Cardiac remodeling in morbidly obese women and its association with adverse perinatal outcomes.

OBJECTIVES: To determine the association of cardiac remodeling in early pregnancy and adverse perinatal outcomes among women with BMI ≥ 40 kg/m2. STUDY DESIGN: We performed a retrospective cohort study including women with BMI ≥ 40 kg/m2 without known cardiac disease. Women who underwent screening transthoracic echocardiography prior to gestational age 24 weeks were included. Women were analyzed by group with normal or abnormal geometry, including concentric remodeling, eccentric hypertrophy, and concentric hypertrophy. Multivariable logistic regression was used to assess the association of abnormal geometry with perinatal outcomes. We had 80% power with alpha 0.05 to detect a 3.0-fold increase in the primary outcome among women with abnormal geometry. MAIN OUTCOME MEASURES: Our primary outcome was a composite of adverse perinatal outcomes including any 1 of the following: preterm birth (<37 weeks), low birth weight (<2500 g), or hypertensive disorders of pregnancy, including gestational hypertension, preeclampsia, and chronic hypertension with superimposed preeclampsia. RESULTS: Of 140 women, 53 (37.9%) had abnormal geometry. The average BMI was similar between those with normal and abnormal geometry (44.7 vs. 44.2 kg/m2, p = 0.53). The primary outcome occurred in 20.7% with normal geometry and 30.2% with abnormal geometry (p = 0.20). After adjustment for parity, chronic hypertension, and tobacco use, abnormal cardiac geometry was not associated with the composite primary outcome (adjusted OR 2.01 [95% CI 0.84-4.78]) but was associated with hypertensive disorders of pregnancy (adjusted OR 2.82 [95% CI 1.03-7.78]). CONCLUSIONS: Cardiac remodeling early in pregnancy is associated with hypertensive disorders of pregnancy.

Dose to the inferior rectum is strongly associated with patient reported bowel quality of life after radiation therapy for prostate cancer.

PURPOSE: To evaluate rectal dose and post-treatment patient-reported bowel quality of life (QOL) following radiation therapy for prostate cancer. METHODS: Patient-reported QOL was measured at baseline and 2-years via the expanded prostate cancer index composite (EPIC) for 90 patients. Linear regression modeling was performed using the baseline score for the QUANTEC normal tissue complication probability model and dose volume histogram (DVH) parameters for the whole and segmented rectum (superior, middle, and inferior). RESULTS: At 2-years the mean summary score declined from a baseline of 96.0-91.8. The median volume of rectum treated to ≥70 Gy (V70) was 11.7% for the whole rectum and 7.0%, 24.4%, and 1.3% for the inferior, middle, and superior rectum, respectively. Mean dose to the whole and inferior rectum correlated with declines in bowel QOL while dose to the mid and superior rectum did not. Low (V25-V40), intermediate (V50-V60) and high (V70-V80) doses to the inferior rectum influenced bleeding, incontinence, urgency, and overall bowel problems. Only the highest dose (V80) to the mid-rectum correlated with rectal bleeding and overall bowel problems. CONCLUSIONS: Segmental DVH analysis of the rectum reveals associations between bowel QOL and inferior rectal dose that could significantly influence radiation planning and prognostic models.

Cost-effectiveness of screening strategies for identifying pediatric diabetes mellitus and dysglycemia.

OBJECTIVE: To conduct a cost-effectiveness analysis of screening strategies for identifying children with type 2 diabetes mellitus and dysglycemia (prediabetes/diabetes). DESIGN: Cost simulation study. SETTING: A one-time US screening program. STUDY PARTICIPANTS: A total of 2.5 million children aged 10 to 17 years. INTERVENTION: Screening strategies for identifying diabetes and dysglycemia. MAIN OUTCOME MEASURES: Effectiveness (proportion of cases identified), total costs (direct and indirect), and efficiency (cost per case identified) of each screening strategy based on test performance data from a pediatric cohort and cost data from Medicare and the US Bureau of Labor Statistics. RESULTS: In the base-case model, 500 and 400 000 US adolescents had diabetes and dysglycemia, respectively. For diabetes, the cost per case was extremely high ($312 000-$831 000 per case identified) because of the low prevalence of disease. For dysglycemia, the cost per case was in a more reasonable range. For dysglycemia, preferred strategies were the 2-hour oral glucose tolerance test (100% effectiveness; $390 per case), 1-hour glucose challenge test (63% effectiveness; $571), random glucose test (55% effectiveness; $498), or a hemoglobin A1c threshold of 5.5% (45% effectiveness; $763). Hemoglobin A1c thresholds of 5.7% and 6.5% were the least effective and least efficient (ranges, 7%-32% and $938-$3370) of all strategies evaluated. Sensitivity analyses for diabetes revealed that disease prevalence was a major driver of cost-effectiveness. Sensitivity analyses for dysglycemia did not lead to appreciable changes in overall rankings among tests. CONCLUSIONS: For diabetes, the cost per case is extremely high because of the low prevalence of the disease in the pediatric population. Screening for diabetes could become more cost-effective if dysglycemia is explicitly considered as a screening outcome.