Daily Almond Consumption Reduces Insulin Resistance and Serum Cholesterol Levels in Overweight Asian Indian Adults with Cardiometabolic Risk – A Randomized Controlled Trial

Objectives

The present study aimed to evaluate the efficacy of almonds consumption on insulin resistance, glycemia and lipid profile in overweight Asian Indian adults with cardiometabolic risks.

Methods

A parallel-arm open-labelled, randomized controlled trial was conducted on 184 adults with cardiometabolic risks (CMR) (92 in each group). Adults with CMR were identified using the harmonizing criteria which includes presence of minimum of 3 of the following conditions: raised blood pressure, dyslipidemia (raised triglycerides and lowered high-density lipoprotein cholesterol), impaired fasting glucose, and central obesity. The intervention group received 43g (1.5 oz) almonds/day for 12 weeks. The control group was instructed to follow their habitual diet except to exclude nuts in any form. The anthropometric, clinical, biochemical and dietary data of the participants were assessed periodically and their change from baseline were analysed using generalized linear model in SAS 9.4 version.

Results

The study was completed by 165 adults (response rate 82.5%). Their mean age was 40 years and waist circumference 97 ± 9.6 cm at baseline. Significant reductions [mean (95%CI)] in IR (−0.5(−1.0–0.0); P = 0.04), serum total cholesterol (−10.6 mg/dl (−17.8- −3.4); P = 0.004) and low-density lipoprotein cholesterol (−7.5 mg/dl (−14.2- −0.8); P = 0.03) were observed in the intervention group compared to the control group. Within the intervention group, significant reduction of 1% each for body weight, body mass index, waist circumference, 3% fasting glucose and 2% serum triglyceride were noted compared to baseline. Multiple 24hr dietary recall as a compliance marker revealed significant increase in total fat, MUFA, PUFA calories and dietary fibre with a propionate reduction in carbohydrate calories in the intervention group compared to control group.

Conclusions

Daily intake of 43g almonds reduced IR, total and LDL serum cholesterol in obese Asian Indians with CMR. Almond consumption also improved the overall quality of the diet.

Funding Sources

The present study was funded by Almond Board of California, Modesto, CA, USA.

Reconstructive utilisation and outcomes following mastectomy surgery in women with breast cancer treated in England

INTRODUCTION

Breast cancer usually necessitates breast-conserving surgery or mastectomy, which adversely affect appearance and wellbeing. Immediate reconstruction restores the breast mound but its availability and efficacy are uncertain.

MATERIALS AND METHODS

Two discrete datasets were used to evaluate mastectomies in England: Hospital Episode Statistics to measure overall activity and variation over time and by region and a national prospective audit to evaluate immediate reconstruction decision making, complication rates and patient-reported satisfaction with information, choice and outcomes.

RESULTS

The 2005-08 Hospital Episode Statistics analyses identified 20% breast-conserving surgery reoperation rates nationally, frequently involving mastectomy. Rates were higher with in-situ disease present (30% vs 18%) and varied across NHS trusts (10th-90th centiles 12-30%). The 2008-09 national audit examined 18,216 women. The 19% immediate reconstruction rate varied regionally (9-43%), as did 2006-09 Hospital Episode Statistics data (8-32%). A total of 48% of women were offered immediate reconstruction, again varying regionally (24-75%). Offer likelihood fell with increasing age. National immediate reconstruction rates increased from 10% to 23% from 2000 to 2014, but regional variation persisted. Despite high care satisfaction, just 65% of mastectomy patients received the right amount of reconstructive information (90% for immediate reconstruction). Women from deprived areas experienced higher complication rates. Flap-based immediate reconstruction led to greater satisfaction with breast area appearance, emotional and sexual wellbeing and overall outcome than mastectomy; implant-only immediate reconstruction scored no better.

CONCLUSION

Reconstruction is central to improving breast cancer outcomes. The differential outcomes and persistent regional inequalities identified should facilitate decision making, support improved access to all reconstructive options and inform the development of an optimal patient pathway.

Association between age and access to immediate breast reconstruction in women undergoing mastectomy for breast cancer

BACKGROUND

National guidelines state that patients with breast cancer undergoing mastectomy in England should be offered immediate breast reconstruction (IR), unless precluded by their fitness for surgery or the need for adjuvant therapies.

METHODS

A national study investigated factors that influenced clinicians' decision to offer IR, and collected data on case mix, operative procedures and reconstructive decision-making among women with breast cancer having a mastectomy with or without IR in the English National Health Service between 1 January 2008 and 31 March 2009. Multivariable logistic regression was used to examine the relationship between whether or not women were offered IR and their characteristics (tumour burden, functional status, planned radiotherapy, planned chemotherapy, perioperative fitness, obesity, smoking status and age).

RESULTS

Of 13 225 women, 6458 (48·8 per cent) were offered IR. Among factors the guidelines highlighted as relevant to decision-making, the three most strongly associated with the likelihood of an offer were tumour burden, planned radiotherapy and performance status. Depending on the combination of their values, the probability of an IR offer ranged from 7·4 to 85·1 per cent. A regression model that included all available factors discriminated well between whether or not women were offered IR (c-statistic 0·773), but revealed that increasing age was associated with a fall in the probability of an IR offer beyond that expected from older patients' tumour and co-morbidity characteristics.

CONCLUSION

Clinicians are broadly following guidance on the offer of IR, except with respect to patients' age.

National trends and regional variation in immediate breast reconstruction rates

BACKGROUND

Previous studies have identified variation in immediate reconstruction (IR) rates following mastectomy for breast cancer across English regions during a period of service reorganization, a national audit and changing guidelines. This study analysed current variations in regional rates of IR in England.

METHODS

Patient-level data from Hospital Episode Statistics were used to define a cohort of women who underwent primary mastectomy for invasive or in situ breast carcinoma in English National Health Service (NHS) hospitals between April 2000 and March 2014. A time series of IR rates was calculated nationally and within regions in 28 cancer networks. Regional IR rates before and after the national audit were compared, using logistic regression to adjust for patient demographics, tumour type, co-morbidity and year of mastectomy.

RESULTS

Between 2000 and 2014, a total of 167 343 women had a mastectomy. The national IR rate was stable at around 10 per cent until 2005; it then increased to 23·3 per cent by 2013-2014. Preaudit (before January 2008), adjusted cancer network-level IR rates ranged from 4·3 to 22·6 per cent. Postaudit (after April 2009) adjusted IR rates ranged from 13·1 to 36·7 per cent, with 20 networks having IR rates between 15 and 24 per cent. The degree of change was not greatest amongst those that started with the lowest IR rates, with four networks with the largest absolute increase also starting with relatively high IR rates.

CONCLUSION

The national IR rate increased throughout the study period. Substantial regional variation remains, although considerable time has elapsed since a period of service reorganization, guideline revision and a national audit.

Socioeconomic deprivation and inpatient complication rates following mastectomy and breast reconstruction surgery

BACKGROUND

Socioeconomic deprivation is known to influence the presentation of patients with breast cancer and their subsequent treatments, but its relationship with surgical outcomes has not been investigated. A national prospective cohort study was undertaken to examine the effect of deprivation on the outcomes of mastectomy with or without immediate breast reconstruction.

METHODS

Data were collected on patient case mix, operative procedures and inpatient complications following mastectomy with or without immediate breast reconstruction in the English National Health Service between 1 January 2008 and 31 March 2009. Multivariable logistic regression was used to examine the relationship between patients' level of (regional) deprivation and the likelihood of local (mastectomy site, flap, flap donor and implant) and distant or systemic complications, after adjusting for potential confounding factors.

RESULTS

Of 13,689 patients who had a mastectomy, 2849 (20.8 per cent) underwent immediate reconstruction. In total, 1819 women (13.3 per cent) experienced inpatient complications. The proportion with complications increased from 11.2 per cent among the least deprived quintile (Q1) to 16.1 per cent in the most deprived (Q5). Complication rates were higher among smokers, the obese and those with poorer performance status, but were not affected by age, tumour type or Nottingham Prognostic Index. Adjustment for patient-related factors only marginally reduced the association between deprivation and complication incidence, to 11.4 per cent in Q1 and 15.4 per cent in Q5. Further adjustment for length of hospital stay, hospital case volume and immediate reconstruction rate had minimal effect.

CONCLUSION

Rates of postoperative complications after mastectomy and breast reconstruction surgery were higher among women from more deprived backgrounds.

Reoperation rates after breast conserving surgery for breast cancer among women in England: retrospective study of hospital episode statistics

OBJECTIVES

To examine whether rate of reoperation after breast conserving surgery is associated with patients' characteristics and investigate whether reoperation rates vary among English NHS trusts.

DESIGN

Cohort study using patient level data from hospital episode statistics.

SETTING

English NHS trusts.

PARTICIPANTS

Adult women who had breast conserving surgery between 1 April 2005 and 31 March 2008.

MAIN OUTCOME MEASURE

Reoperation rates after primary breast conserving surgery within 3 months, adjusted using logistic regression for tumour type, age, comorbidity, and socioeconomic deprivation. Tumours were grouped by whether a carcinoma in situ component was coded at the time of the primary breast conserving surgery.

RESULTS

55,297 women had primary breast conserving surgery in 156 NHS trusts during the three year period. 11,032 (20.0%, 95% confidence interval 19.6% to 20.3%) women had at least one reoperation. 10,212 (18.5%, 18.2% to 18.8%) had one reoperation only; of these, 5943 (10.7%, 10.5% to 11.0%) had another breast conserving procedure and 4269 (7.7%, 7.5% to 7.9%) had a mastectomy. Of the 45,793 women with isolated invasive disease, 8229 (18.0%) had at least one reoperation. In comparison, 2803 (29.5%) of the 9504 women with carcinoma in situ had at least one reoperation (adjusted odds ratio 1.9, 95% confidence interval 1.8 to 2.0). Substantial differences were found in the adjusted reoperation rates among the NHS trusts (10th and 90th centiles 12.2% and 30.2%).

CONCLUSION

One in five women who had breast conserving surgery in England had a reoperation. Reoperation was nearly twice as likely when the tumour had a carcinoma in situ component coded. Women should be informed of this reoperation risk when deciding on the type of surgical treatment of their breast cancer.

Regional variation in use of immediate breast reconstruction after mastectomy for breast cancer in England

AIMS

English national guidelines recommend that breast reconstruction is made available to women with breast cancer undergoing mastectomy. We examined the use of immediate reconstruction (IR) across English Cancer Networks, who are responsible for the regional organisation of cancer services and ensuring equitable access to treatment.

METHODS

We analysed Hospital Episodes Statistics data for all women with breast cancer who underwent mastectomy in the English NHS between April 2006 and February 2009. IR rates were calculated for the 30 Networks. Multivariable logistic regression was used to adjust the rates for patient age, comorbidity, ethnicity and socioeconomic deprivation.

RESULTS

Of 44 837 mastectomy patients, 7375 (16.5%) underwent IR. The IR rate was highest in women under 50 years (32.7%) and lowest in women aged 70 years or over (1.5%), and was lower in women with more comorbidities. Unadjusted IR rates varied from 8.4% to 31.9% among the 30 Networks (p<0.001). Adjusting for their patient characteristics did not appreciably reduce Network-level variation, with adjusted IR rates still ranging from 8.0% to 29.4% (p<0.001). The risk-model also suggested that non-white women and those from more deprived areas were less likely to undergo immediate reconstruction.

CONCLUSIONS

There is substantial regional variation in immediate reconstruction use in England that is not explained by the characteristics of the local patient population. English Cancer Networks should act to reduce this variation. They should also examine why rates of reconstruction differ between particular patient groups.