Comparative evaluation of radiation treatments for clinically localized prostate cancer: an updated systematic review.

BACKGROUND: Radiation therapy is one of many treatment options for patients with prostate cancer. PURPOSE: To update findings on the clinical and biochemical outcomes of radiation therapies for localized prostate cancer. DATA SOURCES: MEDLINE (2007 through March 2011) and the Cochrane Central Register of Controlled Trials (2007 through March 2011). STUDY SELECTION: Published English-language comparative studies involving adults with localized prostate cancer who either had first-line radiation therapy or received no initial treatment. DATA EXTRACTION: 6 researchers extracted information on study design, potential bias, sample characteristics, interventions, and outcomes and rated the strength of overall evidence. Data for each study were extracted by 1 reviewer and confirmed by another. DATA SYNTHESIS: 75 studies (10 randomized, controlled trials [RCTs] and 65 nonrandomized studies) met the inclusion criteria. No RCTs compared radiation therapy with no treatment or no initial treatment. Among the 10 RCTs, 2 compared combinations of radiation therapies, 7 compared doses and fraction sizes of external-beam radiation therapy (EBRT), and 1 compared forms of low-dose rate radiation therapy. Heterogeneous outcomes were analyzed. Overall, moderate-strength evidence consistently showed that a higher EBRT dose was associated with increased rates of long-term biochemical control compared with lower EBRT dose. The body of evidence was rated as insufficient for all other comparisons. LIMITATIONS: Studies inconsistently defined and reported outcomes. Much of the available evidence comes from observational studies with treatment selection biases. CONCLUSION: A lack of high-quality comparative evidence precludes conclusions about the efficacy of radiation treatments compared with no treatments for localized prostate cancer. PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality.

Vancomycin-Associated Acute Kidney Injury with a Steep Rise in Serum Creatinine.

BACKGROUND: Vancomycin-associated (VA) acute kidney injury (AKI) is being increasingly recognized. A distinct pattern of rapid rise in serum creatinine (sCr) during VA-AKI has occasionally been observed. However, such scenarios remain underreported. METHODS: We conducted an online survey at the American Society of Nephrology Communities forum and reviewed publications of VA-AKI via PubMed or Google searching for cases of precipitous AKI (those with rise in sCr ≥1.5 mg/dL/day) attributable to vancomycin. RESULTS: We identified 12 original cases compiled from 6 different hospitals and 4 published cases (n = 16; 38% women, age 43.5 ± 16 years, weight 108 ± 23 kg, body mass index 35 ± 7 kg/m2) of precipitous AKI observed shortly after large cumulative doses of VA (8.8 ± 5 g). The median steepest 24-h rise in sCr was 2.6 mg/dL (range 1.5-3.5 mg/dL) and the slope of the initial 48-h sCr rise was greater than that of a control AKI (non-VA, n = 48) group (2.03 ± 0.1 vs. 0.62 ± 0.0 mg/dL/day; p < 0.0001). The steep rise in sCr in the VA-AKI was not accompanied by anuria. Overt rhabdomyolysis was absent in all cases. Further, in 3 precipitous VA-AKI cases, simultaneous serum cystatin C values did not rise precipitously, suggesting that the reductions in glomerular filtration rate were overestimated by the sCr increase. CONCLUSIONS: VA-AKI can manifest with a precipitous rise in sCr shortly after a high cumulative dose of vancomycin. True toxic tubular injury overrepresented by the sCr rise is postulated.

Independent correlates of chronic kidney disease awareness among adults with type 2 diabetes.

BACKGROUND: Chronic Kidney Disease (CKD) is usually silent until advanced stages. Awareness of CKD is important to mitigate poorer outcomes. This study aims to understand the relationship(s) between CKD self-awareness and diagnosed CKD. METHODS: The study included 345 adults with type 2 diabetes from two primary care settings. Participants completed surveys assessing demographic information, self-care behaviors and co-morbidities. Biological data were taken from medical records. CKD was diagnosed as eGFR=<59ml/min. CKD awareness was defined by a positive response to "has a doctor, nurse or other health professional ever told you that you have a kidney disease?" and/or "have you ever had kidney failure that required dialysis or a kidney transplant?" Logistic regression models were used to examine the association between CKD awareness and clinical/socio-demographic variables. RESULTS: 31% of study patients had CKD based on eGFR (of which only 63% were aware). Stepwise regression showed that non-Hispanic blacks (OR=3.49, p=0.04), those with college education (OR=8.02, p=0.01), history of myocardial infarction (OR=10.12, p=0.002) or hypertension (OR=23.25, p=0.02), and those with Medicare, VA insurance, or other insurance (OR=8.08, 8.72, 101.47, respectively, p<0.01) were significantly more likely to be aware of CKD. Those with a history of stroke or depression (OR=0.21, 0.28, respectively, p=0.03, p=0.04) were significantly less likely to be aware of CKD. CONCLUSION: CKD awareness was found to be lower than diagnosed CKD rates. Factors associated with awareness include race, educational status and cardiovascular disease. Targeted strategies to increase CKD awareness may lead to improved health outcomes.

Auto-titrating versus fixed continuous positive airway pressure for the treatment of obstructive sleep apnea: a systematic review with meta-analyses.

BACKGROUND: Obstructive sleep apnea is a relatively common disorder that can lead to lost productivity and cardiovascular disease. The form of positive airway treatment that should be offered is unclear. METHODS: MEDLINE and the Cochrane Central Trials registry were searched for English language randomized controlled trials comparing auto-titrating positive airway pressure (APAP) with continuous positive airway pressure (CPAP) in adults with obstructive sleep apnea (inception through 9/2010). Six researchers extracted information on study design, potential bias, patient characteristics, interventions and outcomes. Data for each study were extracted by one reviewer and confirmed by another. Random effects model meta-analyses were performed for selected outcomes. RESULTS: Twenty-four randomized controlled trials met the inclusion criteria. In individual studies, APAP and fixed CPAP resulted in similar changes from baseline in the apnea-hypopnea index, most other sleep study measures and quality of life. By meta-analysis, APAP improved compliance by 11 minutes per night (95% CI, 3 to 19 minutes) and reduced sleepiness as measured by the Epworth Sleepiness Scale by 0.5 points (95% CI, 0.8 to 0.2 point reduction) compared with fixed CPAP. Fixed CPAP improved minimum oxygen saturation by 1.3% more than APAP (95% CI, 0.4 to 2.2%). Studies had relatively short follow-up and generally excluded patients with significant comorbidities. No study reported on objective clinical outcomes. CONCLUSIONS: Statistically significant differences were found but clinical importance is unclear. Because the treatment effects are similar between APAP and CPAP, the therapy of choice may depend on other factors such as patient preference, specific reasons for non-compliance and cost.