Risk assessment for cancer-associated thrombosis: what is the best approach?

Venous thromboembolism (VTE) is an increasingly frequent complication of cancer and its treatments. One in five cancer patients are estimated to develop venous and arterial events during the natural history of their illness. However, the risk for VTE varies widely between various subgroups of cancer patients and even in the same cancer patient over time. This narrative review focuses on risk factors, biomarkers and risk assessment tools and attempts to clarify approaches to risk stratification. Clinical risk factors include primary site of cancer, chemotherapy, anti-angiogenic therapy, surgery and hospitalization. Predictive and candidate biomarkers include platelet and leukocyte counts, hemoglobin, D-dimer and tissue factor. However, single risk factors or biomarkers have not, in general, been able to identify sufficiently high-risk populations. A clinical risk score, incorporating 5 simple clinical and laboratory variables, has now been studied in over 10,000 patients and can successfully categorize patients at low- and high-risk for VTE. Recent trials have shown that outpatient prophylactic anticoagulation is both safe and effective, but event rates have been highly variable. Targeted thromboprophylaxis provides an optimal risk-benefit ratio and the best opportunity to reduce the burden of VTE and its consequences for patients with cancer.     

CNS germinomas: what is the best treatment strategy?

CNS germ cell tumors are rare primary brain malignancies. Germinomas comprise approximately two-thirds of CNS germ cell tumors. Owing to their radiosensitivity, radiotherapy has been used to treat patients with CNS germinomas, with favorable treatment outcomes. Historically, craniospinal irradiation has been used. Given the concerns over long-term toxicities associated with craniospinal irradiation, reduced volume radiotherapy with or without chemotherapy has been employed. Data on the use of different strategies in the treatment of CNS germinomas are emerging but a standard strategy has not been established. This article reviews the different strategies used in the management of CNS germinomas.     

Dementia with parkinsonism: what is the diagnosis?

The case presented highlights the difficult differential diagnosis of dementia with parkinsonism. Many disorders affecting the frontal-subcortical circuits produce the triad of impaired cognition, movement disorder, and neuropsychiatric symptoms. The 72-year-old patient whose case is reviewed here had abnormalities in all three domains.     

Physical activity and nutrition health promotion interventions: what is working for people with intellectual disabilities?

A scoping review of studies on physical activity and nutrition health promotion interventions for individuals with intellectual disabilities was conducted. Searches included MEDLINE, PsycINFO, and CINAHL databases from 1986 through July 2006. The final number included 11 articles comprising 12 studies. Generally, this review indicated some evidence for fitness and psychosocial benefits of community-based physical activity and exercise programs for adults with intellectual disabilities. When combined with a more comprehensive health behavior education program incorporating exercise and nutrition information, some evidence exists for reductions in weight.     

Treatment adherence: what is the best that can be achieved?

The modest effectiveness of disease modifying therapies (DMTs) in MS has been amply illustrated by a series of pivotal trials, albeit short term in the context of a life-long disease. Most neurologists and people with MS welcome the opportunity to affect the course of this disorder. However, the individual with MS might not be fully aware of the importance of continuing treatment with these drugs in the absence of feeling better (and often feeling worse) while taking therapy.     

Genetic neuromuscular disorders: what is the best that we can do?

The major advances in genetic neuromuscular disorders in the last 30 years have been: (a) identification of the genetic basis for hundreds of these disorders, (b) through knowing the genes, understanding their pathobiology and (c) subsequent implementation of evidence-based treatments for some of the disorders. New genomic technologies are providing precision diagnosis, mode of inheritance and likely prognosis for more patients than ever before. Parents of children with a genetic diagnosis can then use preimplantation or prenatal diagnosis to avoid having further affected children if they wish. But is this the best we can do for genetic neuromuscular disorders? Since the 1980s, it has been argued it would be better to identify Duchenne muscular dystrophy carrier mothers, rather than diagnose their affected sons. Carrier screening for recessive disorders can identify couples with a high chance of having affected children. It allows couples reproductive choice and can prevent infant morbidity and mortality and significant distress for families. Professional bodies in many countries now recommend prospective parents should be informed about carrier screening. Implementing and funding expensive therapies increases the cost-effectiveness of carrier screening, increasing its attractiveness to governments. Best practice for genetic neuromuscular disorders should include equitable access to carrier screening.     

What is the best adjuvant treatment for very young patients with medulloblastoma?

The standard treatment for medulloblastoma is surgery followed by adjuvant chemotherapy and external beam radiotherapy to the craniospinal axis and posterior fossa. However, in very young children, craniospinal irradiation has a more significant detrimental effect in terms of neurocognitive function and growth. This article reviews the different strategies used for very young patients with medulloblastoma.