Characteristics and outcome of patients with newly diagnosed advanced or metastatic lung cancer admitted to intensive care units (ICUs).

BACKGROUND: Although patients with advanced or metastatic lung cancer have poor prognosis, admission to the ICU for management of life-threatening complications has increased over the years. Patients with newly diagnosed lung cancer appear as good candidates for ICU admission, but more robust information to assist decisions is lacking. The aim of our study was to evaluate the prognosis of newly diagnosed unresectable lung cancer patients. METHODS: A retrospective multicentric study analyzed the outcome of patients admitted to the ICU with a newly diagnosed lung cancer (diagnosis within the month) between 2010 and 2013. RESULTS: Out of the 100 patients, 30 had small cell lung cancer (SCLC) and 70 had non-small cell lung cancer. (Thirty patients had already been treated with oncologic treatments.) Mechanical ventilation (MV) was performed for 81 patients. Seventeen patients received emergency chemotherapy during their ICU stay. ICU, hospital, 3- and 6-month mortality were, respectively, 47, 60, 67 and 71%. Hospital mortality was 60% when invasive MV was used alone, 71% when MV and vasopressors were needed and 83% when MV, vasopressors and hemodialysis were required. In multivariate analysis, hospital mortality was associated with metastatic disease (OR 4.22 [1.4-12.4]; p = 0.008), need for invasive MV (OR 4.20 [1.11-16.2]; p = 0.030), while chemotherapy in ICU was associated with survival (OR 0.23, [0.07-0.81]; p = 0.020). CONCLUSION: This study shows that ICU management can be appropriate for selected newly diagnosed patients with advanced lung cancer, and chemotherapy might improve outcome for patients with SCLC admitted for cancer-related complications. Nevertheless, tumors' characteristics, numbers and types of organ dysfunction should be taken into account in the decisional process before admitting these patients in ICU.

Intensive care in patients with lung cancer: a multinational study.

BACKGROUND: Detailed information about lung cancer patients requiring admission to intensive care units (ICUs) is mostly restricted to single-center studies. Our aim was to evaluate the clinical characteristics and outcomes of lung cancer patients admitted to ICUs. PATIENTS AND METHODS: Prospective multicenter study in 449 patients with lung cancer (small cell, n = 55; non-small cell, n = 394) admitted to 22 ICUs in six countries in Europe and South America during 2011. Multivariate Cox proportional hazards frailty models were built to identify characteristics associated with 30-day and 6-month mortality. RESULTS: Most of the patients (71%) had newly diagnosed cancer. Cancer-related complications occurred in 56% of patients; the most common was tumoral airway involvement (26%). Ventilatory support was required in 53% of patients. Overall hospital, 30-day, and 6-month mortality rates were 39%, 41%, and 55%, respectively. After adjustment for type of admission and early treatment-limitation decisions, determinants of mortality were organ dysfunction severity, poor performance status (PS), recurrent/progressive cancer, and cancer-related complications. Mortality rates were far lower in the patient subset with nonrecurrent/progressive cancer and a good PS, even those with sepsis, multiple organ dysfunctions, and need for ventilatory support. Mortality was also lower in high-volume centers. Poor PS predicted failure to receive the initially planned cancer treatment after hospital discharge. CONCLUSIONS: ICU admission was associated with meaningful survival in lung cancer patients with good PS and non-recurrent/progressive disease. Conversely, mortality rates were very high in patients not fit for anticancer treatment and poor PS. In this subgroup, palliative care may be the best option.

Finding a new normal: a grounded theory study of rehabilitation after treatment for upper gastrointestinal or gynaecological cancers--the patient's perspective.

This paper reports on a study of perspectives of rehabilitation needs by 33 people treated for upper gastrointestinal and gynaecological cancers. This study used focus groups informed by grounded theory and involved adult participants who had completed radical treatment at a UK cancer centre. Patients were involved in the design. Findings indicate that these patients are likely to have ongoing rehabilitation needs and that there was poor awareness of possible treatment of symptoms and of rehabilitation services. Novel findings include distinct perspectives of adults who have completed treatment for upper gastrointestinal and gynaecological cancers regarding their rehabilitation needs. Patients on surgical pathways, or who had longer hospital stays, had a better understanding of the rehabilitation services available to them and they accessed them more easily to ameliorate their post-treatment symptoms. Furthermore rehabilitation services are not equally accessed by patients on different treatment pathways. A grounded theory of cancer rehabilitation was developed with core categories of: impacts on the person, adjustment after treatment, individualised tailored support and information sources. The overarching theme is 'seeking a new normal'. Individualised tailored support is integral to seeking and establishing a new normal. Routine assessment and referral for rehabilitation treatment warrants further evaluation in these groups.

Inverse changes in fetal insulin-like growth factor (IGF)-1 and IGF binding protein-1 in association with higher birth weight in maternal diabetes.

OBJECTIVE: The insulin like growth factor (IGF) system plays a key role in regulating fetal growth, is metabolically regulated, and may influence development of increased birth weight in offspring of mothers with diabetes. We examined IGF-1 and IGF binding protein-1 (IGFBP-1) concentrations in cord blood samples from offspring of mothers with gestational and type 2 diabetes. DESIGN AND PATIENTS: Case-control study of Maori and Pacific Island mothers recruited prospectively at Middlemore Hospital, South Auckland, New Zealand. MEASUREMENTS: Cord blood (for insulin, IGF-1 and IGFBP-1) was taken from umbilical vein at birth from singleton babies born after 32 weeks of gestation from138 mothers with gestational diabetes (GDM), 39 mothers with type 2 diabetes (T2DM) and 95 control mothers. RESULTS: Babies born to mothers with both GDM and T2DM had significantly increased birth weight (Z-score birth weight mean +/- SD: GDM 0.94 +/- 1.31, T2DM 0.53 +/- 1.1) compared to controls (Z-score birth weight -0.08 +/- 1.10). IGFBP-1 was significantly reduced in both diabetic groups (median interquartile range: GDM 67(31-137) ng/ml, T2DM 59(29-105) ng/ml, control 114(56-249) ng/ml). Cord IGF-1 was significantly increased in cord blood of infants of mothers with GDM (42.2 +/- 16.3 ng/ml vs. control 34.7 +/- 18.5 ng/ml) but not T2DM (38.7 +/- 17.4 ng/ml). In all offspring, IGF-1 and IGFBP-1 were positively and negatively correlated with birth weight, respectively. CONCLUSIONS: Maternal diabetes results in inverse changes of circulating fetal IGF-1 and IGFBP-1 at birth. A decrease in circulating IGFBP-1 and to a lesser extent an increase in circulating IGF-1 may present an important mechanism that contributes to increased birth weight in diabetic pregnancies.

Maternal nutritional risk factors for small for gestational age babies in a developed country: a case-control study.

AIMS: To assess the effect of maternal diet during pregnancy on the risk of delivering a baby who is small for gestational age (SGA). METHODS: Case-control study of 844 cases (SGA) and 870 controls (appropriate size for gestational age (AGA)). Only term (37+ completed weeks of gestation) infants were included. Retrospective food frequency questionnaires were completed at birth on the diet at the time of conception and in the last month of pregnancy. RESULTS: At the time of conception, mothers of AGA infants ate significantly more servings of carbohydrate rich food and fruit, and were more likely to have taken folate and vitamin supplements than mothers of SGA infants. There was some evidence that mothers of AGA infants also ate more servings of dairy products, meat, and fish (0.05 < p < 0.1). However, after adjustment for maternal ethnicity, smoking, height, weight, hypertension, and occupation, fish intake (p = 0.04), carbohydrate-rich foods (p = 0.04), and folate supplementation (p = 0.02) were associated with a reduced risk of SGA. In the last month of pregnancy, only iron supplementation was associated with a reduced risk of SGA (p = 0.05) after adjustment for potential confounders. CONCLUSIONS: This study suggests that small variations in maternal diets within the normal range during pregnancy in developed countries are associated with differences in birth weight.

An online tool for investigating clinical decision making.

BACKGROUND: Induction of labour is a common clinical intervention. There has been a recent rise in rates of induction of labour and wide variation between published hospital rates without obvious explanation. Clinician variation has been suggested as a reason. OBJECTIVE: The study described aimed to examine clinical decision making, whilst removing individual patient bias. To achieve this clinical behaviour was studied by the use of imaginary clinical scenarios presented to clinicians by computer. Unlike retrospective audit, the rates thus generated are unaffected by differences in casemix, pressure of time, work or other factors and allow direct comparison between clinicians and comparison with clinical guidelines. METHODS: Data about 15 imaginary pregnant women are presented to the clinician, each may have symptoms or signs of hypertensive disorders, intrauterine growth restriction (IUGR) and/or postdates. From the decision made in each scenario, and the information revealed about each scenario, a set of 'decision rules' is created for each clinician, describing in what circumstances they would induce labour. Data from the National Women's Hospital (Auckland, New Zealand) is then examined using these rules and the induction of labour rate thus generated presented to the clinician. RESULTS: Sixteen clinicians were interviewed. Their induction of labour rate ranged from 10-31%. CONCLUSIONS: Clinician variation in decision making is evident about the intervention when to induce labour. The system is available on the WWW at http://csrs2.aut.ac.nz/scenario

Stress and lack of social support as risk factors for small-for-gestational-age birth.

AIM: To determine the contributions of social support and perceived stress to the risk of small-for-gestational-age birth. METHODS: The investigation was a case-control study of mothers of infants born at 37 or more completed weeks of gestation. Cases weighed less than the sex-specific 10th percentile for gestational age at birth (small for gestational age (SGA), n = 836), and controls (appropriate for gestational age (AGA), n = 870) comprised a random selection of heavier babies. RESULTS: In univariate analyses measures of informal social support, but not perceived stress or formal social support, were associated with SGA birth. It was found that Asian mothers are less likely to receive support from families and friends. After adjustment for ethnicity, informal social support was not associated with SGA. CONCLUSIONS: Support appears to reduce the risk of SGA births, but after adjustment for ethnicity this is no longer the case. Stress during pregnancy was not associated with SGA birth.

Smoking, nicotine and tar and risk of small for gestational age babies.

AIMS: To assess the effect of maternal smoking and environmental tobacco smoke (ETS) on risk of small for gestational age infants (SGA). METHODS: Case-control study of 844 cases and 870 controls. RESULTS: Maternal smoking in pregnancy was associated with an increased risk of SGA (adjusted odds ratio (OR)= 2.41; 95% confidence interval (CI) = 1.78, 3.28). We could not detect an increased risk of SGA with paternal smoking, or with other household smokers when the mother was a non-smoker, but did find an increased risk with exposure to ETS in the workplace or while socializing. Infants of mothers who ceased smoking during pregnancy were not at increased risk of SGA, but those who decreased but did not stop remained at risk of SGA. There was no evidence that the concentration of nicotine and tar in the cigarettes influenced the risk of SGA. CONCLUSIONS: Maternal smoking in pregnancy is a major risk factor for SGA. This study suggests that mothers should be advised to cease smoking completely during pregnancy, and that a reduction in the number of cigarettes smoked or smoking low tar or nicotine concentration cigarettes does not reduce the risk of SGA.

Risk factors for small-for-gestational-age babies: The Auckland Birthweight Collaborative Study.

OBJECTIVE: This case-control study determined whether internationally recognized risk factors for small-for-gestational-age (SGA) term babies were applicable in New Zealand. METHODOLOGY: All babies were born at 37 or more completed weeks of gestation in one of three hospitals in Auckland. Cases weighed less than the sex specific 10th percentile for gestational age at birth, and controls (appropriate-for-gestational-age (AGA)) were a random selection of heavier babies. Information was collected by maternal interview and from obstetric databases. RESULTS: Information from 1714 completed interviews (844 SGA and 870 AGA) was available for analysis. Computerized obstetric records were available for 1691 of the 1701 women who consented to such access. In a multivariate analysis allowing for sex, gestational age at birth, social class and other potential confounders, mothers who smoked had a significantly increased risk of an SGA baby (adjusted OR 2.41; 95% CI 1.78-3.28), as did primiparous mothers (adjusted OR 1.34; 95% CI 1.03-1.73), mothers of Indian ethnicity (adjusted OR 3.22; 95% CI 1.95-5.30), women with pre-eclamptic toxaemia (adjusted OR 2.42; 95% CI 1.08-5.40) and those with pre-existing hypertension toxaemia (adjusted OR 5.49; 95% CI 1.81-16.71). Mothers of SGA infants were shorter (P < 0.001) and reported lower prepregnancy body weights (P < 0.001) than mothers of AGA infants. The population attributable fraction for smoking suggests that up to 18% of SGA infants born in the ABC Study could be related to maternal smoking. CONCLUSIONS: Risk factors associated with SGA births in other countries are also important in New Zealand. Smoking in pregnancy is an important and potentially modifiable behaviour, and efforts to decrease the number of women who smoke during pregnancy should be encouraged.

Ultrasonographic surveillance in red blood cell alloimmunization.

OBJECTIVE: This study was undertaken to audit ultrasonographic measurements of fetal liver length and middle cerebral artery peak velocity in cases of red blood cell alloimmunization between 1986 and 1999. STUDY DESIGN: A total of 200 fetuses at risk for anemia because of red blood cell alloimmunization underwent ultrasonographic measurement of the length of the right lobe of the liver, 45 underwent Doppler recording of middle cerebral artery peak velocity, and 119 underwent fetal blood sampling. RESULTS: The overall survival was 188 of 200 (94%). Among 69 fetuses found to have anemia, liver length values in 64 (93%) were at the 95th percentile or greater, and the other 5 were in the upper part of the normal range. The middle cerebral artery peak velocity was > or =95th percentile in 15 of the 19 cases of anemia in which this value was measured (79%). Among those measured within 1 week of birth, all liver lengths were at least in the upper part of the normal range, with most >95th percentile, including 1 case with a cord blood hemoglobin concentration <90 g/L. CONCLUSIONS: All fetuses with anemia identified at fetal blood sampling had enlarged livers with 93% at > or =95th percentile. The peak velocity in the middle cerebral artery was abnormal in most fetuses with anemia.

Does aspirin have a role in improving pregnancy outcome for women with the antiphospholipid syndrome? A randomized controlled trial.

OBJECTIVE: This pilot investigation was undertaken to assess the efficacy of low-dose aspirin therapy for the treatment of women with antiphospholipid antibodies when recurrent miscarriage is the only sequela. STUDY DESIGN: A double-blind, randomized, placebo-controlled trial was conducted in the setting of the recurrent miscarriage clinic of a tertiary referral obstetric hospital. The participants were 50 women with a history of recurrent miscarriages (>/=3) and antiphospholipid antibodies. Women with systemic lupus erythematosus or a history of thrombosis were excluded. Women were recruited after full investigative screening at the recurrent miscarriage clinic. Women with >/=3 fetal losses and persistently positive results for antiphospholipid antibodies were randomly allocated to receive either aspirin (75 mg daily) or placebo. Investigators, clinicians, and patients were blinded to the treatment. Rates of live births, antenatal complications, and delivery and neonatal outcomes were recorded prospectively. Data were compared by chi(2) analysis with Yates' correction, the Fisher exact test, or the Student t test as appropriate. RESULTS: There were 10 exclusions after random assignment because of inappropriate inclusion. Eighty-five percent of the placebo (17/20) group and 80% of the aspirin-treated group (16/20) were delivered of live infants. This difference was not significant. There were no significant differences in antenatal complications or neonatal morbidity between the groups. CONCLUSIONS: This preliminary study suggests that low-dose aspirin has no additional benefit when added to supportive care for women for whom recurrent early fetal loss is the only sequela of the antiphospholipid syndrome. This live birth rate with supportive care alone exceeds the published live birth rates for women with antiphospholipid antibody-mediated recurrent fetal loss who were treated with heparin or corticosteroids. This trial, like all other trials in this field, is small, but its results bring into question the need for pharmacologic intervention for women with antiphospholipid syndrome for whom recurrent fetal loss is the only sequela. Our results highlight the need for a large randomized controlled trial to identify the optimal treatment for this group of women and justify the inclusion of a placebo arm in any such trial.

Human chorionic gonadotrophin for recurrent miscarriage.

BACKGROUND: There may be an association between recurrent miscarriage and abnormal hormone function in the follicular phase. Human chorionic gonadotrophin may play a role in preventing miscarriages. OBJECTIVES: The objective of this review was to assess the effects of human chorionic gonadotrophin administration during early pregnancy on the risk of miscarriage in women with a history of recurrent miscarriage. SEARCH STRATEGY: The Cochrane Pregnancy and Childbirth Group trials register was searched. Date of last search: 9 January 1998. SELECTION CRITERIA: Randomised trials of human chorionic gonadotrophin compared with placebo or no treatment in women who have had two or more miscarriages. DATA COLLECTION AND ANALYSIS: Eligibility and trial quality were assessed by one reviewer. MAIN RESULTS: Four trials involving 180 women were included. The trials were of variable quality. Human chorionic gonadotrophin was associated with a reduced risk of miscarriage for women with a history of recurrent miscarriage (odds ratio 0.26, 95% confidence interval 0.14 to 0.52). This result should be interpreted cautiously because the apparent effect is greatly influenced by the two methodologically weaker studies. REVIEWER'S CONCLUSIONS: There is not enough evidence to evaluate the use of human chorionic gonadotrophin during pregnancy in order to prevent miscarriage in women with a history of unexplained recurrent spontaneous miscarriage.

Cardiotocography for antepartum fetal assessment.

BACKGROUND: Cardiotocography is a form of fetal assessment which simultaneously records fetal heart rate, fetal movements and uterine contractions to investigate hypoxia. OBJECTIVES: The objective was to assess the effects of antenatal cardiotocography on perinatal morbidity and mortality and maternal morbidity. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group trials register and the Cochrane Controlled Trials Register (to 1 November 1998). SELECTION CRITERIA: Randomised trials comparing antenatal cardiotocography with a control group for fetal assessment. DATA COLLECTION AND ANALYSIS: Trial quality was assessed. MAIN RESULTS: Four studies involving 1,588 pregnancies were included. All trials were conducted on high or intermediate risk pregnancies. Antenatal cardiotocography appeared to have no significant effect on perinatal mortality or morbidity. There was a trend to an increase in perinatal deaths in the cardiotocography group (odds ratio 2.85, 95% confidence interval 0.99 to 7.12). There was no increase in the incidence of interventions such as elective caesarean section or induction of labour. The one trial which examined an effect on antenatal patient management showed a significant reduction in hospital admissions and a reduction in inpatient stay in the cardiotocography group. REVIEWER'S CONCLUSIONS: There is not enough evidence to evaluate the use of antenatal cardiotocography for fetal assessment. All of the trials included in this review date from the introduction of antenatal cardiotocography and may be difficult to relate to current practice.

Fetal fibronectin detection in preterm labor: evaluation of a prototype bedside dipstick technique and cervical assessment.

OBJECTIVE: The aims of this study were to evaluate a prototype bedside test for fetal fibronectin detection in women with symptoms of preterm labor, to compare the efficacy of obtaining fetal fibronectin swabs with and without a speculum, and to assess the value of combining the fetal fibronectin test with cervical dilatation for predicting delivery within 10 days. STUDY DESIGN: This investigation prospectively studied a cohort of women with symptoms of preterm labor (n = 121), gestational age between 24 and 33 6/7 weeks, and cervical dilatation /=1 cm predicted delivery within 10 days with sensitivity, specificity, and positive and negative predictive values of 71%, 87%, 46%, and 95%, respectively, with positive and negative likelihood ratios of 5.5 and 0.33, respectively. Combination of fetal fibronectin testing with cervical dilatation >/=1 cm did not significantly improve the fetal fibronectin test characteristics. After exclusion of women with slight vaginal bleeding, cervical dilatation >/=1 cm and fetal fibronectin status remained the only independent variables associated with delivery within 10 days. CONCLUSION: Fetal fibronectin testing according to this prototype may have a limited role in clinical decision analysis. In this study a cervical dilatation >/=1 cm had predictive values equivalent to those of the fetal fibronectin test, and it should be evaluated further in a clinical setting.