependent diabetes mellitus (IDDM) on the long-term residual insulin secretion (IS).

PATIENTS AND METHODS

186 IDDM subjects diagnosed from 1986 to 1993 were included; 135 subjects have completed a two year follow-up, and 57 have completed a five year follow-up. The influence of individual characteristics at diagnosis (age, sex, clinical presentation, islet-cell antibodies) and during the first two years of follow-up (IS, metabolic control) on IS at five years was evaluated by multiple linear regression. Differences between groups were evaluated by non-parametric tests.

RESULTS

18 patients had a significant insulin secretion at five years (post-glucagon C-peptide > or = 0.15 nmol/l). They showed minor significant differences in sex (77.7 vs 48.7% of males, p = 0.03), duration of symptoms (12.9 vs 7.2 weeks, p = 0.01), ketoacidosis at diagnosis (23.3 vs 46.1%, p = 0.07) and ICA positivity at diagnosis (41.1 vs 69.4%, p = 0.05). They also had a better metabolic control (8.8 vs 10.8% of HbA1, p < 0.001) with lss insulin (0.48 vs 0.71 Ul/kg, p < 0.001) during the first two years of evolution. Initial IS was similar, but differences became significant at 6 months. In the multivariate analysis, only metabolic control during the second year of evolution (p = 0.008), ketoacidosis at diagnosis (p = 0.026) and sex (p = 0.026) had an independent influence on IS at five years. A more intensified therapeutic approach introduced in 1990 induced a better metabolic control and higher IS during the first years of follow-up.

CONCLUSION

The absence of ketoacidosis at diagnosis and a good metabolic control during the first two years can have a positive influence in the long-term preservation of IS in IDDM patients.

[Assessment of prognosis factors in the cure of Cushing's disease surgically treated via a +septotransphenoidal approach]

INTRODUCTION

In Cushing's disease (CD) pituitary surgery or radiotherapy has been proposed by some authors, when plasmatic cortisol after surgery is not clearly low.

AIM

To assess if the different prognostic factors, specially plasmatic cortisol seven days after surgery and/or hypocortisolism phase are predictive of the CD outcome.

METHODS

From 1988, 11 women with CD underwent 13 transsphenoidal microsurgery, because two patients relapsed. The mean age of patients was 27 years (11-52). Plasmatic cortisol was measured seven days after pituitary surgery, and since 45 days, every three-six months, basal plasmatic cortisol and after ACTH and urinary free cortisol were determined.

RESULTS

Follow-up evaluations ranged from 18-84 months (median, 38 months). After pituitary surgery in 13 cases the cumulative remission was 100%, two cases relapsed. In 10 cases plasmatic cortisol seven days after surgery was less than 137 nmol/l and in three cases higher than 137 nmol/l. Three cases did not presented hypocortisolism phase. The two patients who relapsed, one was after eight months of pituitary surgery an previously showed low plasmatic cortisol and the other relapse 25 months after pituitary surgery without low cortisol plasmatic levels.

CONCLUSION

Remission in CD can happen either low or normal plasmatic cortisol levels seven days posttreatment or without hypocortisolism phase. Ours findings ascribe new importance to the different presentations after treatment of CD, and patients with these findings are not a risk for relapse and pituitary surgery or irradiation would not be early indicated.