Potassium intake and risk of incident type 2 diabetes mellitus: the Coronary Artery Risk Development in Young Adults (CARDIA) Study.

AIMS/HYPOTHESIS: Serum potassium has been found to be a significant predictor of diabetes risk, but the effect of dietary potassium on diabetes risk is not clear. We sought to determine if dietary potassium is associated with risk of incident type 2 diabetes in young adults. METHODS: We used data from the Coronary Artery Risk Development in Young Adults (CARDIA) Study. Potassium intake was measured by (1) an average of three 24 h urinary potassium collections at the 5-year study visit, and (2) the CARDIA dietary assessment instrument at baseline. Incident type 2 diabetes cases were ascertained on the basis of use of diabetes medication and laboratory measurements. Analyses were adjusted for relevant confounders including intake of fruit and vegetables and other dietary factors. RESULTS: Of 1,066 participants with urinary potassium measurements, 99 (9.3%) developed diabetes over 15 years of follow-up. In multivariate models, adults in the lowest urinary potassium quintile were more than twice as likely to develop diabetes as their counterparts in the highest quintile (HR 2.45; 95% CI 1.08, 5.59). Of 4,754 participants with dietary history measurements, 373 (7.8%) developed diabetes over 20 years of follow-up. In multivariate models, African-Americans had a significantly increased risk of diabetes with lower potassium intake, which was not found in whites. CONCLUSIONS/INTERPRETATION: Low dietary potassium is associated with increased risk of incident diabetes in African-Americans. Randomised clinical trials are needed to determine if potassium supplementation, from either dietary or pharmacological sources, could reduce the risk of diabetes, particularly in higher-risk populations.

Changes in BMI modulate age-associated changes in sex hormone binding globulin and total testosterone, but not bioavailable testosterone in young adult men: the CARDIA Male Hormone Study.

OBJECTIVES: To compare age-associated 8-year changes in total testosterone, calculated bioavailable testosterone and sex hormone binding globulin (SHBG) across five groups of men stratified according to change in body mass index (BMI) (i.e., BMI stable (+/-0.69 kg/m(2)), decreased (-0.7 kg/m(2)), increased minimally (0.7-1.74 kg/m(2)), increased moderately (1.75-3.19 kg/m(2)) and increased most (> or =3.20 kg/m(2))). DESIGN: Eight-year longitudinal cohort study. SUBJECTS: Four hundred and seventy-four black and 695 white men, aged 24-31 years at the time of the first hormone measurement. MEASUREMENTS: Aging-related changes in serum SHBG, total testosterone and bioavailable testosterone. RESULTS: SHBG significantly increased with age for men whose BMI decreased, and there were progressively smaller increases for men whose BMI was stable, or whose BMI increased minimally or moderately (range 1.1-0.3 nM per year, P< or =0.03, respectively). There was no age relationship with SHBG among men whose BMI increased most. Total testosterone did not change with age for men whose BMI decreased, was stable or increased minimally, but for men whose BMI increased moderately and most there was a graded decrease in total testosterone with age (beta=-0.2 and -0.4 nM per year, respectively, P< or =0.005). However, bioavailable testosterone decreased with age to a similar extent across all groups. CONCLUSIONS: These results suggest that changes in BMI during young adulthood modulate age-related changes in SHBG and total testosterone, but not bioavailable testosterone.

Association of education with dietary intake among young adults in the bi-ethnic Coronary Artery Risk Development in Young Adults (CARDIA) cohort.

OBJECTIVE: To examine associations of changes in dietary intake with education in young black and white men and women. DESIGN: The Coronary Artery Risk Development in Young Adults (CARDIA) study, a multi-centre population-based prospective study. Dietary intake data at baseline and year 7 were obtained from an extensive nutritionist-administered diet history questionnaire with 700 items developed for CARDIA. SETTING: Participants were recruited in 1985-1986 from four sites: Birmingham, Alabama; Chicago, Illinois; Minneapolis, Minnesota; and Oakland, California. SUBJECTS: Participants were from a general community sample of 703 black men (BM), 1006 black women (BW), 963 white men (WM) and 1054 white women (WW) who were aged 18-30 years at baseline. Analyses here include data for baseline (1985-1986) and year 7 (1992-1993). RESULTS: Most changes in dietary intake were observed among those with high education (>or=12 years) at both examinations. There was a significant decrease in intake of energy from saturated fat and cholesterol and a significant increase in energy from starch for each race-gender group (P<0.001). Regardless of education, taste was considered an important influence on food choice. CONCLUSION: The inverse relationship of education with changes in saturated fat and cholesterol intakes suggests that national public health campaigns may have a greater impact among those with more education.

Postload plasma glucose concentration and 27-year prostate cancer mortality (United States).

OBJECTIVE: Findings from epidemiologic studies on the association between diabetes and prostate cancer risk are inconsistent. However, data from at least three studies suggest that the direction and strength of this association differs according to duration of diabetes. To determine the potential effects of early-stage abnormal glucose metabolism on risk, we assessed the relationship of postload glycemia in the absence of self-reported diabetes with risk of prostate cancer mortality. METHODS: Data from the Chicago Heart Association Detection Project in Industry were used to examine this relationship. Between 1967 and 1973 some employees of 84 Chicago area organizations underwent a health screening examination. Blood was drawn for measurement of plasma glucose concentration approximately 1 h after a 50-g oral glucose load among 20,433 men. After a mean length of follow-up of 27 years, 176 men died of prostate cancer. Cox regression was used to compute adjusted relative risks (RRs) and 95% confidence intervals (CIs). RESULTS: After controlling for age, body mass index, heart rate, education, and race, the RRs of prostate cancer mortality for postload plasma glucose levels of 6.7-8.8, 8.9-11, and > or = 11.1 mmol/L compared to < or = 6.6 mmol/L were 1.64, 1.37, and 1.64. respectively (p for trend=0.19). The RR (95% CI) associated with a 2.2 mmol/L (1 standard deviation) higher glucose concentration was 1.1 (0.95-1.2). CONCLUSIONS: These results provide weak evidence of an association between hyperglycemia and prostate cancer mortality.

Effects of xerostomia on perception and performance of swallow function.

BACKGROUND: Head and neck cancer treatment with high-dose chemoradiation may cause xerostomia and affect the patient's perception of swallowing ability. METHOD: Whole saliva production was measured in 36 patients with advanced-stage cancer of the oropharynx before treatment and 3 months after treatment by weighing a 4 x 4 inch gauze before and after a 2-minute chewing period. Presence of multiple eating difficulties was measured by patient interview. Swallowing was examined videofluorographically (VFG). RESULTS: Saliva weight decreased from a mean (SEM) of 5.1 (0.5) g pretreatment to 1.4 (0.5) g after treatment (p<.0001). At 3 months, significantly more patients perceived difficulty swallowing, dry mouth, needing water while eating, food stuck in the mouth or throat, and change in taste. Saliva weight was not correlated with VFG measures of bolus transit or observations of residue. CONCLUSIONS: Chemoradiation treatment results in xerostomia and a significant increase in patient perception of swallowing difficulties. Saliva weight in patients who perceive swallowing problems was lower. Xerostomia did not affect the physiologic aspects of bolus transport. Xerostomia affected the sensory process and comfort of eating more than bolus transport.

Temporal and biomechanical characteristics of oropharyngeal swallow in younger and older men.

As the U.S. population ages, there is increasing need for data on the effects of aging in healthy elderly individuals over age 80. This investigation compared the swallowing ability of 8 healthy younger men between the ages of 21 and 29 and 8 healthy older men between the ages of 80 and 94 during two swallows each of 1 ml and 10 ml liquid. Videofluoroscopic studies of these swallows were analyzed to confirm the absence of swallowing disorders. Biomechanical analysis of each swallow was completed, from which data on temporal, range of motion, and coordination characteristics of the oropharyngeal swallow were taken. Position of the larynx at rest, length of neck, and pattern of hyoid bone movement were also compared between the two groups. None of the younger or older men exhibited any swallowing disorders. The C2 to C4 distance of older men was significantly shorter than that of younger men, and laryngeal position at rest was lower than in younger men but not significantly so. Older men had a significantly longer pharyngeal delay than younger men and significantly faster onset of posterior pharyngeal wall movement in relation to first cricopharyngeal opening. The older men exhibited significantly reduced maximum vertical and anterior hyoid movement as compared to the younger men even when accounting for the difference in C2 to C4 distance in older men. These data support the hypothesis of reduced muscular reserve in the swallows of older men as compared to younger men. Older men also exhibited less width of cricopharyngeal opening than younger men at 10 ml volume, indicating less upper esophageal sphincter flexibility in the swallows of older men. The potential for exercise to improve reserve is discussed. Significant changes in extent of hyoid elevation and duration of cricopharyngeal opening were seen as liquid bolus volume increased.

Tumor size and pretreatment speech and swallowing in patients with resectable tumors.

The pretreatment relationship of tumor burden to speech and swallowing function in 230 patients with oral or oropharyngeal cancer before surgery was assessed. Reduced articulation, reduced conversational understandability, or self-reported dysphagia were present in at least 34% of patients before treatment. Videofluoroscopy showed at least 9% of patients had reduced swallowing efficiency on liquid, paste, or cookie boluses. By use of regression techniques, the percentages of the oral tongue and of the anterior floor of mouth affected by neoplasm were found to be significantly related to reduced articulation; T stage and the percentage of the oral tongue affected with tumor were mildly related to reduced understandability; tumor volume and having soft palate affected by neoplasm were significantly related to self-reported dysphagia; and percentages of affected oral tongue and of affected tongue base were significantly related to reduced swallowing efficiency. Tumor burden may contribute to functional deficits at diagnosis in patients who have resectable tumors.

Relating speech and swallow function to dropout in a longitudinal study of head and neck cancer.

The relation between functional outcome and dropout from a 12-month follow-up period was examined in a longitudinal study whose objective was to define and quantify the functional effects of oral surgical resection and reconstruction on speech and swallowing in patients with head and neck cancer. In a group of 150 patients recruited to a surgical study in the Cancer Control Science Program in Head and Neck Cancer Rehabilitation, dropout from all causes and dropout from specific causes (medical, patient, and administrative specific) were assessed in relation to longitudinal speech and swallow function. In univariate analysis, better speech articulation was associated with decreased risk of dropout from all causes and from medical-specific causes. Better swallow performance was associated with decreased risk of medical-specific dropout. Multivariate analysis revealed the following: (1) only articulation function was associated with dropout from all causes; (2) the association of speech articulation function with medical dropout was diminished after adjusting for advanced age and surgical resection variables; (3) the association of speech articulation function became significant for patient-specific dropout after adjusting for advanced age and surgical resection variables and indicated that better function decreased the risk of this type of dropout; and (4) swallowing function was not related to dropout. Patients treated for oral or oropharyngeal cancer who have poorer speech outcomes are more likely to drop out from a longitudinal study. Basing study results on only patients who complete a longitudinal study will understate the level of dysfunction experienced.

Factors related to dropout in a study of head and neck cancer patients after surgery.

The extent and nature of dropout was assessed in a longitudinal study whose objective was to define and quantify the functional effects of oral surgical resection and reconstruction on speech and swallowing function in patients with head and neck cancer. Of 150 patients who were enrolled to be followed up with speech and swallow assessments for 1 year after surgery, 113 (75%) dropped out and 37 (25%) returned to complete the study at the final 12-month evaluation point. In general, those completing the study had a smaller resection than the patients who dropped out before the 12-month evaluation. Fifty percent of the dropout was accounted for by medical reasons, 23% by administrative reasons, and 27% by patient-specific reasons (i.e., reasons known only to the patient). Analysis of the dropout categories revealed that higher cancer stage, larger volume of resection, and having a flap surgical closure versus a primary closure or skin graft increased a patient's chance of dropping out. A larger volume of resection was also related to an increased chance of being a patient-specific dropout. Patients who reported no or low alcohol usage had a greater chance of completing follow-up than being a patient-specific dropout.

Incidence and patient characteristics associated with silent aspiration in the acute care setting.

Coughing is a physiologic response to aspiration in normal healthy individuals. However, there are published records that report no cough in response to aspiration (i.e., silent aspiration) in dysphagic patients. In this retrospective study, for more than 2 years in two acute care hospitals we examined frequency of the cough response in patients identified as aspirators by using videofluoroscopy. One thousand one hundred one patients underwent videofluorographic evaluation of their swallowing during this 2-year period; 469 aspirated; 276 were silently aspirating. Two hundred twenty-four of these silent aspirators aspirated once during a swallow and 52 silently aspirated more than once during a swallow. These two groups of patients were analyzed separately. Univariate (chi-square and Fisher's exact tests) and multivariate (logistic regression) analyses were conducted to assess the relationship of silent aspiration to age, gender, medical diagnosis, timing of aspiration, and etiology of aspiration. In univariate analysis, age (p < 0.001), gender (p < 0.004), and medical diagnosis (p = 0.05) were significantly associated with silent aspiration in the group who aspirated once during a swallow. No significant associations were seen in the group of patients who aspirated more than once during a swallow.

Surgical variables affecting speech in treated patients with oral and oropharyngeal cancer.

Postoperative speech function may be influenced by a number of treatment variables. The objective of this study was to examine the relationships among various treatment factors to determine the impact of these measures on speech function. Speech function was tested prospectively in 142 patients with surgically treated oral and oropharyngeal cancer 3 months after treatment. Each patient's speech was recorded during a 6- to 7-minute conversation and while performing a standard articulation test, producing speech outcome measures of percent correct consonant phonemes and percent conversational understandability. Correlational analyses were used to determine the relationships among the speech outcome measures and 14 treatment parameters. Speech function was mildly to moderately negatively correlated with most surgical resection variables, indicating that larger amounts of tissue resected were associated with worse speech function. Overall measures of conversational understandability and percent correct consonant phonemes were related to extent of oral tongue resection, floor of mouth resection, soft palate resection, and total volume of tissue resected. These relationships varied depending on the method of surgical closure. Method of surgical reconstruction had a profound impact on postoperative speech function 3 months after treatment and was an important factor in determining how oral tongue resection influenced articulation and intelligibility. The combination of closure type, percent oral tongue resected, and percent soft palate resected had the strongest relationship with overall speech function for patients with surgically treated oral and oropharyngeal cancer 3 months after treatment.

Speech and swallowing in irradiated and nonirradiated postsurgical oral cancer patients.

The effect of radiation on speech and swallowing function was assessed for 18 patients surgically treated for oral and oropharyngeal cancer. Nine patients received surgical intervention and postoperative radiation therapy, and nine received surgery only. Patients were matched regarding percentage of oral tongue resected, percentage of tongue base resected, locus of resection, and method of reconstruction. Speech and swallowing function was assessed before and at 1, 3, 6, and 12 months after surgery following a standardized protocol. Speech tasks included an audio recording of a brief conversation and of a standard articulation test; swallowing function was examined with videofluoroscopy. Statistical testing indicated that overall speech function did not differ between the irradiated and nonirradiated patients. Irradiated patients had significantly reduced oral and pharyngeal swallowing performance, specifically, longer oral transit times on paste boluses, lower oropharyngeal swallow efficiency, increased pharyngeal residue, and reduced cricopharyngeal opening duration. Impaired function may be the result of radiation effects such as edema, fibrosis, and reduced salivary flow. Increased use of tongue range-of-motion exercises during and after radiation treatment may reduce the formation of fibrotic tissue in the oral cavity and may improve pharyngeal clearance by maintaining adequate tongue base-to-pharyngeal wall contact.

Age and volume effects on liquid swallowing function in normal women.

Understanding the nature of swallowing in persons without swallowing problems is a prerequisite to evaluating the nature and extent of dysphagia in persons with compromised swallowing. In order to determine how swallowing varies with age and with liquid bolus volume in women, we assessed 167 normal female swallowers videofluoroscopically and obtained multiple measures of swallowing function. The women in this study demonstrated a change in swallowing function with age, due primarily to an increase in pharyngeal transit and total duration of the motor response. The duration of closure and opening of valves in the upper aerodigestive tract also increased with age, and the duration of laryngeal elevation and hyoid movement peaked in the 60-79-year-old age groups. Bolus volume effects were quite consistent across most measures. As the bolus volume increased from 1 ml to 10 ml, transit times decreased and durations of valve closure and opening increased. The results of this study may be used to specify the relationship of swallowing function to age and liquid bolus volume in women, relationships that heretofore have been observed only in part and in smaller and more heterogeneous populations.

Super-supraglottic swallow in irradiated head and neck cancer patients.

BACKGROUND: After radiotherapy to the head and neck, many patients experience swallowing difficulties. Preliminary work indicates that these patients benefit from the super-supraglottic swallow maneuver. METHODS: Lateral videofluoroscopic studies examined oropharyngeal swallowing in 9 patients who suffered from dysphagia after radiation to the head and neck. Each patient completed two swallows each of 1 mL or 3 mL liquid barium without a voluntary swallow maneuver and with the super-supraglottic swallow designed to close the entrance to the airway early. The videotape of each swallow was digitized and the location of pharyngeal structures marked throughout the swallow. Movement over time plots were generated to measure changes in structural movement resulting from the maneuver. RESULTS: The super-supraglottic swallow resulted in changes in airway entrance closure and hyolaryngeal movement. One patient who aspirated without the maneuver stopped aspirating with the maneuver. Two others had aspiration reduced to a trace with the maneuver. Fewer swallowing disorders were observed with the maneuver. CONCLUSION: The super-supraglottic swallow results in improved biomechanics of swallow in irradiated head and neck cancer patients.

Speech and swallowing rehabilitation for head and neck cancer patients.

Head and neck cancer and its treatment frequently cause changes in both speech and swallowing, which affect the patient's quality of life and ability to function in society. The exact nature and severity of the post-treatment changes depend on the location of the tumor, the choice of treatment, and the availability and use of speech and swallowing therapy during the first 3 months after treatment. This paper reviews the literature on speech and swallowing problems in various types of treated head and neck cancer patients. Effective swallowing rehabilitation depends on the inclusion of a video-fluorographic assessment of the patient's oropharyngeal swallow in the post-treatment evaluation. Pilot data support the use of range of motion (ROM) exercises for the jaw, tongue, lips, and larynx in the first 3 months after oral or oropharyngeal ablative surgical procedures, as patients who perform ROM exercises on a regular basis exhibit significantly greater improvement in global measures of both speech and swallowing, as compared with patients who do not do these exercises.

Swallowing disorders in head and neck cancer patients treated with radiotherapy and adjuvant chemotherapy.

The nature of swallowing problems was examined in nine patients treated primarily with external-beam radiation and adjuvant chemotherapy for newly diagnosed tumors of the head and neck. All subjects underwent videofluorographic examination of their swallowing. Three analyses were completed, including the following: observations of motility disorders, residue, and aspiration; temporal analyses; and biomechanical analyses. Oropharyngeal swallow efficiency was calculated for the first swallow of each bolus. Swallow motility disorders were observed in both the oral and pharyngeal stages. Seven of the nine patients demonstrated reduced posterior tongue base movement toward the posterior pharyngeal wall and reduced laryngeal elevation during the swallow. Oropharyngeal swallow efficiency measures were significantly lower in the nine irradiated patients than in age-matched normal subjects. Between patients and normal subjects, significant differences were found in the measures of timing and distance of pharyngeal structural movements during the swallow, as well as in the measures of coordination during the swallow. Although treatment of head and neck cancer with external-beam radiation is designed to provide cancer cure and preserve organ functioning, oral and pharyngeal motility for swallow can become compromised if external-beam radiation treatment is provided to either the larynx or tongue base regions.

Management of early-stage Hodgkin's lymphoma. The radiation oncology experience at Northwestern University/Northwestern Memorial Hospital.

Early-stage Hodgkin's lymphoma patients treated with radiotherapy alone or combined modality therapy were retrospectively analyzed for survival, patterns of failure, salvage, and toxicity. Of 75 evaluable patients, 47 were given radiotherapy alone and 28 were given combination radiotherapy and chemotherapy. Of the patients studied, 26 were clinical stage I and 49 were clinical stage II, with nine patients upstaged at laparotomy. Minimum follow-up was 2 years, with a median of 81 months. Complete response rate was 95%. Relapse-free survival and overall survival were 89% and 96%, respectively, at 2 years; 78% and 86% at 5 years; and 76% and 82% at 10 years. Of 16 patients who relapsed (21%), 13/47 patients were treated with radiotherapy and 3/28 were treated with combined modality therapy. Salvage rates were higher in those treated with radiotherapy alone. There were 13 deaths: six from disease, two from treatment-related complications, and five from second primary malignancies. There was a higher incidence of second malignancies and deaths due to complication in patients treated with combined modality therapy. Radiotherapy alone or with chemotherapy is an effective modality in the treatment of Hodgkin's lymphoma. Treatment should be selected properly to optimize results and decrease complications.

T stage and functional outcome in oral and oropharyngeal cancer patients.

BACKGROUND: The locus and extent of resection and the type of reconstruction used in surgery are important joint determinants of functional outcome in oral and oropharyngeal cancer patients. However, prediction of functional outcome from broader factors such as clinical T stage and approximate locus of resection is important for the preoperative period when the extent of resection and the exact surgical reconstruction to be used may not be decided and preoperative counseling about potential functional outcomes is needed. METHODS: Oropharyngeal swallow efficiency (OPSE) and conversational speech understandability (CU) were measured preoperatively and 3 months posthealing in 68 patients. Analysis of variance (ANOVA) was used to determine whether clinical T stage and planned surgical locus were significantly related to these two functional measures, and discriminant analysis was used on the data obtained at 3 months to determine how well CU and liquid OPSE jointly relate to the T stages. RESULTS: In patients with a planned oral tongue locus of resection, significant differences were found at 3 months posthealing on both CU and liquid OPSE between stages T1 -T2 and T3 and between T1-T2 and T4. In patients with a planned oropharynx locus of resection, significant differences were found only on CU at 3 months. These occurred between T1-T2 and T4 and between T3 and T4. Discriminant analysis classified into the correct T stages 70% of T1-T2 and 75% of T4 stage patients, but only 28% of T3 stage patients. However, the T3-stage patients who were misclassified as T4 had significantly larger mean percent of oral tongue resected than those T3 stage patients who were misclassified as T1-T2. CONCLUSIONS: These results are useful for the preoperative counseling of patients with clinical T stages 1-2 and 4. The relationship between T stage and postsurgical function found here is stronger than reported by previous authors, but is still very general.

Longitudinal assessment of quality of life in laryngeal cancer patients.

BACKGROUND: Although quality of life (QL) and performance status are important outcomes in head and neck (HN) cancer, there is little systematic inclusion of these parameters in treatment trials. METHODS: Rate and recovery of function were evaluated over a 6-month period in 21 laryngeal cancer patients, 7 in each of 3 treatment groups: total laryngectomy (group 1), hemilaryngectomy (group 2), and radiotherapy only (group 3). Assessment included Performance Status Scale for Head and Neck Cancer Patients (PSS-HN: Diet, Speech, and Eating in Public subscales) and the FACT-HN, a multidimensional QL measure. RESULTS: Groups differed in patterns of performance recovery over time in expected directions. Group 1 recovered most slowly, without achieving normal functioning by 6 months; most of group 2 returned to normal functioning by 3 months; group 3 showed little overall dysfunction. There was no difference in overall QL between groups or over time. Performance status was significantly correlated with the FACT head and neck subscale and somewhat with the Physical subscale. In contrast, ability to eat and/or speak was not associated with overall QL nor with any other specific QL dimension (eg, emotional or social well-being). CONCLUSIONS: Results support the sensitivity and applicability of two site-specific performance/QL measures: PSS-HN and FACT-HN. Findings also emphasize the need to employ multidimensional tools to adequately evaluate the nonmedical outcomes in head and neck patients.

Intraoperative blood loss and prognosis in prostate cancer patients undergoing radical retropubic prostatectomy.

PURPOSE: To assess more thoroughly the prognostic significance of perioperative transfusions, we examined a previously ignored factor, namely intraoperative blood loss. MATERIALS AND METHODS: Univariate and multivariate stepwise regression analysis was performed on results of a 10-year series of 251 consecutive men who underwent radical retropubic prostatectomy for clinically localized carcinoma. RESULTS: Gleason score, operative blood loss and pathological stage were significantly (p < 0.0001) associated with progression-free survival. A risk ratio of 1.08 (95% confidence interval 1.05 to 1.10) was demonstrated for every 100 ml. of operative blood loss. CONCLUSIONS: The operative blood loss but not the type (autologous or allogeneic) of blood transfused was significantly related to decreased recurrence-free survival after radical retropubic prostatectomy. This finding implies that the operative events necessitating transfusion are potentially more significant than the immunological effects of the transfusion.