Perioperative Management of Patients with Diabetes and Cancer: Challenges and Opportunities.

BACKGROUND: Both diabetes and cancer are major global health issues that are among the leading causes of morbidity and mortality. There is a high prevalence of diabetes among cancer patients, many of whom require a surgical procedure. This review focuses on the operative complications in patients with diabetes and cancer, and the perioperative management of diabetes in cancer patients. METHODOLOGY: A literature search of articles in English-published between January 2010 and May 2024-was carried out using the databases PubMed, MEDLINE, Google Scholar, and the Cochrane Database of Systematic Reviews. The search primarily focused on the operative complications in patients with diabetes and cancer, and perioperative management strategies. RESULTS: The relationship between cancer and diabetes is complex; cancer patients have a high risk of developing diabetes, while diabetes is a risk factor for certain cancers. In addition, various cancer therapies can induce or worsen diabetes in susceptible patients. Many individuals with cancer and diabetes require surgery, and due to underlying diabetes, they may have elevated risks for operative complications. Optimal perioperative management for these patients includes managing perioperative glycemia and other comorbid illnesses, adjusting diabetic and cancer treatments, optimizing nutrition, minimizing the duration of fasting, supporting early mobilization, and providing patient education to enable self-management. CONCLUSIONS: While evidence is limited, optimal perioperative management for patients with both diabetes and cancer is necessary in order to reduce surgical complications. Future studies are needed to develop evidence-informed perioperative strategies and improve outcomes for these patients.

Obesity and Cancer: A Current Overview of Epidemiology, Pathogenesis, Outcomes, and Management.

BACKGROUND: Obesity or excess body fat is a major global health challenge that has not only been associated with diabetes mellitus and cardiovascular disease but is also a major risk factor for the development of and mortality related to a subgroup of cancer. This review focuses on epidemiology, the relationship between obesity and the risk associated with the development and recurrence of cancer and the management of obesity. METHODS: A literature search using PubMed and Google Scholar was performed and the keywords 'obesity' and cancer' were used. The search was limited to research papers published in English prior to September 2022 and focused on studies that investigated epidemiology, the pathogenesis of cancer, cancer incidence and the risk of recurrence, and the management of obesity. RESULTS: About 4-8% of all cancers are attributed to obesity. Obesity is a risk factor for several major cancers, including post-menopausal breast, colorectal, endometrial, kidney, esophageal, pancreatic, liver, and gallbladder cancer. Excess body fat results in an approximately 17% increased risk of cancer-specific mortality. The relationship between obesity and the risk associated with the development of cancer and its recurrence is not fully understood and involves altered fatty acid metabolism, extracellular matrix remodeling, the secretion of adipokines and anabolic and sex hormones, immune dysregulation, and chronic inflammation. Obesity may also increase treatment-related adverse effects and influence treatment decisions regarding specific types of cancer therapy. Structured exercise in combination with dietary support and behavior therapy are effective interventions. Treatment with glucagon-like peptide-1 analogues and bariatric surgery result in more rapid weight loss and can be considered in selected cancer survivors. CONCLUSIONS: Obesity increases cancer risk and mortality. Weight-reducing strategies in obesity-associated cancers are important interventions as a key component of cancer care. Future studies are warranted to further elucidate the complex relationship between obesity and cancer with the identification of targets for effective interventions.

Diabetes and Cancer: Risk, Challenges, Management and Outcomes.

BACKGROUND: Diabetes mellitus and cancer are commonly coexisting illnesses, and the global incidence and prevalence of both are rising. Cancer patients with diabetes face unique challenges. This review highlights the relationship between diabetes and cancer and various aspects of the management of diabetes in cancer patients. METHODS: A literature search using keywords in PubMed was performed. Studies that were published in English prior to July 2021 were assessed and an overview of epidemiology, cancer risk, outcomes, treatment-related hyperglycemia and management of diabetes in cancer patients is provided. RESULTS: Overall, 8-18% of cancer patients have diabetes as a comorbid medical condition. Diabetes is a risk factor for certain solid malignancies, such as pancreatic, liver, colon, breast, and endometrial cancer. Several novel targeted compounds and immunotherapies can cause hyperglycemia. Nevertheless, most patients undergoing cancer therapy can be managed with an appropriate glucose lowering agent without the need for discontinuation of cancer treatment. Evidence suggests that cancer patients with diabetes have higher cancer-related mortality; therefore, a multidisciplinary approach is important in the management of patients with diabetes and cancer for a better outcome. CONCLUSIONS: Future studies are required to better understand the underlying mechanism between the risk of cancer and diabetes. Furthermore, high-quality prospective studies evaluating management of diabetes in cancer patients using innovative tools are needed. A patient-centered approach is important in cancer patients with diabetes to avoid adverse outcomes.

Orbital lymphomas: a clinicopathologic study of a rare disease.

OBJECTIVE: To evaluate the clinicopathologic features and prognosis of patients with orbital lymphomas. METHODS: Clinical and pathologic data of 35 patients with biopsy-proven orbital lymphoma diagnosed at a tertiary care hospital from 1992 to 2001 were reviewed. Lymphomas were divided into low-grade and high-grade lymphomas. Survival of patients was compared according to age, gender, disease site, extent of disease, tumor grade, and treatment modality by using log rank test. RESULTS: Median patient age was 75 years (23-94) and the male-to-female ratio was 1:2.9. Twenty-three patients (66%) were diagnosed with low-grade lymphoma, and 12 patients (34%) were found to have high-grade lymphoma. Among low-grade lymphomas, marginal zone lymphoma (n=6), follicle center cell lymphoma (n= 6), and small lymphocytic lymphoma (n=5) were common entities, whereas diffuse large cell B-cell lymphoma (n=5) was the most common entity in patients with high-grade lymphoma. Disease was clinically localized in 74% of patients at the time of diagnosis. Radiation alone or with chemotherapy was the primary treatment modality in 83% of patients. All except one patient had an objective response to therapy. Over the median follow-up period of 47 months (range, 1.5-141 months), disease recurred in 37% patients who achieved a complete response. The estimated 5- and 10-year survival rates were 64% and 42%, respectively. Overall, 13 (37%) patients died, 6 with high-grade and 7 with low-grade lymphoma. No clinical variable was found to be prognostically significant with respect to survival. CONCLUSIONS: Orbital lymphoma is a disease of the elderly with a female preponderance. It tends to be localized to the orbit at the time of diagnosis and responds well to local or systemic therapy.

Unusual causes of abdominal pain: sickle cell anemia.

Sickle cell disease is characterized by chronic hemolytic anemia and vaso-occlusive painful crises. The vascular occlusion in sickle cell disease is a complex process and accounts for the majority of the clinical manifestation of the disease. Abdominal pain is an important component of vaso-occlusive painful crises. It often represents a substantial diagnostic challenge in this population of patients. These episodes are often attributed to micro-vessel occlusion and infarcts of mesentery and abdominal viscera. Abdominal pain due to sickle cell vaso-occlusive crisis is often indistinguishable from an acute intra-abdominal disease process such as acute cholecystitis, acute pancreatitis, hepatic infarction, ischemic colitis and acute appendicitis. In the majority of cases, however, no specific cause is identified and spontaneous resolution occurs. This chapter will focus on etiologies, pathophysiology and management of abdominal pain in patients with sickle cell disease.

Malignant pleural effusions in lymphoproliferative disorders.

In order to determine variables that correlate with malignant pleural effusion and mortality in patients with lymphoproliferative disorders and pleural effusion, a retrospective study was performed. Clinical data of hospitalized patients with a lymphoid malignancy and pleural effusion who underwent thoracentesis from January 1993 to December 2002 were collected. A logistic regression analysis was carried out to determine prognostic variables that predict malignant pleural effusion and hospital mortality. There were 86 patients who were admitted on 91 occasions. The median age was 70 years (range 4 - 92) and the male:female ratio was 44:42. Sixty-four patients (74%) had advanced disease, 43 (50%) had received prior chemotherapy and 9 (10%) were in remission. Of 91 cases of pleural effusions, 44 (48%) were bilateral, 80 (88%) were exudates and 48 (53%) were due to malignant involvement of pleura. In multivariate analysis, symptomatic pleural effusion (odds ratio 10.3, 95% confidence interval 1.7 - 98.3), pleural fluid mesothelial cell count < 5% (odds ratio 8.0, 95% confidence interval 1.4 - 58.2), pleural fluid:serum lactate dehydrogenase (LDH) > or =1 (odds ratio 6.4, 95% confidence interval 1.2 - 45.6) and pleural fluid lymphocyte percentage > or =50 (odds ratio 6.4, 95% confidence interval 1.2 - 50) were significantly correlated with malignant effusion. A secondary cancer (odds ratio 11.9, 95% confidence interval 2.3 - 88.8), pleural fluid:serum LDH > or =1 (odds ratio 10.9, 95% confidence interval 2.6 - 64.9), and pneumonia (odds ratio 6.4, 95% confidence interval 1.7 - 28.6) were significantly correlated with hospital mortality. In conclusion, malignant pleural effusion is the common etiology of pleural effusion in patients with lymphoid malignancy. Many clinical and cytochemical markers have discriminatory values in identifying malignant effusion. A high pleural fluid to serum LDH level correlates with malignant pleural involvement and hospital mortality.

Extrapulmonary small cell cancer: a Canadian province's experience.

BACKGROUND: The objective of this study was to determine variables that correlate with the survival of patients with extrapulmonary small cell carcinoma (EPSCC). METHODS: Medical records of 101 eligible patients with EPSCC who were diagnosed in Saskatchewan from 1971 to 2002 were reviewed. Survival was calculated by using the Kaplan-Meier method. A logistic regression analysis with a backward elimination was carried out to determine prognostic variables that predicted mortality. RESULTS: The median patient age was 72 years (range, 24-100 years), and the male-to-female ratio was 1.4:1. The primary disease sites were as follows: breast, 9%; gastrointestinal, 20%; genitourinary, 18%; gynecologic, 11%; head and neck, 10%; thymus, 2%; and unknown primary site, 31%. Fifty-one patients had limited disease (LD), and 50 patients had extensive disease (ED). Patients with LD had a median overall survival of 34 months (range, 0.2-276 months) compared with 2 months (range, 0.1-108 months) in patients with ED (P < .0001). Among different primary sites, patients with gynecologic small cell cancer (SCC) had a median survival of 54.4 months, whereas patients with SCC of an unknown primary site had a survival of 2.5 months. Among various variables that were examined with respect to their prognostic importance, an abnormal white blood cell count (odds ratio [OR], 6.9; 95% confidence interval [95% CI], 3.4-14.1), an Eastern Cooperative Oncology Group performance status >2 (OR, 4.5; 95% CI, 2.1-9.9), and ED (OR, 2.7; 95% CI, 1.4-5.0) were found to be correlated significantly with mortality. CONCLUSIONS: The gastrointestinal and genitourinary tracts were the 2 major sites involved by EPSCC in the current series. Survival varied according to the primary sites, and patients with gynecologic tumors had the best prognosis. An abnormal white blood cell count, a poor performance status, and disease extent were important factors in predicting survival.

Hemoglobin oxygen saturation discrepancy using various methods in patients with sickle cell vaso-occlusive painful crisis.

OBJECTIVE: To evaluate agreement among various methods for measuring oxyhemoglobin (O2Hb) saturation in adult hypoxic patients with sickle cell disease (SCD) during painful vaso-occlusive crisis and to compare those results with a control group. PATIENTS AND METHODS: The hemoglobin oxygen saturation was determined simultaneously by pulse oximetry (SpO2), co-oximetry [SO2 (functional oxyhemoglobin saturation) and FO2Hb (oxyhemoglobin fraction)] and by calculation (SaO2) using a normal O2Hb dissociation curve in 18 adult patients with SCD during vaso-occlusive crisis and 12 non-SCD patients with various cardiopulmonary diagnoses. The method proposed by Bland and Altman was used to evaluate agreement of various methods in each of the two groups. RESULTS: Mean differences between various methods in patients with SCD were significantly larger than the control group. Limits of agreement (LOA) were also wider in the SCD group than in the control group. Mean bias between SpO2 and SO2, and SpO2 and FO2Hb in patients with SCD were -3.1 +/- 4.4 (LOA: -11.9 to 5.7) and 2 +/- 4.1 (LOA: -6.2 to 10.2) respectively, compared with -1.4 +/- 1.4 (LOA: -4.2 to 1.4) and 1.2 +/- 1.5 (LOA: -1.9 to 4.3) in the control group. A mean bias of -4.5 +/- 4 (LOA: -12.5 to 3.5) between SpO2 and SaO2 was noted in patients with SCD compared with -0.1 +/- 2.1 (LOA: -4.3 to 4.1) in the control group. The width of LOA for various methods in patients with SCD ranged from 9.8 to 17.6 compared with 1.3 to 8.4 in the control group. CONCLUSION: Patients with SCD during vaso-occlusive crisis have discrepancies in O2Hb saturation measurements by various methods. Abnormal pulse oximetry values in these patients should be interpreted cautiously and supplemented by arterial blood gas analysis and co-oximetry.

Echocardiographic abnormalities in sickle cell disease.

Echocardiographic abnormalities in patients with sickle cell disease (SCD) were determined, and pulmonary arterial systolic pressure (PASP) was estimated. Clinical data and echocardiograms of 38 adult hospitalized patients with SCD at two tertiary care hospitals were reviewed. Fisher's exact test was performed to determine correlation between pulmonary hypertension and various clinical variables. Pulmonary hypertension was the most common abnormality identified in 22 (58%) patients. The estimated mean PASP was 37.5 +/- 10.9 mmHg. Older age and prior history of acute chest syndrome were significantly correlated with an increased prevalence of pulmonary hypertension (P < 0.05). Patients with hemoglobin levels <8 g/dL had PASP 43.2 +/- 0.5 compared to a mean PASP of 33.3 +/- 6.0 in patients with hemoglobin > or =8 g/dL (P = 0.01). Eight (21%) patients had evidence of a hyperdynamic left ventricle. Left heart abnormalities included dilated atrium in 14 (37%), dilated ventricle in 5 (13%), ventricle hypertrophy in 5 (13%), and ventricle dysfunction in 3 (9%) patients. Right heart abnormalities included dilated atrium in 9 (24%), dilated ventricle in 6 (16%), and ventricle dysfunction in 3 (9%) patients. Despite an increased incidence of abnormal flow across the valves on Doppler analysis, no patient had structurally abnormal valves. A majority of patients with SCD had evidence of pulmonary hypertension, which correlated with older age and history of acute chest syndrome. Other structural and functional echocardiographic abnormalities were less common.

Prognostic variables in newly diagnosed childhood immune thrombocytopenia.

Immune thrombocytopenia (ITP) has a favorable prognosis in children. Only a small number of children go on to develop chronic ITP. However, at the time of diagnosis, it is not possible to predict the course of the disease. In order to determine prognostic factors that could predict the disease course at diagnosis, we retrospectively evaluated various clinical variables in 103 pediatric patients with newly diagnosed ITP at our institution from 1995 to 2001. Sixty-eight (66%) patients had a mean platelet volume (MPV) of <8 fL on admission. Of 72 patients who had a follow-up period of at least 6 months, 54 (75%) achieved a durable remission within 6 months and 18 (25%) developed chronic ITP. In univariate analysis, a low admission MPV (<8), history of viral prodrome, and a low admission platelet count (<10 x 10(9)/L) predicted for a favorable outcome. Age and sex did not correlate with remission. In multivariate analysis, a low admission MPV and a history of a viral prodrome were the only independent factors correlated with a durable CR. The adjusted odds ratio for achieving a durable remission was 8.9 (95% CI: 1.54-51.8) for history of a viral prodrome and 14 (95% CI: 2.52-83.3) for low admission MPV value. In conclusion, our study showed that a majority of the children with newly diagnosed ITP presented with a low MPV value. A history of viral illness and a low admission MPV were found to be independent prognostic variables that predicted for the achievement of a durable CR in childhood ITP.

Effect of low-dose warfarin on D-dimer levels during sickle cell vaso-occlusive crisis: a brief report.

OBJECTIVE: To evaluate the activation of clotting systems in patients with sickle cell disease (SCD) by measuring the plasma D-dimer level and to determine the effect of low-dose warfarin on D-dimer level during vaso-occlusive crisis. METHODS: Plasma D-dimer level was measured in 65 blood samples of 37 adult patients with SCD who were hospitalized for vaso-occlusive painful crisis. D-dimer level of patients who were on low-dose warfarin was compared with those patients who were not on any anticoagulation treatment. Analysis of variance (anova) was carried out to determine factors significantly associated with low D-dimer level in patients with SCD. The following factors were included in the anova model; warfarin, homozygous hemoglobin S, history of blood transfusion in past 3 months, hydroxyurea, hemoglobin S%, hemoglobin F%, white blood cell counts, hemoglobin level, platelet count, and plasma fibrinogen level. RESULTS: Overall median D-dimer level in 65 samples was 2.7 microg fibrinogen equivalent units (FEU)/mL (0.34-4). Patients who were on low-dose warfarin had a median D-dimer level of 0.81 microg FEU/mL (0.34-1.8) compared with 3.1 microg FEU/mL (0.94-4) in those patients who were not on anticoagulation treatment. Using anova to model D-dimer levels, only warfarin was significantly correlated with low D-dimer levels after controlling for other variables. CONCLUSIONS: Patients with SCD during vaso-occulsive painful crisis have an elevated D-dimer level. Low-dose anticoagulation treatment is associated with a significant reduction in the D-dimer levels.