ESMO consensus guidelines for the management of patients with metastatic colorectal cancer

Colorectal cancer (CRC) is one of the most common malignancies in Western countries. Over the last 20 years, and the last decade in particular, the clinical outcome for patients with metastatic CRC (mCRC) has improved greatly due not only to an increase in the number of patients being referred for and undergoing surgical resection of their localised metastatic disease but also to a more strategic approach to the delivery of systemic therapy and an expansion in the use of ablative techniques. This reflects the increase in the number of patients that are being managed within a multidisciplinary team environment and specialist cancer centres, and the emergence over the same time period not only of improved imaging techniques but also prognostic and predictive molecular markers. Treatment decisions for patients with mCRC must be evidence-based. Thus, these ESMO consensus guidelines have been developed based on the current available evidence to provide a series of evidence-based recommendations to assist in the treatment and management of patients with mCRC in this rapidly evolving treatment setting.

Multidisciplinary accident investigation. Freeway off-ramp departure; school bus rollover; 29 fatalities. MDAI team report.

National Highway Traffic Safety Administration, Washington, D.C.

Multidisciplinary accident investigation - school bus locomotive-caboose collision, Lafayette, Oregon, September 8, 1976. MDAI team report.

National Highway Traffic Safety Administration, Washington, D.C.

Asthma management by New Zealand pharmacists: a pharmaceutical care demonstration project

Background: Pharmaceutical care services became recognized in New Zealand in the mid-1990s, albeit with limited evidence of the acceptability and effectiveness of the model. An asthma-specific pharmaceutical care service was trialled in southern New Zealand, based on a 'problem-action-outcome' method, with pharmacists adopting a patient-centred, outcome-focused approach with multidisciplinary consultation. Objective: To report on the implementation and outcomes of a specialist asthma service offered by community pharmacists. Design: Pharmacists in five pharmacies, servicing predominantly rural, established clientele, received training in the asthma service and research documentation. Ten patients per pharmacy were recruited in each year (years 1 and 2) of the study. The patients were entered into the study in cohorts of five per pharmacy twice yearly, with year 2 mirroring year 1. The phase-in design minimized the impact on the pharmacists. The patients acted as their own controls. All patients received individualized care and had approximately monthly consultations with the pharmacist, with clinical and quality of life (QoL) monitoring. Results: A total of 100 patients were recruited. On average, 4.3 medication-related problems were identified per patient; two-thirds of them were compliance-related. The most common interventions were revision of patients' asthma action plans, referral and medication counselling. Clinical outcomes included reduced bronchodilator use and improved symptom control in around two-thirds of patients. Asthma-specific QoL changes were more positive and correlated well with clinical indicators. Conclusion: Further research is warranted to integrate this service into daily practice. Clinical outcomes were generally positive and supported by QoL indicators. Characteristics of New Zealand practice and this sample of pharmacies may limit the generalizability of these findings.

Core stability exercise in chronic low back pain

Exercise is commonly used in the management of chronic musculoskeletal conditions, including chronic low back pain (CLBP). The focus of exercise is varied and may include parameters ranging from strength and endurance training, to specific training of muscle coordination and control. The assumption underpinning these approaches is that improved neuromuscular function will restore or augment the control and support of the spine and pelvis. In a biomechanical model of CLBP, which assumes that pain recurrence is caused by repeated mechanical irritation of pain sensitive structures [1], it is proposed that this improved control and stability would reduce mechanical irritation and lead to pain relief [1]. Although this model provides explanation for the chronicity of LBP, perpetuation of pain is more complex, and contemporary neuroscience holds the view that chronic pain is mediated by a range of changes including both peripheral (eg, peripheral sensitization) and central neuroplastic changes [2]. Although this does not exclude the role of improved control of the lumbar spine and pelvis in management of CLBP, particularly when there is peripheral sensitization, it highlights the need to look beyond outdated simplistic models. One factor that this information highlights is that the refinement of control and coordination may be more important than simple strength and endurance training for the trunk muscles. The objective of this article is to discuss the rationale for core stability exercise in the management of CLBP, to consider critical factors for its implementation, and to review evidence for efficacy of the approach.

Unravelling the complexity of muscle impairment in chronic neck pain

Exercise interventions are deemed essential for the effective management of patients with neck pain. However, there has been a lack of consensus on optimal exercise prescription, which has resulted from a paucity of studies to quantify the precise nature of muscle impairment, in people with neck pain. This masterclass will present recent research from our laboratory, which has utilized surface electromyography to investigate cervical flexor muscle impairment in patients with chronic neck pain. This research has identified deficits in the motor control of the deep and superficial cervical flexor muscles in people with chronic neck pain, characterized by a delay in onset of neck muscle contraction associated with movement of the upper limb. In addition, people with neck pain demonstrate an altered pattern of muscle activation, which is characterized by reduced deep cervical flexor muscle activity during a low load cognitive task and increased activity of the superficial cervical flexor muscles during both cognitive tasks and functional activities. The results have demonstrated the complex, multifaceted nature of cervical muscle impairment, which exists in people with a history of neck pain. In turn, this has considerable implications for the rehabilitation of muscle function in people with neck pain disorders. (C) 2004 Elsevier Ltd. All rights reserved.

Neck flexor muscle fatigue is side specific in patients with unilateral neck pain

Despite the evidence of greater fatigability of the cervical flexor muscles in neck pain patients, the effect of unilaterality of neck pain on muscle fatigue has not been investigated. This study compared myoelectric manifestations of sternocleidomastoid (SCM) and anterior scalene (AS) muscle fatigue between the painful and non-painful sides in patients with chronic unilateral neck pain. Myoelectric signals were recorded from the sternal head of SCM and the AS muscles bilaterally during sub-maximal isometric cervical flexion contractions at 25% and 50% of the maximum voluntary contraction (MVC). The time course of the mean power frequency, average rectified value and conduction velocity of the electromyographic signals were calculated to quantify myoelectric manifestations of muscle fatigue. Results revealed greater estimates of the initial value and slope of the mean frequency for both the SCM and AS muscles on the side of the patient's neck pain at 25% and 50% of MVC. These results indicate greater myoelectric manifestations of muscle fatigue of the superficial cervical flexor muscles ipsilateral to the side of pain. This suggests a specificity of the effect of pain on muscle function and hence the need for specificity of therapeutic exercise in the management of neck pain patients. (C) 2003 European Federation of Chapters of the International Association for the Study of Pain. Published by Elsevier Ltd. All rights reserved.

A proposed new classification system for whiplash associated disorders - implications for assessment and management

The development of chronic symptoms following whiplash injury is common and contributes substantially to costs associated with this condition. The currently used Quebec Task Force classification system of whiplash associated disorders is primarily based on the severity of signs and symptoms following injury and its usefulness has been questioned. Recent evidence is emerging that demonstrates differences in physical and psychological impairments between individuals who recover from the injury and those who develop persistent pain and disability. Motor dysfunction, local cervical mechanical hyperalgesia and psychological distress are present soon after injury in all whiplash injured persons irrespective of recovery. In contrast those individuals who develop persistent moderate/severe pain and disability show a more complex picture, characterized by additional impairments of widespread sensory hypersensitivity indicative of underlying disturbances in central pain processing as well as acute posttraumatic stress reaction, with these changes present from soon after injury. Based on this heterogeneity a new classification system is proposed that takes into account measurable disturbances in motor, sensory and psychological dysfunction. The implications for the management of this condition are discussed. (C) 2004 Elsevier Ltd. All rights reserved.

Patients with neck pain demonstrate reduced electromyographic activity of the deep cervical flexor muscles during performance of the craniocervical flexion test

Study Design. Cross-sectional study. Objective. The present study compared activity of deep and superficial cervical flexor muscles and craniocervical flexion range of motion during a test of craniocervical flexion between 10 patients with chronic neck pain and 10 controls. Summary of Background Data. Individuals with chronic neck pain exhibit reduced performance on a test of craniocervical flexion, and training of this maneuver is effective in management of neck complaints. Although this test is hypothesized to reflect dysfunction of the deep cervical flexor muscles, this has not been tested. Methods. Deep cervical flexor electromyographic activity was recorded with custom electrodes inserted via the nose and fixed by suction to the posterior mucosa of the oropharynx. Surface electrodes were placed over the superficial neck muscles ( sternocleidomastoid and anterior scalene). Root mean square electromyographic amplitude and craniocervical flexion range of motion was measured during five incremental levels of craniocervical flexion in supine. Results. There was a strong linear relation between the electromyographic amplitude of the deep cervical flexor muscles and the incremental stages of the craniocervical flexion test for control and individuals with neck pain ( P = 0.002). However, the amplitude of deep cervical flexor electromyographic activity was less for the group with neck pain than controls, and this difference was significant for the higher increments of the task ( P < 0.05). Although not significant, there was a strong trend for greater sternocleidomastoid and anterior scalene electromyographic activity for the group with neck pain. Conclusions. These data confirm that reduced performance of the craniocervical flexion test is associated with dysfunction of the deep cervical flexor muscles and support the validity of this test for patients with neck pain.

Medication management reviews for people from the former Yugoslavia now resident in Australia

Aim: The objective of this prospective study was to conduct medication management reviews (MMR) in people from a non-English speaking background (NESB) (Bosnian/Serbian/ Croatian, from former Yugoslavia, currently residing in Australia) in their native language in order to identify medication-related problems (needs analysis) and implement appropriate therapeutic interventions, in collaboration with their general practitioners (GPs). Methods: Twenty-five participants entered the study. Each was interviewed and medication-related issues were identified by the health care team. Results: Various interventions (over 150 for the whole group, an average of 6 per participant), based on actual and potentia medication-related problems, were designed to improve the use of medicines. The MMRs introduced effective changes into the participants' health care. Psychological (e.g., feeling depressed) and sociological factors (e.g., costs of medicines, not understanding labels written in English) were identified having significant impacts on medication management. Conclusions: These data confirmed there are avoidable medication-related problems in people from a NESB. GPs and pharmacists working in health care teams with a trained interpreter could greatly improve medication use through regular review and a team approach to problem identification and solving.

Measuring impacts of an holistic farm business management training program

A case study approach within an action research framework incorporating qualitative and quantitative domains was adopted to explore the impact on Queensland farmers of a farm business management extension programme. Three new indices were developed to quantify changes perceived by participants. The first measure, the Bennett Change Index, provided statistically significant evidence that attitudinal and behavioural changes were more frequent in participants with less formal education, but also more frequent in participants who had high urbanisation and self-directed learning index scores. The other 2 new indices, Management Constructs Change and Management Objectives Change, provided evidence of statistically significant changes in participant beliefs about, and attitudes towards, farm business management. Although highly correlated with each other, these changes were unrelated statistically to any of 6 other commonly used biographical or psychometric indices employed; including level of formal education. It is concluded that these new measures, with context-relevant modifications, have potential as aids to programme impact evaluation in a range of agricultural and wider applications. They may provide insights into personal psychological issues that complement direct behavioural measures of change.

Dysynchiria: Watching the mirror image of the unaffected limb elicits pain on the affected side

People with complex regional pain syndrome type 1 (CRPS1) watched a reflected image of their unaffected limb being touched and felt pain or paresthesia at the corresponding site on the affected limb. The authors suggest that allodynia and paresthesia can be mediated by the brain and that dysynchiria has implications for the understanding and management of CRPS1.

Predictors of responsiveness to physiotherapy management of cervicogenic headache

A recent randomized controlled trial tested the effectiveness of therapeutic exercise and manipulative therapy on 200 subjects with cervicogenic headache. Although treatments were efficacious, 25% of patients did not achieve a clinically acceptable outcome - 50% reduction in headache frequency This study aimed to identify predictors from variables in subjects' demographics and headache history which might identify those who did or did not achieve a 50-79% or 80-100% reduction in headache immediately after the active treatments and 12 months postintervention. The results revealed no consistent pattern of predictors, although the absence of light-headedness indicated higher odds of achieving either a 50-79% [odds ratio (OR) = 5.45) or 80-100% (OR = 5.7) reduction in headache frequency in the long term. Headaches of at least moderate intensity, the patient's age and chronicity of headache did not mitigate against a successful outcome from physiotherapy intervention.

Central hypersensitivity in whiplash: Implications for physiotherapy assessment and management

It is emerging that whiplash-associated disorder (WAD) is a complex condition characterised by a variety of physical and psychological features. Generalised sensory hypersensitivity is one of these features and its presence reflects augmented central pain processing mechanisms. Whilst most studies have investigated these processes in chronic WAD, it is becoming clear that in some of the whiplash injured, sensory disturbances are present from soon after injury, and are associated with both poor recovery and recalcitrance to multimodal physiotherapy interventions. Evidence for sensory hypersensitivity in WAD and possible underlying mechanisms of these phenomena are reviewed. Physiotherapists play an important role in the evaluation and management of whiplash injury. It is important that sensory disturbances be identified early in the clinical assessment of the whiplash injured patient and that ensuing management strategies address these changes, if the aim of treatment is to prevent the transition to chronicity.

The effect of motor control exercise versus placebo in patients with chronic low back pain

Background: While one in ten Australians suffer from chronic low back pain this condition remains extremely difficult to treat. Many contemporary treatments are of unknown value. One potentially useful therapy is the use of motor control exercise. This therapy has a biologically plausible effect, is readily available in primary care and it is of modest cost. However, to date, the efficacy of motor control exercise has not been established. Methods: This paper describes the protocol for a clinical trial comparing the effects of motor control exercise versus placebo in the treatment of chronic non-specific low back pain. One hundred and fifty-four participants will be randomly allocated to receive an 8-week program of motor control exercise or placebo (detuned short wave and detuned ultrasound). Measures of outcomes will be obtained at follow-up appointments at 2, 6 and 12 months after randomisation. The primary outcomes are: pain, global perceived effect and patient-generated measure of disability at 2 months and recurrence at 12 months. Discussion: This trial will be the first placebo-controlled trial of motor control exercise. The results will inform best practice for treating chronic low back pain and prevent its occurrence.