Occupational therapy in fall prevention: current evidence and future directions

Falls are a serious public health concern among older adults in the United States. Although many fall prevention recommendations exist, such as those published by the American Geriatrics Society (AGS) and the British Geriatrics Society (BGS) in 2010, the specific role of occupational therapy in these efforts is unclear. This article presents a scoping review of current published research documenting the role of occupational therapy in fall prevention interventions among community-dwelling older adults, structured by the AGS and BGS guidelines. We identified evidence for occupational therapy practitioner involvement in fall prevention in environmental modifications, exercise, and multifactorial and multicomponent interventions. Although research documenting the efficacy of occupational therapy interventions is identified as part of the Occupational Therapy Practice Framework: Domain and Process (2nd ed.; American Occupational Therapy Association, 2008), we identified little or no such research examining interventions to modify behaviors (e.g., fear of falling), manage postural hypotension, recommend appropriate footwear, and manage medications. Although occupational therapy is represented in the fall prevention research, the evidence for the profession's role in many areas is still lacking.     

Stroke prevention in atrial fibrillation: current anticoagulation management and future directions

Atrial fibrillation (AF) is an important cause of stroke, and stroke risk stratification is critical to the management of patients with AF. Anticoagulation with warfarin is the current standard of care for stroke prevention in these patients, despite the need for close monitoring. Aspirin alone is not as effective. Warfarin is recommended for patients with AF and valvular disease or with AF and one or more stroke risk factors. Other novel anticoagulants and antiplatelet combinations are under investigation. Curative procedures for AF are possible, but their long-term safety and effect on stroke risk are unknown.     

Understanding cardiovascular injury after treatment for cancer: an overview of current uses and future directions of cardiovascular magnetic resonance

While cancer-free survival has improved over the past 20 years for many individuals with prostate, renal, breast, and hematologic malignancies, the increasingly recognized prevalence of cardiovascular (CV) events in cancer survivors has been an unintended consequence of many of the therapies that have improved these survival rates. The increase in CV events threatens to offset the improvement in cancer related survival. As a result, there is an emerging need to develop methods to identify those individuals treated for cancer at increased risk of cardiovascular events. With its inherent ability to characterize myocardial tissue and identify both cardiac and vascular dysfunction, cardiovascular magnetic resonance (CMR) has the potential to identify both subclinical and early clinical CV injury before the development of an overt catastrophic event such as a myocardial infarction, stroke, or premature cardiac death. Early identification provides an opportunity for the implementation of primary prevention strategies to prevent such events, thereby improving overall cancer survivorship and quality of life. This article reviews the etiology of CV events associated with cancer therapy and the unique potential of CMR to provide early diagnosis of subclinical CV injury related to the administration of these therapies.     

Biosimilars: current status and future directions

Importance of the field: Expiration of patents covering biopharmaceuticals, has provided opportunities for pharmaceutical companies to develop, produce and market biosimilars or follow-on biologicals. However, there have been concerns over the degree of similarity of these complex drugs in addition to the hope that their introduction may lower the cost of such expensive medicinal products.

Areas covered in this review: The introduction/manufacturing considerations, immunogenicity and regulatory approaches to biosimilars around the world. In addition, arguments and techniques employed by pharmaceutical companies to advance or discredit biosimilar drugs will be outlined. Issues with post-marketing surveillance programmes and their limitations are described.

What the reader will gain: This evaluation outlines the controversial issues associated with introduction of biosimilar medicines across a range of pharmacological indications. Also the differences between regulatory approved medicines and biopharmaceutical products not subjected to regulatory approval (‘B-NSRA’) are highlighted. The review is limited by the rapid changes in regulatory approval and licencing of biosimilars.

Take home message: Hopefully biosimilar medicines will allow more widespread availability of expensive biopharmaceutical products. Clinicians need to be wary of non-transparent promotion of innovator/biosimilar products.     

Psychosocial adjustment to coronary artery disease: current knowledge and future directions

Adjusting to the diagnosis of coronary artery disease can be a challenge to the coping abilities of patients and their families. To effectively support these clients' coping efforts, cardiovascular nurses must be knowledgeable about factors that affect the adjustment process. This article reviews recent findings regarding physiologic, psychologic, and sociodemographic influences on adjustment and presents a model that integrates these findings. Possible directions for further research are suggested.     

Neurocognitive sequelae of sickle cell disease: current issues and future directions.

Sickle cell disease is a genetic disorder with an autosomal recessive pattern of inheritance. This disease is most prevalent among those of African American and Mediterranean descent. Cerebral vascular accident (CVA) or stroke is one of the major complications of hemoglobin SS (Hgb SS) disease. CVA has implications for physical as well as neurocognitive function for children. Recent literature suggests that some children with sickle cell disease without overt signs of CVA may still have evidence of neurological deficit, both on magnetic resonance imaging and neurological examination. There is a growing body of knowledge that further aids in delineation of risk factors for CVA, silent infarct, and neurocognitive deficits in children with Hgb SS disease. More research is needed to continue to explore avenues for identification and intervention. The purpose of this article is to delineate areas of ongoing research in this important area.     

The need for wider and appropriate utilization of aspirin and statins in the treatment and prevention of cardiovascular disease

There is an increasing burden of occlusive cardiovascular disease (CVD) in developed, as well as in developing, countries. In fact, the WHO has projected that CVD will become the leading cause of death in the world in the next 10 years. The proximate cause of virtually all occlusive vascular events is thrombosis and the principal underlying cause is atherosclerosis. Aspirin, which inhibits platelet-dependent cyclooxygenase for the entire life of the platelet, has clinically important antithrombotic effects. Statins, which principally decrease low-density lipoprotein cholesterol, triglycerides and increase high-density lipoprotein cholesterol, have clinically important antiatherogenic effects. In secondary prevention, in a wide range of patients who have survived a prior myocardial infarction (MI), occlusive stroke, transient ischemic attack, as well as other high-risk conditions, long-term use of aspirin confers statistically significant and clinically important reductions in MI, stroke and CVD death. In addition, aspirin confers similar benefits when administered during acute MI or acute occlusive stroke. In primary prevention, aspirin confers a statistically significant and clinically important reduction in risk of a first MI but the data on stroke and CVD death remain inconclusive, so aspirin should be prescribed on an individual basis by the healthcare provider who weighs this clear benefit against long-term side effects. In a meta-analysis of 14 randomized trials of 90,056 subjects treated for 5 years, statins confer statistically significant and clinically important reductions in MI, stroke, CVD death and total mortality. In a meta-analysis of randomized trials of statins, in which aspirin was used in varying frequencies, the combination of aspirin and statins conferred greater clinical benefits than either agent alone on MI, occlusive stroke and CVD death. At present, the wider and more appropriate use of aspirin and statins will reduce premature MI, stroke and CVD death.     

Virtual colonoscopy: current status and future directions

Virtual colonoscopy (CT colonography) is a technique whereby CT images of the cleansed and distended colon are acquired, ostensibly for detecting colonic neoplasia, although also providing additional diagnostic information from extracolonic organs. This article examines the current status of virtual colonoscopy, reviewing the technical parameters, performance characteristics, and issues surrounding implementation in routine clinical practice. Future directions for virtual colonoscopy are explored, including advances toward prepless examinations and automated interpretation.     

Cancer biomarkers: current issues and future directions

Cancer biomarkers and characteristics of an ideal biomarker for cancer are discussed in this review, as well as technologies for their detection. The focus of this article is on the use of biomarkers for anticancer drug development and clinical applications, including determination of prognosis as well as monitoring of response to therapy. Types of biomarkers include methylated DNA sequences, mitochondrial DNA and microRNA. Within clinical research, oncology is expected to have the largest gains from biomarkers over the next five to ten years. Development of personalized medicine for cancer is closely linked to biomarkers, which may serve as the basis for diagnosis, drug discovery and monitoring of diseases. A major challenge in development of cancer biomarkers will be the integration of proteomics with genomics and metabolomics data and their functional interpretation in conjunction with clinical data and epidemiology.     

Hypertension pharmacogenomics: current status and future directions

Hypertension is the most common chronic disease in the Western world, and while there are many drug classes from which to choose therapy, only 34% of North Americans currently have their blood pressure controlled. The potential clinical utility of pharmacogenomics in helping to guide antihypertensive drug therapy selection is described. The hypertension pharmacogenetics literature is reviewed, which highlights that only a small fraction of the genes that likely contribute to antihypertensive response have been studied to date. The genes for alpha-adducin (diuretic response), the beta1-adrenergic receptor (beta-blocker response) and angiotensinogen (response to multiple drug classes) are among the genes with the most compelling data (based on replication) as pharmacogenetic candidates. Potential limitations of current studies are also discussed. These include reliance on clinic blood pressure, which is probably a suboptimal response phenotype, and the relatively small sample sizes of most studies to date. Also discussed is the relatively simplistic genetic approach that has been taken, which has focused largely on a single gene or single nucleotide polymorphism within a gene. Multiple ways to overcome these potential limitations are described. Hypertension pharmacogenomics holds tremendous potential for providing a mechanism by which management of hypertensive patients might be improved, and future studies should help move this field towards its clinical potential.     

Children and war: current understandings and future directions

During the last decade, the number of children whose lives have been disrupted by war, oppression, terror, and other forms of conflict has grown tremendously. When the United Nations High Commission for Refugees was first established during the 1950s to provide international protection to refugees following World War II, it was estimated that there were 1.5 million refugees and displaced persons. Today there are approximately 14 million, about three-fourths of whom are women and children. Although the experiences of refugee children and adolescents vary considerably, many have witnessed or experienced the death or murder of loved ones. Upon resettlement, they face numerous challenges. Research with this population is a relatively new area of investigation, but there is evidence that many of these young people experience long-term physical and emotional health problems. In this article, current research findings are reviewed, the widespread emphasis in the literature on post-traumatic stress disorder (PTSD) is critically examined, future research directions are suggested, and implications for public health nurses are addressed.     

Contrast agents in abdominal imaging: current and future directions

Magnetic resonance imaging is an established imaging method for the evaluation of the abdomen. Accurate assessment of the liver, spleen, pancreas, bile ducts, vascular structures, and retroperitoneal organs (eg, the kidneys, the collecting system, and the adrenals) are possible on MR imaging. The intravenous administration of MR contrast agents can frequently improve the examination and provide more specific diagnoses. The advent of more specific, "hepatobiliary" contrast agents has further improved the differential diagnostic process, particularly for MR imaging of the liver. The availability of orally administered MR contrast agents has further extended the range of abdominal applications, making MR imaging of the small bowel and the colon established imaging procedures.     

Fatigue in multiple sclerosis: current understanding and future directions

Fatigue is a very common symptom of multiple sclerosis (MS). Theoretically, fatigue may be related to neuromodulation by soluble products of the autoimmune process or by disruption of central nervous system pathways necessary for sustained activity, but little empirical evidence supports these possibilities. Amantadine, pemoline, and modafanil improved fatigue in placebo-controlled clinical trials, but these studies all had significant limitations. Difficulty measuring fatigue has impeded studies of its characteristics, mechanisms, and therapeutics. Most studies have relied on self-report questionnaires. These may be inappropriate, however, because they can be easily confounded by other symptoms of MS, they are entirely subjective, and they require patients to make difficult retrospective assessments. Studies of fatigue would be improved by including measures of more rigorously defined, quantifiable components of fatigue. For example, motor fatigue can be measured as the decline in strength during sustained muscle contractions. Cognitive fatigue can be measured as the analogous decline in cognitive performance during tasks requiring sustained attention. Lassitude is defined as a subjective sense of reduced energy, and it can be measured with the use of a visual analog diary. These measures provide reproducible results and demonstrate significant differences between MS patients and healthy controls. Dividing fatigue into these components can provide objective assessments that are less likely to be confounded by other symptoms of MS, such as weakness, spasticity, cognitive impairment, and depressed mood.     

Pharmacogenomics in breast cancer: current trends and future directions

Pharmacogenomics is the study of genetic variations between individuals to predict the risk of toxic side effects and the probability that a patient will respond to single- or multidrug chemotherapy. Breast cancer remains one of the most common cancers among women worldwide and is second only to lung cancer in cancer-related death. A better understanding of the mechanisms of initiation and progression of breast cancer is needed for early diagnosis and development of better therapeutic methodologies. Differences in cancer patients' responses to chemotherapy have often been attributed to pathogenesis and severity of the disease, drug interactions, patient's age, gender, nutritional status, organ functions and tumor biology. It is now well recognized that genetic variations in drug target genes, disease pathway genes and drug metabolizing enzymes can have greater influence on drug efficacy and toxicity. In addition, germline variants can be used to study breast cancer susceptibility, as well as the variable response to both drug and radiation therapy used in the treatment of breast cancer. This review discusses clinically relevant individual gene variations that influence breast cancer susceptibility and cancer therapy, as well as the microarray-based expression profiling studies that have great potential in cancer pharmacogenomics in terms of tumor classification, drug and biomarker discovery and drug efficacy testing.