Day: 03/16/2011

Which Patients Are Fit to Drive After a Stroke?

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The pertinent issue may be not which patients are likely to fail a road test, but rather who should take the test in the first place.

What are the best clinical predictors of passing a road test after a stroke? To find out, investigators conducted a literature search for English language reports on outcome of a pass/fail road test after a stroke. The researchers identified 30 such studies, 27 of which provided sufficient data to be included in a meta-analysis. “Fitness-to-drive” data were analyzed for 1728 people; all had been active drivers before they had their strokes.

Of 54 measures of physical, visual, and cognitive function that were evaluated, only 5 (Cube Copy, Stroke Drivers Screening Assessment, Road Sign Recognition, the Compass task, and Trail Making Test part B) were clinically relevant (i.e., met the effect-size cutoff of >0.8) and had statistically significant P values. Road Sign Recognition, the Compass task, and the Trail Making Test were the best determinants of fitness to drive after a stroke. Motor deficits were not predictive, largely because vehicles can usually be outfitted to accommodate such limitations. Visual deficits were not predictive because any substantial visual impairment precluded being licensed to drive.

Road-test pass/fail rates varied enormously across the studies, suggesting wide variation in the road tests themselves, in the participant-selection criteria, or both. In four studies, fail rates were at least double the pass rates, perhaps because of extremely difficult road tests or nonstringent criteria for including participants. In six studies, pass rates were at least double the fail rates, perhaps because of easy road tests or selective inclusion criteria. In one instance, the pass rate was nearly 8 times the fail rate, likely attributable to in-depth screening before the road test.

Comment: The authors assert that “more than half of persons with stroke are fit to drive following a successful on-road examination.” This estimate does not account for the large number of patients who are never referred for a road test in the first place — either because of severe disabilities that clearly preclude safe driving or because of apparent recovery to prestroke function. The more effective the poststroke screening, the less the apparent need for road testing. Although several office-based tests were predictive of road-test performance, this study was not designed to answer the best screening tests to determine referral for road testing. Most physicians are not familiar with the office-based tests used in this study, so they should refer patients to specialists (e.g., occupational therapists) who are. Ultimately, clinicians should become adept at determining which of their patients should be referred for a road test.

— Germaine L. Odenheimer, MD

Dr. Odenheimer is Associate Professor, Donald W. Reynolds Department of Geriatrics, University of Oklahoma College of Medicine, and Veterans Affairs Medical Center, Oklahoma City.

Published in Journal Watch Neurology

 

New Insights About Trastuzumab for HER2-Positive Early Breast Cancer

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Substantial benefits persisted at 4-year follow-up and were also seen in patients who crossed over to trastuzumab.

The benefits of trastuzumab are well established for patients with human epidermal growth factor receptor 2 (HER2)-positive breast cancer (whether early or advanced). The current standard is 1 year of trastuzumab therapy, but the optimal duration of treatment in the adjuvant setting remains unknown. The Herceptin Adjuvant (HERA) trial is an ongoing international, multicenter, randomized, phase III trial involving >5000 women with HER2-positive, early stage breast cancer who completed local regional therapy (surgery with or without radiation therapy) and at least 4 cycles of chemotherapy (adjuvant, neoadjuvant, or both). Patients were randomly assigned to observation or trastuzumab for 1 or 2 years. At median follow-up of 1 year, disease-free survival (DFS) was significantly better in patients who received trastuzumab than in those who did not (hazard ratio, 0.54); thus, the trial protocol was amended to allow crossover for patients without recurrence who did not receive trastuzumab initially. Subsequent analysis at median follow-up of 2 years showed that, compared with chemotherapy alone, the addition of trastuzumab was associated with better DFS (HR, 0.64) and overall survival (OS; HR, 0.66; JW Oncol Hematol Feb 5 2007).

Now, HERA investigators report data on trastuzumab versus observation at median follow-up of 4 years in an analysis that incorporated the effect of crossover from observation to trastuzumab. The study population included 1698 patients initially randomized to observation and 1703 patients to trastuzumab for 1 year.

Intent-to-treat (ITT) analysis of DFS showed a substantial benefit in the trastuzumab group versus observation (4-year DFS: 78.6% vs. 72.2%; HR, 0.76); however, ITT analysis of OS showed no significant difference in risk for death (4-year OS: 89.3% and 87.7%; HR, 0.85). In all, 885 of 1698 patients in the observation group (52%) ultimately crossed over to trastuzumab, beginning treatment a median of 22.8 months after initial randomization. DFS outcomes in these patients were substantially better than in those who remained on observation.

Comment: These results reaffirm that the addition of trastuzumab significantly improves outcomes of patients with early stage, HER2-positive breast cancer. A more nuanced view discloses additional insights. Most trials have shown incremental improvement in survival with concurrent chemotherapy plus trastuzumab as opposed to the sequential approach in the HERA trial. The HERA trial also suggests that late administration of trastuzumab (i.e., long after adjuvant chemotherapy has been completed) can confer significant benefit to patients who did not receive trastuzumab at the outset of treatment. However, such an approach is unlikely to be adopted or tested in prospective clinical trials because standard of care dictates that anti-HER2 therapy be instituted soon after completion of local therapy.

— William J. Gradishar, MD

Published in Journal Watch Oncology and Hematology

 

The use of herbal medicines by people with cancer: a cross-sectional survey

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A large proportion of cancer patients are estimated to use herbal medicines, but data to substantiate this are lacking. This study aimed to investigate the prevalence of herbal medicine use among cancer patients in the West Midlands, and determine the characteristics predicting herbal medicine use.

Methods:

A cross-sectional survey of oncology patients (n=1498) being followed up at a hospital in Coventry was undertaken. Recipients were asked about herbal medicine use since their cancer diagnosis, and the association between sociodemographic and cancer-related characteristics and herbal medicine use was evaluated.

Results:

A total of 1134 responses were received (75.7%). The prevalence of herbal medicine use was 19.7% (95% CI: 17.4–22.1; n=223). Users were more likely to be affluent, female, and aged under 50 years. Usage increased with time since cancer diagnosis (X2 for trend=4.63; P=0.031). A validation data set, derived from a survey of oncology patients in Birmingham (n=541) with differing socioeconomic characteristics showed no significant difference in estimated prevalence (16.6%; 95% CI: 11.9–22.2).

Conclusion:

A substantial number of people with cancer are likely to be taking herbal medicines. Understanding the self-medication behaviours of these individuals is essential if health-care professionals are to support treatment adherence and avoid unwanted pharmacological interactions.

source: British journal of Oncology

MicroRNA dysregulation in colorectal cancer: a clinical perspective

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Recent researches have shed light on the biological importance of microRNAs (miRNAs) in colorectal cancer (CRC) genesis, progression and response to treatments. The potential utility of miRNAs in the preclinical stage have been explored and investigated. In this review, we explored the literature and reviewed the cutting edge progress in the discovery of noninvasive plasma and faecal miRNAs for CRC early diagnosis, as well as their measurability and predictability. We also discussed the utility of miRNAs as novel prognostic and predictive markers, and their association with CRC clinical phenotypes including recurrence, metastasis and therapeutic outcomes. Finally, we summarised miRNA-related single-nucleotide polymorphisms and their potential influence on sporadic CRC susceptibility and therapeutic response. In conclusion, the use of miRNAs as biomarker for CRC is still in its infancy and need further characterisation and evaluation.

source: British journal of oncology

 

At-Home Use of Bulb Syringes May Reduce Clinic Visits for Earwax

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Home use of a bulb syringe may help relieve earwax occlusion more effectively than a clinical procedure, according to an Annals of Family Medicine study.

Researchers randomized some 240 adults in the U.K. either to ear drops and home use of a bulb syringe or to ear drops and irrigation by a clinic nurse. Patients were reassessed after 2 weeks, and those with persistent occlusions had their ears irrigated at the clinic.

At 2 years’ follow-up, patients initially managed clinically returned to the clinic for earwax concerns more often than the home-treatment group (73% vs. 60%).

The authors conclude: “Rather than routine attendance with a clinician, self-treatment with drops and then self-irrigation may offer a significantly less costly alternative.”

Source:Annals of Family Medicine