Early nutritional intervention improves treatment tolerance and outcomes in head and neck cancer patients undergoing concurrent chemoradiotherapy

Goals of work

Patients with head and neck cancer (HNC) undergoing chemoradiotherapy are at high risk of malnutrition, which is related to complication rate. The aim of this study was to investigate the impact of an early intensive nutritional intervention on nutritional status and outcomes in patients undergoing chemoradiotherapy for HNC.

Materials and methods

We analysed retrospectively the clinical documentation of 33 HNC patients who were referred for early nutritional intervention (nutrition intervention group, NG) before they were submitted to chemoradiotherapy. The outcome of these patients was compared to that of 33 patients who received chemoradiotherapy without receiving a specifically designed early nutrition support programme (control group, CG).

Main results

NG patients lost less weight during chemoradiotherapy compared to CG patients (?4.6?±?4.1% vs ?8.1?±?4.8% of pre-treatment weight, p?<?0.01, at the completion of treatment). Patients in the NG experienced fewer radiotherapy breaks (>5 days) for toxicity (30.3% vs 63.6%, p?<?0.01); the mean number of days of radiation delayed for toxicity was 4.4?±?5.2 in NG vs 7.6?±?6.5 in CG (p?<?0.05); a linear correlation was found between percentage of weight lost from baseline to chemoradiotherapy completion and days of radiation delays (p?<?0.01). There were less patients who had an unplanned hospitalisation in the NG relative to the CG (16.1% vs 41.4%, p?=?0.03). In the NG, symptoms having an effect on the nutritional status developed early and were present in the nearly totality of patients at chemotherapy completion; 60.6% of NG patients needed tube feeding.

Conclusions

Early nutrition intervention in patients with HNC receiving chemoradiotherapy resulted in an improved treatment tolerance and fewer admissions to hospital. This result suggests that nutritional intervention must be initiated before chemoradiotherapy, and it needs to be continued after treatment completion.     

Nutritional supplements and plasma antioxidants in childhood asthma

Objective

This study investigated the relationship of plasma antioxidants to airway inflammation and systemic oxidative stress in children suffering from atopic asthma with consideration of the intake of nutritional supplements.

Subjects and research methods

A total of 35 asthmatic children (AG) and 21 healthy controls (CG) participated in this study. Plasma levels of vitamins A and E, β-carotene, coenzyme Q10 and malondialdehyde (MDA) were analyzed with high-performance liquid chromatography (HPLC); the total antioxidant capacity (TAC) was measured photometrically, and selenium was determined by atomic absorption spectroscopy (AAS). The volume of fractionated exhaled nitric oxide (FeNO) was measured with the NIOX nitric oxide monitoring system.

Results

The plasma antioxidants vitamins A and E, selenium, and coenzyme Q10 but not β-carotene were significantly (p < 0.05) lower in asthmatics than in controls. Further, asthmatic children had significantly reduced plasma concentrations of TAC (p < 0.01), significantly enhanced levels of MDA (p < 0.001), and exhaled a significantly (p < 0.001) higher mean volume of FeNO than healthy children. Regular intake of supplements had a significant positive influence on plasma vitamin E (p < 0.01), selenium (p < 0.01), TAC (p < 0.05), MDA (p < 0.01), and FeNO (p < 0.01) in asthmatics but not in controls. Additionally, significant negative associations of vitamin E and MDA (AG: p < 0.01; CG: p < 0.05), and vitamin E and FeNO (AG: p < 0.05; CG: p > 0.05) were identified.

Conclusion

These results indicate that nutritional supplements beneficially modulate plasma antioxidants and thus might have a positive influence on systemic redox balance and subsequently, pulmonary inflammation in asthmatic children.     

Red blood cell transfusion in non-bleeding critically ill patients with moderate anemia: is there a benefit?

Purpose

This study was undertaken to investigate the efficacy of red blood cell transfusion (RBCT) at reversing the deleterious effects of moderate anemia in critically ill, non-bleeding patients.

Methods

This was a retrospective, pair-matched (ratio 1:1) cohort study. Non-bleeding critically ill patients with moderate anemia (nadir hemoglobin level between 70 and 95 g/l), admitted to the ICU over a 27-month period, were included. Anemic patients were included upon meeting five matching criteria of having the same nadir hemoglobin (±5 g/l), APACHE II score (±5), SOFA score (±2), admission diagnostic group, and age (±5 years). Outcome events occurring over the whole ICU stay and after RBCT were collected. After hospital discharge, all patients had a 2-year follow-up period.

Results

Two hundred fourteen non-transfused anemic patients (NTAPs) were successfully matched with 214 transfused anemic patients (TAPs). In addition to the matching criteria, at baseline, both groups were homogenous with respect to multiple comorbidities. Compared with TAPs, NTAPs showed significantly lower rates of hospital mortality (21 vs.13 %, respectively; p < 0.05) and ICU re-admission (7.4 vs. 1.9 %, respectively; p < 0.05). Additionally, NTAPs had significantly lower rates of nosocomial infection (12.9 vs. 6.7 %, respectively; p < 0.05) and acute kidney injury (24.8 vs. 16.7 %, respectively; p < 0.05). Similar results were obtained in subgroup analysis where only more anemic patients (68 matched pairs) or patients with cardiovascular comorbidities (63 matched pairs) were considered.

Conclusions

RBCT does not improve the clinical outcome in non-bleeding critically ill patients with moderate anemia.     

Prevalence of different forms of infarct-atypical late gadolinium enhancement in patients early and late after heart transplantation

Background

Late gadolinium enhancement cardiac magnetic resonance (LGE-CMR) enables high-resolution myocardial tissue characterization, showing the results of different injuries, especially in the early period after heart transplantation (HTX).

Objectives

We sought to apply LGE-CMR to investigate the prevalence and patterns of infarct-atypical myocardial involvement and associated mechanisms in patients early and late after HTX.

Methods

LGE-CMR was performed on a 1.5-T MRI scanner (Philips, Best, the Netherlands) in 89 patients: group 1 (48 patients) less than 2.5 years after operation (1.2 ± 0.5 years) and group 2 (41 patients) later this period (8.2 ± 4.2 years). Following LGE-CMR, the presence, distribution, patterns of infarct-atypical LGE and possible associated mechanisms were assessed.

Results

71 % of group 1 patients (34/48) showed infarct-atypical LGE whereas 57 % of group 2 patients (22/41) were affected (p = 0.25). Fewer segments/patients were involved later after HTX (1.6 ± 2.0 vs. 2.9 ± 3.1 segments/patient; p = 0.03), but only diffuse LGE-CMR pattern decreased significantly (11.5 % of affected segments in group 1 vs. 6.5 % in group 2; p < 0.001). Group 2 had lower ischemic time (181 ± 53 vs. 208 ± 61 min; p = 0.03), the donors were younger (33 ± 13 vs. 41 ± 13 years; p = 0.01) and fewer donors were Toxoplasma gondii seropositive (4 vs. 22pts; p < 0.001).

Conclusion

Infarct-atypical LGE was found in a significant number of patients early post-HTX, however, fewer patients and myocardial segments per patient were affected later after HTX. Many potential factors seem to be involved, but the exact mechanisms are still unclear. Future studies are necessary to test prognostic implications associated with LGE-CMR patterns.     

Exploring clinical determinants and anxiety symptom domains among Asian breast cancer patients

Purpose

Psychological distress, such as anxiety, is commonly experienced by breast cancer patients. This study was designed to evaluate the presentation of anxiety symptom domains among Asian breast cancer patients and to identify clinical factors that were associated with occurrence of anxiety.

Methods

An observational study was conducted between August 2009 and January 2012. Breast cancer patients (stages I to III) with different chemotherapy treatment status completed the Beck Anxiety Inventory (BAI) to evaluate the prevalence and severity of their anxiety symptoms. Demographical and clinical data were collected. Multiple linear regression was conducted to delineate clinical factors associated with anxiety.

Results

A total of 319 patients were recruited (age: 51?±?9 years; 80.9 % Chinese; 69.6 % stage I/II). The median BAI total score was 8 (IQR, 4–14). Anxiety severities varied greatly across patients with different chemotherapy treatment status: patients who were receiving concurrent chemotherapy at the point of assessment (n?=?161) experienced more severe anxiety symptoms, as compared to pre-chemotherapy receiving (n?=?78) patients and post-chemotherapy (n?=?88) patients (29.8 % vs. 9.0 % vs. 20 %, respectively; p?=?0.021). Regression model identified fatigue (p?<?0.001) and the concurrent receipt of chemotherapy (p?<?0.001) as the strongest factors associated with anxiety. Concomitant neuropsychiatric medicines (antidepressants, anxiolytics, and hypnotics) were moderately associated with anxiety occurrence.

Conclusions

This is the largest series to date to evaluate anxiety symptom domains among Asian breast cancer patients. Results suggest that toxicities of chemotherapy may have contributed to the presentation of anxiety symptoms.     

Reperfusion therapy and mortality in octogenarian STEMI patients: results from the Belgian STEMI registry

Background

Treatment strategies and outcome of ST-elevation myocardial infarction (STEMI) have been mainly studied in middle-aged patients. With increasing lifetime expectancy, the proportion of octogenarians will substantially increase. We aimed to evaluate whether the benefit of currently recommended reperfusion strategies is maintained in octogenarians.

Methods

Reperfusion therapy and in-hospital mortality were evaluated in 1,092 octogenarians and compared with 7,984 STEMI patients <80 years old based on data from the prospective Belgian STEMI registry.

Results

The octogenarian STEMI group had more cardiovascular comorbidities, contained more female patients and presented more frequently with cardiac failure (Killip class >1, 40 vs. 20 %) compared with their younger counterparts (all p < 0.05). Although the rate of thrombolysis was similar (9.2 vs. 9.9 %) between both groups, a conservative approach was chosen more frequently (13.8 vs. 4.7 %), while PCI was performed less frequently (76.9 vs. 85.4 %) in octogenarians (p < 0.001). Moreover, ischemic time and door-to-needle/balloon time were longer for octogenarians. In-hospital mortality for octogenarians was 17.8 vs. 5.5 % in the younger group [adjusted OR 2.43(1.92–3.08)]. In haemodynamically stable octogenarians, PCI seemed to improve outcome compared with thrombolysis or conservative treatment (5.7 vs. 12.7 vs. 8.5 %, p = 0.09). In octogenarians with cardiac failure, in-hospital mortality was extremely high independent of the chosen reperfusion therapy (34.6 vs. 31.6 vs. 36.3 %, p = 0.88).

Conclusions

In-hospital mortality in octogenarian STEMI patients was high and related to a high prevalence of cardiac failure. Less PCI was performed in the octogenarian group compared with the younger patients, although mortality benefit of PCI was maintained in haemodynamically stable octogenarians.     

Contribution of comorbidities to functional impairment is higher in heart failure with preserved than with reduced ejection fraction

Background

Comorbidities negatively affect prognosis more strongly in heart failure with preserved (HFpEF) than with reduced (HFrEF) ejection fraction. Their comparative impact on physical impairment in HFpEF and HFrEF has not been evaluated so far.

Methods and results

The frequency of 12 comorbidities and their impact on NYHA class and SF-36 physical functioning score (SF-36 PF) were evaluated in 1,294 patients with HFpEF and 2,785 with HFrEF. HFpEF patients had lower NYHA class (2.0?±?0.6 vs. 2.4?±?0.6, p?<?0.001) and higher SF-36 PF score (54.4?±?28.3 vs. 54.4?±?27.7, p?<?0.001). All comorbidities were significantly (p?<?0.05) more frequent in HFrEF, except hypertension and obesity, which were more frequent in HFpEF (p?<?0.001). Adjusting for age and gender, COPD, anemia, hyperuricemia, atrial fibrillation, renal dysfunction, cerebrovascular disease and diabetes had a similar (p for interaction >?0.05) negative effect in both groups. Obesity, coronary artery disease and peripheral arterial occlusive disease exerted a significantly (p?<?0.05) more adverse effect in HFpEF, while hypertension and hyperlipidemia were associated with fewer (p?<?0.05) symptoms in HFrEF only. The total impact of comorbidities on NYHA (AUC for prediction of NYHA III/IV vs. I/II) and SF-36 PF (r ²) in multivariate analyses was approximately 1.5-fold higher in HFpEF, and also much stronger than the impact of a 10% decrease in ejection fraction in HFrEF or a 5?mm decrease in left ventricular end-diastolic diameter in HFpEF.

Conclusion

The impact of comorbidities on physical impairment is higher in HFpEF than in HFrEF. This should be considered in the differential diagnosis and in the treatment of patients with HFpEF.     

Right ventricular function in grown-up patients after correction of congenital right heart disease

Aims

We investigated whether a correlation exists between biomarkers of the neurohumoral system and clinical markers in grown-up patients with congenital heart disease (GUCH) and right ventricular function.

Methods and results

Prospective, cross-sectional, multicenter study of 104 GUCH patients (median) 16?years (range 6?C43?years) after corrective surgery with RV pressure and/or volume overload and 54 healthy controls. Clinical, functional, and laboratory parameters were assessed. Natriuretic peptide levels were significantly increased in GUCH patients (NTproBNP 101 vs. 25?pg/ml, p?<?0.001), but we observed no differences in norepinephrine, aldosterone, angiotensin II and Endothelin-1 levels. NTproBNP correlated significantly with clinical markers such as NYHA classification, prolonged QRS duration and reduced exercise capacity (VO₂ peak) (all p?<?0.001), as well as self-reported quality of life (p?<?0.001). MRI and echocardiography derived RV volumes were elevated and ejection fraction reduced in the patients (both p?<?0.001). Tissue Doppler parameter showed significantly restricted ventricular longitudinal systolic function (longitudinal tricuspid valve movement, 1.7 vs. 2.3?cm, p?<?0.001), suggesting stiffness and reduced RV compliance.

Conclusion

In conclusion, grown-up patients with congenital right heart disease NTproBNP correlates well with various clinical markers of RV failure, such as prolongation of QRS duration, exercise capacity, echocardiography and MRI parameters, and quality of life.     

The revised EuroSCORE II for the prediction of mortality in patients undergoing transcatheter aortic valve implantation

Background

The assessment of procedural risk is crucial in patients with severe symptomatic aortic stenosis. Logistic EuroSCORE and STS score are currently used to estimate procedural risk and mortality for surgical and transcatheter aortic valve implantation (TAVI). The recently published EuroSCORE II might provide a helpful tool.

Methods

The new EuroSCORE II was calculated in 206 patients undergoing transfemoral TAVI and compared to the established logistic EuroSCORE and STS mortality score. Discriminative power and calibration of each test was statistically evaluated.

Results

30-day and 1-year mortality rates were 6.8 % (14/206) and 27.2 % (56/206). In-hospital mortality rate was 29.2 ± 17.8 % with logistic EuroSCORE, 9.5 ± 6.8 % with STS score, and 9.22 ± 7.12 % with EuroSCORE II: Logistic EuroSCORE and EuroSCORE II were significantly increased in non-survivors compared to survivors at 30 days and at 1 year. EuroSCORE II and STS score (r = 0.49, p < 0.001) showed moderate correlation, whereas strong correlation was found between EuroSCORE II and logistic EuroSCORE (r = 0.71, p < 0.001). ROC curve analyses for the prediction of 30-day mortality (AUC 0.79 vs. 0.69 vs. 0.71) and 1-year mortality (AUC 0.72 vs. 0.70 vs. 0.70) were performed. Statistical comparison revealed no difference between the AUCs (p > 0.05).

Conclusion

In percutaneous TAVI patients, 30-day mortality was best approximated by the new EuroSCORE II, whereas the logistic EuroSCORE best reflected 1-year mortality. However, EuroSCORE II does not provide additional prognostic information beyond the established logistic EuroSCORE. For more exact risk prediction in TAVI, a distinct TAVI risk score would be desirable.     

Strength and endurance training in the treatment of lung cancer patients in stages IIIA/IIIB/IV

Purpose

This randomized controlled trial tested the effects of a specially designed strength and endurance training on the independence and quality of life in lung cancer patients in stages IIIA/IIIB/IV during palliative chemotherapy.

Methods

Between August 2010 and December 2011, 46 patients were randomized into two groups receiving either conventional physiotherapy or special physiotherapeutic training. The Barthel Index served as primary endpoint. The secondary endpoints were the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core-30 (EORTC QLQ C-30/LC-13) questionnaire, the 6-Minute Walk Test (6MWT), stair walking, the Modified Borg Scale, and muscle strength. Nonparametrical data were analyzed with the Wilcoxon and Mann–Whitney U test. For parametric, data student t tests were used. A p value of ≤.05 was accepted.

Results

Twenty-nine patients completed the trial (Intervention group (IG), n?=?18; control group (CG), n?=?11). Significant differences were detectable in the Barthel Index (IGmean?=?92.08; CGmean?=?81.67; p?=?.041), in single scores of the EORTC QLQ C-30/LC-13 questionnaire (physical functioning, p?=?.025; hemoptysis, p?=?.019; pain in arms or shoulder, p?=?.048; peripheral neuropathy, p?=?.050; cognitive functioning, p?=?.050), in the 6MWT, stair walking, strength capacity, and in the patient’s dyspnoea perception during submaximal walking activities (IG?>?CG).

Conclusion

According to these findings, lung cancer patients should receive enhanced physical activity intervention during palliative chemotherapy.     

Multimodal exercise training during myeloablative chemotherapy: a prospective randomized pilot trial

Purpose

Cancer and its treatment-related side effects induce loss of physical performance. This study evaluated the effects of multimodal aerobic and strength exercises on physical performance in hospitalized cancer patients while receiving myeloablative chemotherapy.

Methods

In this prospective pilot study, 48 evaluable patients were randomly assigned to a training (TG, n?=?24) or control (CG, n?=?24) group. The TG performed an individually supervised exercise program five times a week with ergometer training and strength exercises for 20 min each during the hospitalization period for chemotherapy. The CG received standard physiotherapy. Physical performance was evaluated using spiroergometry, lung function, and muscle strength testing. Treatment-related side effects were assessed by daily interviews, quality of life by EORTC-QLQ-C30, and fatigue using the Modified Fatigue Impact Scale (MFIS) questionnaire.

Results

Physical performance significantly increased in the TG (8.96?±?24 W) and decreased in the CG (?7.24?±?20 W, p?=?0.02). At 2-mmol/ml blood lactate concentration, the TG achieved significantly increased oxygen consumption (p?=?0.03) and expiratory minute ventilation (p?=?0.04) compared to the CG. Furthermore, physical functioning increased significantly in the TG (p?=?0.04). Patients in the TG required less antiemetics (p?=?0.01) and experienced significantly less fatigue (p?=?0.04), although MFIS analysis was not able to detect this beneficial effect. Patients of the CG displayed higher impairments of cognitive (p?=?0.02) and psychosocial function (p?=?0.03) after chemotherapy. No adverse events due to the study intervention were observed.

Conclusions

Multimodal exercise has beneficial effects on physical performance, physical functioning, and treatment-related symptoms even during myeloablative chemotherapy. We suggest an enhanced physical activity intervention program during hospitalization of cancer patients.     

Early acid–base and blood pressure effects of continuous renal replacement therapy intensity in patients with metabolic acidosis

Purpose

In acute kidney injury patients, metabolic acidosis is common. Its severity, duration, and associated changes in mean arterial pressure (MAP) and vasopressor therapy may be affected by the intensity of continuous renal replacement therapy (CRRT). We aimed to compare key aspects of acidosis and MAP and vasopressor therapy in patients treated with two different CRRT intensities.

Methods

We studied a nested cohort of 115 patients from two tertiary intensive care units (ICUs) within a large multicenter randomized controlled trial treated with lower intensity (LI) or higher intensity (HI) CRRT.

Results

Levels of metabolic acidosis at randomization were similar [base excess (BE) of ?8 ± 8 vs. ?8 ± 7 mEq/l; p = 0.76]. Speed of BE correction did not differ between the two groups. However, the HI group had a greater increase in MAP from baseline to 24 h (7 ± 3 vs. 0 ± 3 mmHg; p < 0.01) and a greater decrease in norepinephrine dose (from 12.5 to 3.5 vs. 5 to 2.5 μg/min; p < 0.05). The correlation (r) coefficients between absolute change in MAP and norepinephrine (NE) dose versus change in BE were 0.05 and ?0.37, respectively.

Conclusions

Overall, LI and HI CRRT have similar acid–base effects in patients with acidosis. However, HI was associated with greater improvements in MAP and vasopressor requirements (clinical trial no. NCT00221013).     

Carotid artery interventions for restenosis after prior stenting: is it different from interventions of de novo lesions? Results from the carotid artery stent (CAS)—registry of the Arbeitsgemeinschaft Leitende Kardiologische Krankenhausärzte (ALKK)

Objective

To compare characteristics and outcome of patients with re-stenoses after prior carotid artery stenting (CAS) treated with repeat carotid interventions (Re-CI) with CAS for de novo lesions.

Background

The treatment of re-stenosis is a major problem in vascular interventions. Patients with re-stenoses after prior CAS treated with Re-CI are not well defined.

Methods

We analyzed data from the prospective ALKK CAS Registry.

Results

Out of 3,817 CAS procedures 95 were intended in 93 patients (2.5%) for a restenosis after prior CAS and 3,722 CAS in 3,655 patients (97.5%) for a de novo stenosis. There was no difference in age (p = 0.302) or distribution of gender (p = 0.545) between the two groups. Patients treated for a restenosis after CAS were less likely to be treated for a symptomatic lesion (22.7 vs. 40.1%, p = 0.001). Coronary heart disease (p = 0.017), peripheral arterial disease (p < 0.001) as well as diabetes mellitus (p = 0.004) were more prevalent in the restenosis group. Lesions were less complicated in restenosis patients, with less ulcers (7.4 vs. 19.9%, p = 0.003) and less severe calcifications (7.4 vs. 23.6%, p < 0.001). The intended interventions were more often not performed in the Re-CI group (9.5 vs. 3.3%; p = 0.001). In-hospital, the stroke or death rate was 0% in the Re-CI group as compared to 3.1% in the de novo group (p = 0.115).

Conclusions

Patients treated with Re-CI for repeat stenoses after prior CAS represent 2.5% of current CAS patients. Although representing a subgroup with more concomitant diseases, Re-CI seems to be associated with lower event rates as compared to CAS for de novo lesions.     

Effects of a 12-week home-based exercise program on the level of physical activity, insulin, and cytokines in colorectal cancer survivors: a pilot study

Purpose

The purposes of this study are to examine (1) the feasibility and efficacy of two different home-based exercise protocols on the level of physical activity (PA), and (2) the effect of increased PA via home-based exercise program on biomarkers of colorectal cancer.

Methods

Seventeen patients (age 55.18 ± 13.3 years) with stage II–III colorectal cancer completed the 12-week home-based exercise program. Subjects were randomized into either casually intervened home-based exercise group (CIHE) or intensely intervened home-based exercise group (IIHE). The primary outcome was the level of PA. Furthermore, insulin, homeostasis model assessment of insulin resistance, insulin-like growth factor axis, and adipocytokines were measured.

Results

Both CIHE and IIHE program significantly increased the level of PA at 12 weeks compared to its level at baseline (CIHE, 10.00?±?8.49 vs. 46.07?±?45.59; IIHE, 12.08?±?11.04 vs. 35.42?±?27.42 MET hours per week). Since there was no difference in PA change between groups (p?=?0.511), the data was combined in analyzing the effects of increased PA on biomarkers. Increase in PA significantly reduced insulin (6.66?±?4.58 vs. 4.86?±?3.48 μU/ml, p?=?0.006), HOMA-IR (1.66?±?1.23 vs. 1.25?±?1.04, p?=?0.017), and tumor necrosis alpha-α (TNF-α 4.85?±?7.88 vs. 2.95?±?5.38 pg/ml, p?=?0.004), and significantly increased IGF-1 (135.39?±?60.15 vs. 159.53 ng/ml, p?=?0.007), IGF binding protein (IGFBP)-3 (2.67?±?1.48 vs. 3.48?±?1.00 ng/ml, p?=?0.013), and adiponectin (6.73?±?3.07 vs. 7.54?±?3.96 μg/ml, p?=?0.015).

Conclusion

CIHE program was as effective as IIHE program in increasing the level of PA, and the increase in PA resulted in significant change in HOMA-IR, IGF-1 axis, TNF-α, and adiponectin levels in stage II–III colorectal cancer survivors.     

Impact of copeptin on diagnosis, risk stratification, and intermediate-term prognosis of acute coronary syndromes

Background

The aim of the current study was to evaluate the diagnostic and intermediate-term prognostic impact of C-terminal portion of provasopressin (copeptin) in combination with troponin I.

Methods

In this prospective single-center study we recruited a total of 230 unselected patients with suspected recent acute coronary syndrome (ACS) presenting consecutively at our chest pain unit. Troponin I and copeptin levels were determined at presentation and after 3–6 h. Follow-up was performed after 180 days.

Results

Acute myocardial infarction (AMI) was the final diagnosis in 107 patients (STEMI: 24, NSTEMI: 83). The median copeptin level was significantly higher in patients having AMI than in those without (20.83 vs. 12.2 pmol/L, p < 0.0001). A troponin I level <0.04 ng/mL in combination with copeptin <14 pmol/L at admission ruled out AMI with an negative predictive value (NPV) of 97.3 %. p = 0.0045 for the added value of copeptin to troponin I. Kaplan–Meier analysis showed that copeptin levels above the diagnostic cut-off were associated with an elevated intermediate-term (180 days) mortality (p = 0.019), while no patient with copeptin values below the cut-off died. Univariate Cox regression analysis identified copeptin as strong predictor of intermediate-term mortality (HR 4.28, 95 % CI 1.58?11.6, p = 0.004). The predictive performance for prediction of 180-day mortality was significantly better if copeptin was included (C-index of 0.80) compared with that of troponin alone (C-index 0.78, p = 0.01 for the added value of copeptin to troponin I).

Conclusions

Additional assessment of copeptin allows a rapid and reliable exclusion of AMI and improves diagnostic accuracy in myocardial ischemia. This study showed for the first time that copeptin provides valuable predictive information for risk stratification and intermediate-term outcome in ACS patients.     

A randomized trial of intravenous glutamine supplementation in trauma ICU patients

Purpose

To evaluate the effect of the intravenous (i.v.) l-alanyl-l-glutamine dipeptide supplementation during 5 days on clinical outcome in trauma patients admitted to the intensive care unit (ICU).

Methods

This was a prospective, randomized, double-blind, multicenter trial. Glutamine was not given as a component of nutrition but as an extra infusion. The primary outcome variable was the number of new infections within the first 14 days.

Results

We included 142 patients. There were no differences between groups in baseline characteristics. Up to 62 % of the patients in the placebo group and 63 % in the treatment group presented confirmed infections (p = 0.86). ICU length of stay was 14 days in both groups (p = 0.54). Hospital length of stay was 27 days in the placebo group and 29 in the treatment group (p = 0.88). ICU mortality was 4.2 % in both groups (p = 1). Sixty percent of the patients presented low glutamine levels before randomization. At the end of the treatment (6th day), 48 % of the patients maintained low glutamine levels (39 % of treated patients vs. 57 % in the placebo group). Patients with low glutamine levels at day 6 had more number of infections (58.8 vs. 80.9 %; p = 0.032) and longer ICU (9 vs. 20 days; p < 0.01) and hospital length of stay (24 vs. 41 days; p = 0.01).

Conclusions

There was no benefit with i.v. l-alanyl-l-glutamine dipeptide supplementation (0.5 g/kg body weight/day of the dipeptide) during 5 days in trauma patients admitted to the ICU. The i.v. glutamine supplementation was not enough to normalize the plasma glutamine levels in all patients. Low plasma glutamine levels at day 6 were associated with a worse outcome.     

The impact of radiotherapy on quality of life for cancer patients: a longitudinal study

Purpose

The aim of this study was to assess for changes in quality of life (QOL) among cancer patients who undergo radiotherapy (RT) and to identify factors that influence QOL in this group.

Materials and methods

Three hundred sixty-seven cancer patients who received curative RT were investigated using the EORTC QLQ-C30 questionnaire at the start of RT, end of RT, and 1 and 6 months post-RT.

Results

The patients were 49 % women, 51 % men, and median age at diagnosis was 57 years (range, 16–86 years). Compared to pre-RT, at the end of RT, the global health status score (p?<?0.001), nausea/vomiting (p?<?0.001), and apetite loss scores (p?<?0.001) were significantly poorer. Compared to the end of RT, at 1 and 6 months post-RT, global health status, all functional, and all symptom scores were significantly improved (p?<?0.001). Patient sex influenced scores for pain (p?=?0.036), appetite loss (p?=?0.027), and financial difficulty (p?=?0.003). Performance status influenced scores for global health status (p?=?0.006), physical functioning (p?<?0.001), cognitive functioning (p?=?0.001), and role functioning (p?=?0.021). Comorbidity influenced fatigue score (p?<?0.001). Cancer stage influenced scores for physical functioning (p?=?0.001), role functioning (p?=?0.010), and fatigue (p?<?0.001). Treatment modality (chemoRT vs. RT alone) influenced scores for physical functioning (p?=?0.016), fatigue (p?<?0.001), nausea/vomiting (p?=?0.009), and appetite loss (p?<?0.001); and RT field influenced scores for nausea/vomiting (p?=?0.001), appetite loss (p?=?0.003), and diarrhea (p?=?0.037). Radiotherapy dose functioning (p?<?0.001), cognitive functioning (p?<?0.001), social functioning (p?<?0.001), fatigue (p?<?0.001), and pain (<60 vs ≥60 Gy) had an effect on scores for physical functioning (p?<?0.001), role functioning (p?<?0.001), emotional (p?<?0.001), insomnia (p?<?0.001), constipation (p?<?0.001).

Conclusion

While RT negatively affects cancer patients’ QOL, restoration tends to be rapid and patients report significant improvement by 1 month post-RT. Various patient- and disease-specific factors and RT modality affect QOL in this patient group. We advocate measuring cancer patients’ QOL regularly as part of routine patient management.     

Motor unit potential morphology differences in individuals with non-specific arm pain and lateral epicondylitis

Background

The pathophysiology of non-specific arm pain (NSAP) is unclear and the diagnosis is made by excluding other specific upper limb pathologies, such as lateral epicondylitis or cervical radiculopathy. The purpose of this study was to determine: (i) if the quantitative parameters related to motor unit potential morphology and/or motor unit firing patterns derived from electromyographic (EMG) signals detected from an affected muscle of patients with NSAP are different from those detected in the same muscle of individuals with lateral epicondylitis (LE) and/or control subjects and (ii) if the quantitative EMG parameters suggest that the underlying pathophysiology in NSAP is either myopathic or neuropathic in nature.

Methods

Sixteen subjects with NSAP, 11 subjects with LE, eight subjects deemed to be at-risk for developing a repetitive strain injury, and 37 control subjects participated. A quantitative electromyography evaluation was completed using decomposition-based quantitative electromyography (DQEMG). Needle- and surface-detected EMG signals were collected during low-level isometric contractions of the extensor carpi radialis brevis (ECRB) muscle. DQEMG was used to extract needle-detected motor unit potential trains (MUPTs), and needle-detected motor unit potential (MUP) and surface detected motor unit potential (SMUP) morphology and motor unit (MU) firing rates were compared among the four groups using one-way analysis of variance (ANOVA). Post hoc analyses were performed using Tukey's pairwise comparisons.

Results

Significant group differences were found for all MUP variables and for MU firing rate (p < 0.006). The post-hoc analyses revealed that patients with NSAP had smaller MUP amplitude and SMUP amplitude and area compared to the control and LE groups (p < 0.006). MUP duration and AAR values were significantly larger in the NSAP, LE and at-risk groups compared to the control group (p < 0.006); while MUP amplitude, duration and AAR values were smaller in the NSAP compared to the LE group. SMUP duration was significantly shorter in the NSAP group compared to the control group (p < 0.006). NSAP, LE and at-risk subjects had lower mean MU firing rates than the control subjects (p < 0.006).

Conclusion

The size-related parameters suggest that the NSAP group had significantly smaller MUPs and SMUPs than the control and LE subjects. Smaller MUPs and SMUPs may be indicative of muscle fiber atrophy and/or loss. A prospective study is needed to confirm any causal relationship between smaller MUPs and SMUPs and NSAP as found in this work.     

Effect of valproic acid on acute lung injury in a rodent model of intestinal ischemia reperfusion

Objectives

Acute lung injury (ALI) can develop during the course of many clinical conditions, and is associated with significant morbidity and mortality. Valproic acid (VPA), a well-known anti-epileptic drug, has been shown to have anti-oxidant and anti-inflammatory effects in various ischemia/reperfusion (I/R) models. The purpose of this study was to investigate whether VPA could affect survival and development of ALI in a rat model of intestinal I/R.

Methods

Two experiments were performed. Experiment I: Male Sprague-Dawley rats (250-300 g) were subjected to intestinal ischemia (1 h) and reperfusion (3 h). They were randomized into 2 groups (n = 7 per group) 30 min after ischemia: Vehicle (Veh) and VPA (300 mg/kg, IV). Primary end-point for this study was survival over 4 h from the start of ischemia. Experiment II: The histological and biochemical effects of VPA treatment on lungs were examined 3 h (1 h ischemia + 2 h reperfusion) after intestinal I/R injury (Veh vs. VPA, n = 9 per group). An objective histological score was used to grade the degree of ALI. Enzyme linked immunosorbent assay (ELISA) was performed to measure serum levels of interleukins (IL-6 and 10), and lung tissue of cytokine-induced neutrophil chemoattractant (CINC) and myeloperoxidase (MPO). In addition, the activity of 8-isoprostane was analyzed for pulmonary oxidative damage.

Results

In Experiment I, 4-h survival rate was significantly higher in VPA treated animals compared to Veh animals (71.4% vs. 14.3%, p = 0.006). In Experiment II, ALI was apparent in all of the Veh group animals. Treatment with VPA prevented the development of ALI, with a reduction in the histological score (3.4 ± 0.3 vs. 5.3 ± 0.6, p = 0.025). Moreover, compared to the Veh control group the animals from the VPA group displayed decreased serum levels of IL-6 (952 ± 213 pg/ml vs. 7709 ± 1990 pg/ml, p = 0.011), and lung tissue concentrations of CINC (1188 ± 28 pg/ml vs. 1298 ± 27 pg/ml, p < 0.05), MPO activity (368 ± 23 ng/ml vs. 490 ± 29 ng/ml, p < 0.05) and 8-isoprostane levels (1495 ± 221 pg/ml vs. 2191 ± 177 pg/ml, p < 0.05).

Conclusion

VPA treatment improves survival and attenuates ALI in a rat model of intestinal I/R injury, at least in part, through its anti-oxidant and anti-inflammatory effects.     

An optimized set-up for helmet noninvasive ventilation improves pressure support delivery and patient�Cventilator interaction

Objective

To test the effects on mechanical performance of helmet noninvasive ventilation (NIV) of an optimized set-up concerning the ventilator settings, the ventilator circuit and the helmet itself.

Subjects and methods

In a bench study, helmet NIV was applied to a physical model. Pressurization and depressurization rates and minute ventilation (MV) were measured under 24 conditions including pressure support of 10 or 20?cmH₂O, positive end expiratory pressure (PEEP) of 5 or 10?cmH₂O, ventilator circuit with ??high??, ??intermediate?? or ??low?? resistance, and cushion deflated or inflated. In a clinical study pressurization and depressurization rates, MV and patient?Cventilator interactions were compared in six patients with acute respiratory failure during conventional versus an ??optimized?? set-up (PEEP increased to 10?cmH₂O, low resistance circuit and cushion inflated).

Results

In the bench study, all adjustments simultaneously applied (increased PEEP, inflated cushion and low resistance circuit) increased pressurization rate (46.7?±?2.8 vs. 28.3?±?0.6?%, p?<?0.05), depressurization rate (82.9?±?1.9 vs. 59.8?±?1.1?%, p????0.05) and patient MV (8.5?±?3.2 vs. 7.4?±?2.8?l/min, p?<?0.05), and decreased leaks (17.4?±?6.0 vs. 33.6?±?6.0?%, p?<?0.05) compared to the basal set-up. In the clinical study, the optimized set-up increased pressurization rate (51.0?±?3.5 vs. 30.8?±?6.9?%, p?<?0.002), depressurization rate (48.2?±?3.3 vs. 34.2?±?4.6?%, p?<?0.0001) and total MV (27.7?±?7.0 vs. 24.6?±?6.9?l/min, p?<?0.02), and decreased ineffective efforts (3.5?±?5.4 vs. 20.3?±?12.4?%, p?<?0.0001) and inspiratory delay (243?±?109 vs. 461?±?181?ms, p?<?0.005).

Conclusions

An optimized set-up for helmet NIV that limits device compliance and ventilator circuit resistance as much as possible is highly effective in improving pressure support delivery and patient?Cventilator interaction.