Investigation of clinical characteristics and genome associations in the 'UK Lipoedema' cohort.

Lipoedema is a chronic adipose tissue disorder mainly affecting women, causing excess subcutaneous fat deposition on the lower limbs with pain and tenderness. There is often a family history of lipoedema, suggesting a genetic origin, but the contribution of genetics is currently unclear. A tightly phenotyped cohort of 200 lipoedema patients was recruited from two UK specialist clinics. Objective clinical characteristics and measures of quality of life data were obtained. In an attempt to understand the genetic architecture of the disease better, genome-wide single nucleotide polymorphism (SNP) genotype data were obtained, and a genome wide association study (GWAS) was performed on 130 of the recruits. The analysis revealed genetic loci suggestively associated with the lipoedema phenotype, with further support provided by an independent cohort taken from the 100,000 Genomes Project. The top SNP rs1409440 (ORmeta ≈ 2.01, Pmeta ≈ 4 x 10-6) is located upstream of LHFPL6, which is thought to be involved with lipoma formation. Exactly how this relates to lipoedema is not yet understood. This first GWAS of a UK lipoedema cohort has identified genetic regions of suggestive association with the disease. Further replication of these findings in different populations is warranted.

Surveillance Is Important After Surgical Excision of Giant Fibrovascular Polyps of the Esophagus.

Giant fibrovascular polyps of the esophagus are rare benign tumors arising from the cervical esophagus or hypopharynx. Radiologic and endoscopic investigation may struggle to identify a stalk or to delineate the tumor as luminal or submucosal in origin. Excision is advised, although the diagnosis, and therefore the optimal operative approach, may not be apparent until the time of operation. Individual case reports describe the technical success of surgical excision but rarely include follow-up. Our case series highlights the range of approaches for surgical excision and also the importance of long-term follow-up because of the risk of recurrence and potential for airway obstruction.

Consequences of Late-Stage Non-Small-Cell Lung Cancer Cachexia on Muscle Metabolic Processes.

INTRODUCTION: The loss of muscle is common in patients with advanced non-small-cell lung cancer (NSCLC) and contributes to the high morbidity and mortality of this group. The exact mechanisms behind the muscle loss are unclear. PATIENTS AND METHODS: To investigate this, 4 patients with stage IV NSCLC who met the clinical definitions for sarcopenia and cachexia were recruited, along with 4 age-matched healthy volunteers. After an overnight fast, biopsy specimens were obtained from the vastus lateralis, and the key components associated with inflammation and the control of muscle protein, carbohydrate, and fat metabolism were assessed. RESULTS: Compared with the healthy volunteers, significant increases in mRNA levels for interleukin-6 and NF-κB signaling and lower intramyocellular lipid content in slow-twitch fibers were observed in NSCLC patients. Although a significant decrease in phosphorylation of the mechanistic target of rapamycin (mTOR) signaling protein 4E-BP1 (Ser65) was observed, along with a trend toward reduced p70 S6K (Thr389) phosphorylation (P = .06), no difference was found between groups for the mRNA levels of MAFbx (muscle atrophy F box) and MuRF1 (muscle ring finger protein 1), chymotrypsin-like activity of the proteasome, or protein levels of multiple proteasome subunits. Moreover, despite decreases in intramyocellular lipid content, no robust changes in mRNA levels for key proteins involved in insulin signaling, glycolysis, oxidative metabolism, or fat metabolism were observed. CONCLUSION: These findings suggest that examining the contribution of suppressed mTOR signaling in the loss of muscle mass in late-stage NSCLC patients is warranted and reinforces our need to understand the potential contribution of impaired fat metabolism and muscle protein synthesis in the etiology of cancer cachexia.

Factors influencing exercise performance in thoracic cancer.

BACKGROUND: Patients with incurable thoracic cancer often complain of a reduced ability to exercise, but the cause of this has been little studied. Thus, we have explored how various physiological and psychological factors relate to exercise performance in this group. METHODS: Inspiratory muscle strength, peripheral muscle power, lung function and mastery over breathlessness were assessed using sniff nasal inspiratory pressure, leg extensor power, simple spirometry and the mastery domain of the Chronic Respiratory Disease Questionnaire respectively. Exercise performance was assessed using the Incremental Shuttle Walking Test (ISWT) during which patients wore a K4 b(2) system permitting measurement of resting and breakpoint heart rate, minute ventilation (VE) and oxygen uptake (VO(2)). Relationships between ISWT distance and the four factors were determined using correlation and ß regression coefficients. RESULTS: Forty-one patients (21 male, mean (SD) age 64 (8) years) walked a median [IQR] of 320 [250-430] metres and reached a mean (SD) of 76 (10), 77 (25), and 48 (14) of their percent predicted maximum heart rate, VO(2), and VE respectively. Exercise performance was significantly associated only with inspiratory muscle strength (r = 0.42, P < 0.01) and peripheral muscle power (r = 0.39, P = 0.01). These factors were also significant determinants of exercise performance (ß coefficients [95%CI] 1.77 [0.53, 3.01] and 1.22 [0.31, 2.14] respectively). CONCLUSION: Of the factors examined, only inspiratory and peripheral muscle performance were significantly related to and predictive of exercise performance. Rehabilitation interventions which include inspiratory and peripheral muscle training are worth exploring further in this group of patients with thoracic cancer.

How practical are transmucosal fentanyl products for breakthrough cancer pain? Novel use of placebo formulations to survey user opinion.

BACKGROUND: Three transmucosal fentanyl products have recently been licensed for cancer-related breakthrough pain: a sublingual tablet, a buccal/sublingual tablet and a nasal spray. Limited comparative data hinder identifying the most appropriate to use and adopt onto a service formulary. However, the availability of placebo formulations provides a unique opportunity to compare the practical aspects of their use. METHODS: 30 patients with cancer accessed and administered a placebo of each product and were asked to rate them using 1-7 Likert agree-disagree scales and free-text responses, with regard to ease of access and administration, palatability and overall impression. Participants rated their usual rescue analgesic similarly, based on recall. They also indicated whether they would be prepared to use the fentanyl product, and their most preferred. RESULTS: For accessibility, the usual rescue analgesic was rated best (median score 3), significantly better than the buccal/sublingual tablet (p=0.01) and nasal spray (p<0.01), but not the sublingual tablet. Conversely, the nasal spray was rated significantly worse (median score 7) than the others (p<0.01). For ease of administration, the usual rescue analgesic and sublingual tablet were rated equally best (median score 1), with only the latter being significantly different to the buccal/sublingual tablet (p=0.04) and nasal spray (p=0.05). For palatability, the sublingual tablet was rated the best (median score 2), but was significantly different only to the buccal/sublingual tablet (p<0.01). For overall impression, the sublingual tablet was rated significantly better (median score 3) than the others, with more patients prepared to use it and selecting it as their most preferred (27 and 18, respectively). CONCLUSION: This survey provides valuable insight into the practical aspects of these three transmucosal fentanyl products for practitioners considering their use.

The prevalence of nocturnal hypoxemia in advanced cancer.

Nocturnal hypoxemia is associated with excessive daytime sleepiness in patients with chronic respiratory disease. This relationship has not been explored in patients with cancer. This study examined the prevalence of nocturnal hypoxemia in patients admitted to a specialist palliative care unit, and explored relationships with demographic and physiological parameters, opioid or other sedative drug use, and daytime sleepiness, fatigue, and quality of life. Demographic details, diagnosis, performance status, body mass index, opioid or other sedative drug use, hemoglobin, spirometry, and sniff nasal inspiratory pressures were obtained, along with Epworth Sleepiness Scale, Multidimensional Fatigue Inventory, and Short Form-36 health questionnaire scores. An oximeter recorded resting daytime oxygen saturation (SaO2); overnight SaO2 was recorded for a minimum of five hours. Nocturnal hypoxemia was defined as SaO2<90% for >or=2% of the monitored nighttime. Of 100 patients, 35 had nocturnal hypoxemia. These were more likely to have lung disease (P<0.05), a lower forced expiratory volume in one second % predicted (P=0.01), lower daytime SaO2 (P=0.01) and higher levels of mental fatigue (difficulty concentrating) (P=0.02), compared to those without nocturnal hypoxemia. Both groups exhibited abnormal levels of daytime sleepiness. Nocturnal hypoxemia is common in this group of patients and may contribute to mental fatigue (difficulty concentrating).

The ethical and legal implications of deactivating an implantable cardioverter-defibrillator in a patient with terminal cancer.

In this paper, the ethical and legal issues raised by the deactivation of implantable cardioverter-defibrillators (ICDs) in patients with terminal cancer is considered. It is argued that the ICD cannot be well described either as a treatment or as a non-treatment option, and thus raises complex questions regarding how rules governing deactivation should be framed. A new category called "integral devices" is proposed. Integral devices require their own special rules, reflecting their position as a "halfway house" between a form of treatment and a part of the body. The practical problems faced by doctors working in palliative medicine with regard to the deactivation of ICDs are also considered.

Microbiologically confirmed meningoencephalitis due to Enterococcus avium: a first report.

We describe an 80-year-old lady with a meningoencephalitic illness followed by vertebral discitis. Enterococcus avium was cultured from her cerebrospinal fluid. No other pathogen was incriminated in her illness. The meningoencephalitic illness settled after 3 weeks of antimicrobials, but the vertebral discitis required longer therapy.

Endovascular aneurysm repair with the Talent stent-graft.

PURPOSE: Evaluation of the Talent endovascular aortic stent graft in the management of abdominal aortic aneurysms. MATERIALS AND METHODS: Thirty-eight patients with suitable abdominal aortic aneurysms were treated over an 18-month period using the modular Talent stent graft. The suprarenal Talent device was deployed in 31 cases. Clinical follow-up of all patients has been performed by clinical examination, contrast-enhanced CT, and Duplex ultrasound for a mean period of 12.5 months. RESULTS: Graft placement was successful in all 38 patients. The immediate exclusion rate was 84%, the 1-month primary exclusion rate was 92.1%, and the 3-month exclusion rate was 97%. There were no deaths in the first 30 days, one death at 3 months due to a presumed rupture, and one other death at 1 year due to carcinomatosis. There have been no migrations or renal complications in the suprarenal group. CONCLUSIONS: Our short- and medium-term results are comparable with other published Talent stent-graft series. Suprarenal graft fixation is a safe procedure that may aid in preventing graft migration. Long-term follow-up is required to assess the durability of the suprarenal Talent device.

Effectiveness of open versus antireflux stents for palliation of distal esophageal carcinoma and prevention of symptomatic gastroesophageal reflux.

PURPOSE: To compare the effectiveness of an antireflux stent with that of a standard open stent in preventing symptoms of gastroesophageal reflux in patients with inoperable distal esophageal cancer. MATERIALS AND METHODS: Fifty consecutive patients with inoperable distal esophageal tumors underwent placement of either a standard open or an antireflux stent across the cardia. Stents were allocated randomly before assessment of the stricture. All patients were followed up prospectively by the departmental research nurses. Technical and clinical success, reflux symptoms, complications, and reintervention rates were assessed. P values of observed differences were calculated by using the chi(2) and log-rank tests as appropriate. RESULTS: The technical success rate was 100%. Improvement in dysphagia was identical in both groups (three points on a five-point scale). Twenty-four (96%) of 25 patients with standard open stents had symptoms of esophageal reflux; 19 (76%) of 25 required treatment. Three (12%) of 25 patients with antireflux stents reported esophageal reflux; one (4%) of 25 required treatment. This difference was significant (P <.001). There was no significant difference in survival, complications, or reintervention rate. One case of late esophageal perforation occurred in each group. One patient died of aspiration within 24 hours after insertion of a standard open stent; no procedure-related deaths occurred with the antireflux stent. CONCLUSION: This antireflux stent is as safe and effective as the standard open stent in relieving malignant dysphagia and was successful in reducing symptomatic gastroesophageal reflux.