Metabolic syndrome is a sequela of radiation exposure in hypothalamic obesity among survivors of childhood brain tumors.

Survivors of childhood brain tumors may be at risk for early onset of metabolic syndrome, possibly secondary to surgery and/or radiation exposure. This study examines effects of radiation exposure to hypothalamus-pituitary-adrenal axis (HPA) on metabolic risk among survivors of childhood brain tumors. One hundred forty-two met inclusion criteria; 60 had tumor surgery plus radiation exposure (>1 Gray (Gy)) to HPA. The second subgroup of 82 subjects had surgery only and were not exposed to radiation. Both subgroups had survived for approximately 5 years at the time of study. All had clinical evaluation, vital signs, anthropometry, measurement of body composition by dual X-ray absorptiometry and fasting laboratory assays (metabolic panel, insulin, C-peptide, insulin-like growth factor-1, leptin and adiponectin). Body composition data for both subgroups was compared with the National Health and Nutrition Survey (NHANES) subgroup of similar age, gender and body mass index. Cranial surgery was associated with obesity of similar severity in both subgroups. However, survivors exposed to radiation to the HPA also had increased visceral fat mass and high prevalence of growth hormone deficiency and metabolic syndrome. Fat mass alone did not explain the prevalence of the metabolic syndrome in radiation exposure subgroup. Other factors such as growth hormone deficiency may have contributed to metabolic risk. We conclude that prevalence of metabolic syndrome among subjects exposed to hypothalamic radiation was higher than expected from hypothalamic obesity alone. Radiation exposure may exert untoward endocrinopathies due to HPA exposure that worsens metabolic risk. Early screening for metabolic syndrome in this population is indicated.

Cost-effectiveness analysis of intensity modulated radiation therapy versus 3-dimensional conformal radiation therapy for anal cancer.

PURPOSE: To compare the cost-effectiveness of intensity modulated radiation therapy (IMRT) and 3-dimensional conformal radiation therapy (3D-CRT) for anal cancer and determine disease, patient, and treatment parameters that influence the result. METHODS AND MATERIALS: A Markov decision model was designed with the various disease states for the base case of a 65-year-old patient with anal cancer treated with either IMRT or 3D-CRT and concurrent chemotherapy. Health states accounting for rates of local failure, colostomy failure, treatment breaks, patient prognosis, acute and late toxicities, and the utility of toxicities were informed by existing literature and analyzed with deterministic and probabilistic sensitivity analysis. RESULTS: In the base case, mean costs and quality-adjusted life expectancy in years (QALY) for IMRT and 3D-CRT were $32,291 (4.81) and $28,444 (4.78), respectively, resulting in an incremental cost-effectiveness ratio of $128,233/QALY for IMRT compared with 3D-CRT. Probabilistic sensitivity analysis found that IMRT was cost-effective in 22%, 47%, and 65% of iterations at willingness-to-pay thresholds of $50,000, $100,000, and $150,000 per QALY, respectively. CONCLUSIONS: In our base model, IMRT was a cost-ineffective strategy despite the reduced acute treatment toxicities and their associated costs of management. The model outcome was sensitive to variations in local and colostomy failure rates, as well as patient-reported utilities relating to acute toxicities.

Identification and prevention of antiepileptic drug noncompliance: the collaborative use of state-supplied pharmaceutical data.

Background. Antiepileptic drugs (AEDs) noncompliance is associated with increased risk of seizures and morbidity in seizure disorder patients. Objective. To identify risk factors that correlated to higher levels of morbidity, measured by emergency room (ER) utilization by seizure disorder members taking AED. Methods. Patients with primary or secondary diagnosis of seizures, convulsions, and/or epilepsy and prescribed AEDs during an 11-month period were included in the study. Variables were analyzed using multivariate statistical analysis including logistic regression. Results. The study identified 201 members. No statistical significance (NS) between age, gender, number of tablets, type of drug, or other risk factors was associated with increased mortality. Statistical significance resulted with medication compliance review of 0-14 days, 15-60 days, and 61+ days between refills. 68% of patients with ER visit had noncompliance refill between 0 and 14 days compared to 52% of patients in non-ER group (P = 0.04). Contrastingly, 15% of ER group had refills within 15-60 days compared with 33% of non-ER group (P = 0.01). There was NS difference between two groups when noncompliance was greater than 60 days (P = 0.66). Conclusions. The study suggests that careful monitoring of pharmaceutical refill information could be used to identify AED noncompliance in epileptic patients.

Outcome of patients with pilocytic astrocytoma and leptomeningeal dissemination.

PURPOSE: To determine the patient, tumor, and treatment characteristics of patients with pilocytic astrocytoma (PA) and leptomeningeal dissemination (LMD). METHODS AND MATERIALS: A PubMed search of English-language studies pertaining to PA with LMD was performed using a combination of keywords that included juvenile pilocytic astrocytoma, low-grade astrocytoma, low-grade glioma, leptomeningeal dissemination, neuraxis spread, and radiotherapy. We found 26 studies with 58 patients between 1976 and 2005 that met these criteria. RESULTS: The median survival for PA patients with LMD was 65 months. The 1-, 2-, and 5-year overall survival (OS) rate after the diagnosis of LMD was 81.1%, 75.7%, and 55.5%. The 1-, 2-, and 5-year progression-free survival (PFS) rate after the diagnosis of LMD was 69.3%, 66.5%, and 34.6%, respectively. Age, gender, primary site location, timing of LMD presentation (synchronous vs. metachronous), and LMD location did not significantly influence OS or PFS. No statistically significant difference was found in OS or PFS between the chemotherapy and radiotherapy groups. Likewise, no difference was found in OS or PFS according to the use of craniospinal irradiation vs. less extensive RT fields. CONCLUSIONS: Approximately one-half of PA patients were alive 5 years after the diagnosis of LMD. Both chemotherapy and radiotherapy have efficacy against LMD. Although the use of craniospinal irradiation did not have an effect on PFS, the patient numbers were small and a larger number treated with craniospinal irradiation is needed to determine its efficacy.

Cost-effectiveness analysis of SBRT versus IMRT: an emerging initial radiation treatment option for organ-confined prostate cancer.

OBJECTIVES: The purpose of this study is to compare the cost-effectiveness of 2 external beam radiation therapy techniques for treatment of lowto intermediate-risk prostate cancer: stereotactic body radiation therapy (SBRT) and intensitymodulated radiation therapy (IMRT). MATERIALS AND METHODS: A Markov decision analysis model with probabilistic sensitivity analysis was designed with the various disease states of a 70-year-old patient with organ-confined prostate cancer to evaluate the cost-effectiveness of 2 external beam radiation treatment options. RESULTS: The Monte Carlo simulation revealed that the mean cost and quality-adjusted life-years (QALYs) for SBRT and IMRT were $22,152 and 7.9 years and $35,431 and 7.9 years, respectively. The sensitivity analysis revealed that if the SBRT cohort experienced a decrease in quality of life of 4% or a decrease in efficacy of 6%, then SBRT would no longer dominate IMRT in cost-effectiveness. In fact, with these relaxed assumptions for SBRT, the incremental cost-effectiveness ratio of IMRT met the societal willingness to pay threshold of $50,000 per QALY. CONCLUSIONS: Compared with IMRT, SBRT for lowto intermediate-risk prostate cancer has great potential cost savings for our healthcare system payers and may improve access to radiation, increase patient convenience, and boost quality of life for patients. Our model suggests that the incremental cost-effectiveness ratio of IMRT compared with SBRT is highly sensitive to quality-oflife outcomes, which should be adequately and comparably measured in current and future prostate SBRT studies.

Cost-effectiveness analysis of stereotactic body radiation therapy versus intensity-modulated radiation therapy: an emerging initial radiation treatment option for organ-confined prostate cancer.

PURPOSE: The purpose of this study is to compare the cost-effectiveness of two external beam radiation therapy techniques for treatment of low- to intermediate-risk prostate cancer: stereotactic body radiation therapy (SBRT) and intensity-modulated radiation therapy (IMRT). MATERIALS AND METHODS: A Markov decision analysis model with probabilistic sensitivity analysis was designed with the various disease states of a 70-year-old patient with organ-confined prostate cancer to evaluate the cost-effectiveness of two external beam radiation treatment options. RESULTS: The Monte Carlo simulation revealed that the mean cost and quality-adjusted life-years (QALYs) for SBRT and IMRT were $22,152 and 7.9 years and $35,431 and 7.9 years, respectively. The sensitivity analysis revealed that if the SBRT cohort experienced a decrease in quality of life of 4% or a decrease in efficacy of 6%, then SBRT would no longer dominate IMRT in cost-effectiveness. In fact, with these relaxed assumptions for SBRT, the incremental cost-effectiveness ratio of IMRT met the societal willingness to pay threshold of $50,000 per QALY. CONCLUSION: Compared with IMRT, SBRT for low- to intermediate-risk prostate cancer has great potential cost savings for our health care system payers and may improve access to radiation, increase patient convenience, and boost quality of life for patients. Our model suggests that the incremental cost-effectiveness ratio of IMRT compared with SBRT is highly sensitive to quality-of-life outcomes, which should be adequately and comparably measured in current and future prostate SBRT studies.

Intensity-modulated radiation therapy for the treatment of squamous cell anal cancer with para-aortic nodal involvement.

PURPOSE: To determine the rates of toxicity, locoregional control, distant control, and survival in anal cancer patients with para-aortic nodal involvement, treated with intensity-modulated radiotherapy (IMRT) and concurrent chemotherapy at a single institution. METHODS AND MATERIALS: Between 2001 and 2007, 6 patients with squamous cell anal cancer and para-aortic nodal involvement were treated with IMRT and concurrent infusional 5-fluorouracil and cisplatin. The primary tumor was treated with a median dose of 57.5 Gy (range, 54-60 Gy), involved para-aortic, pelvic, and inguinal lymph nodes were treated with a median dose of 55 Gy (range, 50.5-55 Gy), and noninvolved nodal regions were treated with a median dose of 45 Gy (range, 43.5-45 Gy). RESULTS: After a median follow-up of 25 months, none of the patients had a recurrence at the primary tumor, pelvic/inguinal nodes, or para-aortic nodes, whereas 2 patients developed distant metastases to the liver. Four of the 6 patients are alive. The 3-year actuarial locoregional control, distant control, and overall survival rates were 100%, 56%, and 63%, respectively. Four of the 6 patients developed Grade 3 acute gastrointestinal toxicity during chemoradiation. CONCLUSIONS: Intensity-modulated radiotherapy and concurrent chemotherapy could potentially serve as definitive therapy in anal cancer patients with para-aortic nodal involvement. Adjuvant chemotherapy may be indicated in these patients, as demonstrated by the distant failure rates. These patients need to be followed carefully because of the potential for treatment-related toxicities.

Incidence and clinical characteristics of methicillin-resistant Staphylococcus aureus necrotizing fasciitis in a large urban hospital.

BACKGROUND: Methicillin-resistant Staphylococcus aureus (MRSA) has become a prevalent health issue for soft-tissue infections. In severe soft-tissue infections such as necrotizing fasciitis, MRSA has been identified as an increasingly common pathogen. Herein, we report a 5-year experience of MRSA necrotizing fasciitis at a large urban hospital. METHODS: All cases of necrotizing fasciitis between 2001 and 2006 were reviewed. All patients were taken for surgical debridement. MRSA patients were identified and compared with the non-MRSA patients to identify any clinical variables that impacted incidence or severity of disease. A P value of less than .05 was considered significant. RESULTS: During the 5-year period, there were 74 cases of necrotizing fasciitis with a 39% prevalence of MRSA as the causative organism for the infection. The mean age of patients with MRSA fasciitis was 43 +/- 3 years. There were no discernible social variables (eg, smoking, ethanol use, intravenous drug use) that predisposed patients to MRSA infection. The overall mortality rate was 15%, with no significant difference between groups. One hundred percent of MRSA specimens were susceptible to vancomycin or rifampin, 93% were susceptible to sulfamethoxazole/trimethoprim, and only 62% were susceptible to clindamycin. CONCLUSIONS: The incidence of MRSA fasciitis may be much higher than initially suspected and prompt MRSA-directed antibiotic therapy should be administered. Clinicians should maintain a high index of suspicion for this organism in necrotizing fasciitis.