Despite evidence that low osmolar radiocontrast media is not associated with acute kidney injury, it is important to evaluate this association in critically ill patients with normal kidney function.
...This retrospective observational study included 7,333 adults with an ICU stay at a six-hospital health system in south Florida. Patients who received contrast were compared with unexposed control subjects prior to and following propensity score (PS) matching derived from baseline characteristics, admission diagnoses, comorbidities, and severity of illness. Acute kidney injury (AKI), defined as initial onset (stage I) or increased severity, was determined from serum creatinine levels according to Kidney Disease: Improving Global Outcomes guidelines.
Based on 2,306 PS-matched pairs obtained from 2,557 patients who received IV contrast and 4,776 unexposed control subjects, the increase in AKI attributable to contrast was 1.3% (19.3% vs 18.0%; P = .273), and no association was found between contrast and the pattern of onset and recovery. Hospital mortality increased by 14.3% subsequent to AKI (18.0 vs 3.6; P < .001), but the risk ratio in relation to patients with stable AKI did not vary when stratified according to contrast. Multivariable regression identified sepsis, metabolic disorders, diabetes, history of renal disease, and severity of illness as factors that were more strongly associated with AKI.
In critically ill adults with normal kidney function, low osmolar radiocontrast media did not substantively increase AKI. Rather than limiting the use of contrast in ICU patients, efforts to prevent AKI should focus on the susceptibility of patients with sepsis, diabetes complications, high Acute Physiology and Chronic Health Evaluation scores, and history of renal disease.
Magnetic resonance (MR) imaging and computed tomography (CT) are used almost exclusively in radiation therapy planning of glioblastoma multiforme (GBM), despite their well-recognized limitations. MR ...spectroscopic imaging (MRSI) can identify biochemical patterns associated with normal brain and tumor, predominantly by observation of choline (Cho) and N-acetylaspartate (NAA) distributions. In this study, volumetric 3-dimensional MRSI was used to map these compounds over a wide region of the brain and to evaluate metabolite-defined treatment targets (metabolic tumor volumes MTV).
Volumetric MRSI with effective voxel size of ∼1.0 mL and standard clinical MR images were obtained from 19 GBM patients. Gross tumor volumes and edema were manually outlined, and clinical target volumes (CTVs) receiving 46 and 60 Gy were defined (CTV46 and CTV60, respectively). MTVCho and MTVNAA were constructed based on volumes with high Cho and low NAA relative to values estimated from normal-appearing tissue.
The MRSI coverage of the brain was between 70% and 76%. The MTVNAA were almost entirely contained within the edema, and the correlation between the 2 volumes was significant (r=0.68, P=.001). In contrast, a considerable fraction of MTVCho was outside of the edema (median, 33%) and for some patients it was also outside of the CTV46 and CTV60. These untreated volumes were greater than 10% for 7 patients (37%) in the study, and on average more than one-third (34.3%) of the MTVCho for these patients were outside of CTV60.
This study demonstrates the potential usefulness of whole-brain MRSI for radiation therapy planning of GBM and revealed that areas of metabolically active tumor are not covered by standard RT volumes. The described integration of MTV into the RT system will pave the way to future clinical trials investigating outcomes in patients treated based on metabolic information.
There is no general agreement on the effect of neoadjuvant treatment for esophageal cancer on patient survival.
A meta-analysis was performed to determine the effect of preoperative treatment on ...survival of patients with resectable esophageal cancer and the effect of preoperative treatment on patient mortality. A standard variance-based method was used to derive summary estimates of the absolute difference in both 2-year survival and treatment-related mortality.
Eleven randomized trials involving 2311 patients were analyzed. Preoperative chemotherapy improved 2-year survival compared with surgery alone: the absolute difference was 4.4% (95% confidence interval CI,.3%-8.5%). Marginal evidence of heterogeneity was eliminated by restricting attention to the four most recent studies, which increased the estimate to 6.3% (95% CI, 1.8%-10.7%). For combined chemoradiotherapy, the increase was 6.4% (nonsignificant; 95% CI, -1.2%-14.0%). Treatment-related mortality increased by 1.7% with neoadjuvant chemotherapy (95% CI, -.9%-4.3%) and by 3.4% with chemoradiotherapy (95% CI, -.1%-7.3%), compared with surgery alone.
There seems to be a modest survival advantage for patients who receive neoadjuvant chemotherapy followed by surgery, as compared with surgery alone. There is an apparent increase in treatment-related mortality, mainly for patients who receive neoadjuvant chemoradiotherapy.
Failure to recanalize predicts mortality in acute ischemic stroke. In the North American Solitaire Acute Stroke registry, we investigated parameters associated with mortality in successfully ...recanalized patients.
Logistic regression was used to evaluate baseline characteristics and recanalization parameters for association with 90-day mortality. A multivariable model was developed based on backward selection with retention criteria of P<0.05 from factors with at least marginal significance (P≤0.10), then refit to minimize the number of excluded cases (missing data).
Successfully recanalized patients had lower mortality (25.2% 59/234 versus 46.9% 38/81 P<0.001). There was no difference in symptomatic intracranial hemorrhage between patients with successful versus failed recanalization (9% 21/234 versus 14% 11/79; P=0.205). However, mortality was significantly higher in patients with symptomatic intracranial hemorrhage (72% 23/32 versus 26% 73/281; P<0.001). Proximal occlusion (internal carotid artery or vertebrobasilar), initial National Institutes of Health Stroke Scale≥18, use of rescue therapy (P<0.05), and 3+ passes (P<0.10) were associated with mortality in recanalized patients. In the multivariate model with good predictive power (c index=0.72), proximal occlusion, initial National Institutes of Health Stroke Scale≥18, and use of rescue therapy remained significant independent predictors of 90-day mortality.
Failure to recanalize and presence of symptomatic intracranial hemorrhage resulted in increased mortality. Despite successful recanalization, proximal occlusion, high National Institutes of Health Stroke Scale, and need for rescue therapy were predictors of mortality.
Environmental factors may influence the particularly low rates of physical activity in African American and low-income adults. This cross-sectional study investigated how measured environmental ...factors were related to self-reported walking and vigorous physical activity for residents of low-income public housing developments.
Physical activity data from 452 adult residents residing in 12 low-income housing developments were combined with measured environmental data that examined the neighborhood (800 m radius buffer) around each housing development. Aggregated ecological and multilevel regression models were used for analysis.
Participants were predominately female (72.8%), African American (79.6%) and had a high school education or more (59.0%). Overall, physical activity rates were low, with only 21% of participants meeting moderate physical activity guidelines. Ecological models showed that fewer incivilities and greater street connectivity predicted 83% of the variance in days walked per week, p < 0.001, with both gender and connectivity predicting days walked per week in the multi-level analysis, p < 0.05. Greater connectivity and fewer physical activity resources predicted 90% of the variance in meeting moderate physical activity guidelines, p < 0.001, and gender and connectivity were the multi-level predictors, p < 0.05 and 0.01, respectively. Greater resource accessibility predicted 34% of the variance in days per week of vigorous physical activity in the ecological model, p < 0.05, but the multi-level analysis found no significant predictors.
These results indicate that the physical activity of low-income residents of public housing is related to modifiable aspects of the built environment. Individuals with greater access to more physical activity resources with fewincivilities, as well as, greater street connectivity, are more likely to be physically active.
Purpose.
This study examined associations of environmental variables with obesity prevalence and individual body mass index (BMI) among impoverished residents of public housing developments.
Design.
...Cross-sectional data were drawn from two studies in the same Midwestern metropolitan area of participants within neighborhoods.
Setting.
Pathways to Health interviewed housing development residents and Understanding Neighborhood Determinants of Obesity assessed built environment factors in the surrounding neighborhoods (i.e., 800–m radius from center of housing development).
Subjects.
Four hundred twenty-one residents participated (mean age = 43.8 years; 72.0% women, 59.6% high school degree, 79.6% African-American). Fifty-five physical activity resources were identified and assessed.
Measures.
Demographics and measured weights and heights were obtained for participants. The Physical Activity Resource Assessment measured the type, accessibility, features, amenities, qualities, and incivilities of neighborhood physical activity resources. Neighborhood street connectivity was also measured.
Results.
Average age-adjusted BMI was 31.4 (SD = 1.3), with 45% of residents obese. High negative correlations were found between BMI and street connectivity (p = .05) and between obesity prevalence and resource accessibility (p = .09), number of amenities (p = .04), and amenity quality (p = .04). Higher resource accessibility, feature quality, number of amenities, and fewer incivilities per resource accounted for 71% of obesity variance (p < .05). Male gender and higher feature quality, F(11, 407)37.19 and 12.66, p < .001, predicted lower BMI among residents.
Conclusion.
Supportive neighborhood environments were related to lower obesity prevalence and lower BMI among residents.
Maternal nutritional intake during pregnancy may have important consequences for long-term health in offspring.
The objective was to follow up the offspring in 2 randomized trials of nutrient ...supplementation during pregnancy to investigate the effect on cardiovascular disease (CVD) risk in offspring.
We recruited offspring born during 2 trials in The Gambia, West Africa. One trial provided protein-energy-dense food supplements (1015 kcal and 22 g protein/d) to pregnant (intervention, from 20 wk gestation until delivery) or lactating (control, for 20 wk from birth) women and was randomized at the village level. The second was a double-blind, individually randomized, placebo-controlled trial of calcium supplementation (1.5 g/d), which was also provided from 20 wk gestation until delivery.
Sixty-two percent (n = 1267) of children (aged 11-17 y) born during the protein-energy trial were recruited and included in the analysis, and 64% (n = 350) of children (aged 5-10 y) born during the calcium trial were recruited and included in the analysis. Fasted plasma glucose was marginally lower in children born to mothers receiving protein-energy supplements during pregnancy than in those children of the lactating group (adjusted mean difference: -0.05 mmol/L; 95% CI: -0.10, -0.001 mmol/L). There were no other differences in CVD risk factors, including blood pressure, body composition, and cholesterol, between children born to intervention and control women from the protein-energy trial. Maternal calcium supplementation during pregnancy was unrelated to offspring blood pressure.
These data suggest that providing supplements to pregnant women in the second half of pregnancy may have little effect on the CVD risk of their offspring, at least in this setting and at the ages studied here. This trial was registered at www.controlled-trials.com as ISRCTN96502494.
Abstract Objective To evaluate the feasibility of combining low-dose fractionated whole abdominal radiation (LDF-WAR) with weekly full-dose cisplatin (FD-CDDP) for patients with stage III/IV ...endometrial carcinoma. Methods Patients with optimally debulked stage III/IV carcinoma of the endometrium (without extra-abdominal disease) were eligible for the study. Postoperatively, patients received the institutional standard systemic chemotherapy and vaginal brachytherapy. Patients then underwent experimental six weekly cycles of FD-CDDP (40 mg/m2 , maximum 70 mg IV) followed by LDF-WAR 6–8 hours after initiation of chemotherapy. In a conservative design, 6 patients were accrued to two sequential cohorts of LDF-WAR, at 0.5 Gy/fraction Fx (total 3 Gy) and 0.75 Gy/Fx (total 4.5 Gy). Toxicities and laboratory studies were evaluated at each visit. Results Twelve patients were enrolled from January 2005 to June 2009 with median follow-up of 13.5 months (range: 5–27 months). Seventy-five percent of enrolled patients had uterine papillary serous histology. Eleven patients at least partially completed therapy (range: 2–6 cycles of FD-CDDP/LDF-WAR) with one additional patient opting out at the higher dose level. Combination therapy overall was well tolerated. Three patients in each cohort experienced grade 3 acute hematologic events with one recorded grade 4 toxicity in the second cohort. Of patients receiving any of the experimental treatment, five have experienced recurrences. Three of these patients were in cohort one and received 0.5 Gy/Fx LDF-WAR. Conclusion Combination therapy with LDF-WAR as a novel chemopotentiator to FD-CDDP is a feasible adjuvant regimen in optimally debulked patients with stage III/IV endometrial carcinoma. Further investigation is warranted to determine treatment efficacy.
The objective of this study was to determine the effect, if any, on survival of adjuvant 5-FU–based chemoradiotherapy following pancreaticoduodenectomy for pancreatic carcinoma. A systematic review ...of the published literature was undertaken. Survival estimates were derived from published reports. Five prospective studies (4 level I, 1 level II) with a total of 607 (229 surgery only; 378 surgery-adjuvant) patients followed for survival met selection criteria. Two-year survival ranged from 15%–37% in the surgery only group and 37%–43% in the surgery and adjuvant groups. The survival advantage (absolute difference) ranged from 3%–27% and no individual study achieved statistical significance (5%). Although clinical heterogeneity existed in surgery-alone control groups with regard to trial date, no statistical heterogeneity was detected (
P = 0.459, χ
2 test), allowing pooling of survival data. Using a fixed effects model, the summary estimate showed an absolute 2-year survival benefit with adjuvant therapy of 12% (95% CI, 3%–21%,
P = 0.011). Trials after 1997 (n = 3) indicated a survival benefit of 8% to patients receiving adjuvant therapy (95% CI, −3–18%,
P = 0.145). The result was not statistically significant, and there was no evidence of heterogeneity (
P = 0.626, χ
2 test). Summary estimates were unchanged when the analysis was performed with a random effects model. 5-FU based chemotherapy with radiotherapy given after resection imparts a small overall survival benefit of 2 years. The benefit of 5-FU–based adjuvant therapy, however, has declined in recent years, and its significance remains unproven in the context of current diagnostic and surgical practice.
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