Association between postoperative muscle wasting and survival in older patients undergoing surgery for non-metastatic colorectal cancer

BACKGROUND: Preoperative sarcopenia in older patients is a risk factor for adverse outcomes after colorectal cancer (CRC) surgery. Longitudinal changes in muscle mass in this group have not been studied previously although muscle wasting may have prognostic significance regarding survival. We aimed to determine the association between muscle wasting and overall survival (OS) in older patients who underwent surgery for CRC.METHODS: Patients ≥70 years who underwent surgery for non-metastatic CRC in Gelre hospitals, The Netherlands, between 2011 and 2015 were included. Cross-sectional area of skeletal muscle was measured at the level of the 3rd lumbar vertebra on preoperative and postoperative abdominal CT-scans. Patients who had &gt;1 standard deviation decrease in muscle mass were considered to have muscle wasting. Cox regression analysis was used to evaluate associations between muscle wasting and OS.RESULTS: 233 patients were included (40% female, median age 76 years). Thirty-four patients had muscle wasting. After a median follow-up of 4.7 years, 53 (23%) patients died. The 3-year mortality rate was higher in patients with muscle wasting (27% vs 14%, p = .05). In multivariable analysis adjusted for age, recurrent disease and preoperative muscle mass, muscle wasting was associated with reduced OS (HR 2.8, 95% CI 1.5-5.4, p = .002).CONCLUSION: Muscle wasting predicted poorer survival in older patients who underwent CRC surgery. Measuring changes in muscle mass may improve risk prediction in this patient group. Future studies should address the etiology of muscle wasting in older patients with CRC. Whether perioperative exercise interventions can prevent muscle wasting also warrants further study.</p

Brain damage in patients with manifest arterial disease

In this thesis we assessed whether the risk factors known to affect markers of brain damage in the general population, also effectuate brain damage in patients who already have symptomatic arterial disease. We found that elevated levels of homocysteine were related to slightly lower global cognitive function. The results suggest that vascular mechanisms are not responsible for the relationship between homocysteine and cognitive function. The relation between the metabolic syndrome or type 2 diabetes mellitus, and cognitive function was investigated. The analyses showed that global cognitive function was not affected more in patients with than in patients without the metabolic syndrome. Only the scores on visuoperception and construction were slightly lower. Adjustment for markers of macro- and microvascular disease, and of metabolic disease, did not attenuate the results. Cognition in patients with type 2 diabetes mellitus was similar to cognition in patients with the metabolic syndrome. This suggests that most of the relation between the metabolic syndrome and cognitive function in the general population is attributable to arterial disease. We analysed the relation between four vascular growth factors and cognitive function. The presence of the communicating arteries in the circle of Willis was assessed, as a measure of presence of cerebral collateral vessels; also the total volume flow rate (tVFR) through both internal carotid arteries and the basilar artery was assessed. In patients with internal carotid artery stenosis, higher basic fibroblast growth factor (bFGF) levels were related to higher scores on cognitive function. This relation was weakened by adjustment for tVFR, suggesting a mediating effect. Furthermore, patients with higher vascular endothelial growth factor levels had slightly lower performance on visuoperception and construction. We concluded that bFGF seems the most promising of the four studied growth factors for future clinical studies. Cognitive function was assessed in three categories of patients with manifest arterial disease: no stroke or TIA, and no silent infarcts; silent infarcts; or stroke or TIA at inclusion. While silent infarcts did not influence cognitive function in these patients, patients with stroke or TIA had lower scores than patients with symptoms elsewhere in the arterial tree. Thus, when patients already are vascular compromised, the presence of a silent brain infarct does not add to the cognitive dysfunction due to the arterial disease itself, while symptomatic cerebrovascular disease does affect cognitive function more severely. Patients with manifest arterial disease did not have lower flow to the brain compared with the general population. Presence of diabetes mellitus was associated with lower total volume flow rate, as was increasing BMI. Patients with cerebrovascular disease had lower tVFR values than patients with symptomatic vascular disease elsewhere in the vascular tree. We have reviewed the literature on the fetal type posterior (FTP) circle of Willis. In FTPs there is an embryonic derivation of the posterior cerebral artery from the internal carotid artery. Besides the fact that a larger area is thus dependent on the internal carotid artery, leptomeningeal vessels can not develop between the anterior and posterior circulation. Patients with a bFTP circle of Willis did not have statistically significant different WML volumes than patients without an FTP in our study. These preliminary results will be followed by extended analyses in patients with a unilateral FTP and comparison of different techniques to assess WML

Determinants of Difficulty and Discriminating Power of Image-based Test Items in Postgraduate Radiological Examinations

Rationale and Objectives: The psychometric characteristics of image-based test items in radiological written examinations are not well known. In this study, we explored difficulty and discriminating power of these test items in postgraduate radiological digital examinations. Materials and Methods: We reviewed test items of seven Dutch Radiology Progress Tests (DRPTs) that were taken from October 2013 to April 2017. The DRPT is a semiannual formative examination, required for all Dutch radiology residents. We assessed several stimulus and response characteristics of test items. The response format of test items included true or false, single right multiple choice with 2, 3, 4, or ≥5 answer options, pick-N multiple-choice, drag-and-drop, and long-list-menu formats. We calculated item P values and item-rest-correlation (Rir) values to assess difficulty and discriminating power. We performed linear regression analysis in image-based test items to investigate whether P and Rir values were significantly related to stimulus and response characteristics. Also, we compared psychometric indices between image-based test items and text-alone items. Results: P and Rir values of image-based items (n = 369) were significantly related to the type of response format (P < .001), and not to which of the seven DRPTs the item was obtained from, radiological subspecialty domain, nonvolumetric or volumetric character of images, or context-rich or context-free character of the stimulus. When accounted for type of response format, difficulty and discriminating power of image-based items did not differ significantly from text-alone items (n = 881). Test items with a relatively large number of answer options were generally more difficult, and discriminated better among high- and low-performing candidates. Conclusion: In postgraduate radiological written examinations, difficulty and discriminating power of image-based test items are related to the type of response format and are comparable to those of text-alone items. We recommend a response format with a relatively large number of answer options to optimize psychometric indices of radiological image-based test items

Long-term Survival in Breast Cancer Patients Is Associated with Contralateral Parenchymal Enhancement at MRI: Outcomes of the SELECT Study

BackgroundSeveral single-center studies found that high contralateral parenchymal enhancement (CPE) at breast MRI was associated with improved long-term survival in patients with estrogen receptor (ER)–positive and human epidermal growth factor receptor 2 (HER2)–negative breast cancer. Due to varying sample sizes, population characteristics, and follow-up times, consensus of the association is currently lacking.PurposeTo confirm whether CPE is associated with long-term survival in a large multicenter retrospective cohort, and to investigate if CPE is associated with endocrine therapy effectiveness.Materials and MethodsThis multicenter observational cohort included women with unilateral ER-positive HER2-negative breast cancer (tumor size ≤50 mm and ≤three positive lymph nodes) who underwent MRI from January 2005 to December 2010. Overall survival (OS), recurrence-free survival (RFS), and distant RFS (DRFS) were assessed. Kaplan-Meier analysis was performed to investigate differences in absolute risk after 10 years, stratified according to CPE tertile. Multivariable Cox proportional hazards regression analysis was performed to investigate whether CPE was associated with prognosis and endocrine therapy effectiveness.ResultsOverall, 1432 women (median age, 54 years [IQR, 47–63 years]) were included from 10 centers. Differences in absolute OS after 10 years were stratified according to CPE tertile as follows: 88.5% (95% CI: 88.1, 89.1) in tertile 1, 85.8% (95% CI: 85.2, 86.3) in tertile 2, and 85.9% (95% CI: 85.4, 86.4) in tertile 3. CPE was independently associated with OS, with a hazard ratio (HR) of 1.17 (95% CI: 1.0, 1.36; P = .047), but was not associated with RFS (HR, 1.11; P = .16) or DRFS (HR, 1.11; P = .19). The effect of endocrine therapy on survival could not be accurately assessed; therefore, the association between endocrine therapy efficacy and CPE could not reliably be estimated.ConclusionHigh contralateral parenchymal enhancement was associated with a marginally decreased overall survival in patients with estrogen receptor–positive and human epidermal growth factor receptor 2–negative breast cancer, but was not associated with recurrence-free survival (RFS) or distant RFS