How do we improve outcomes for gastric cancer?

Although the incidence of gastric cancer is decreasing globally, it remains the second leading cause of cancer death, accounting for 600,000 deaths annually worldwide. It is particularly common in Asia and especially in China, Japan and Korea. In Singapore, it is the fourth commonest cancer in men, who have a 1:50 lifetime risk of developing gastric cancer. Gastric cancer traditionally carries a poor prognosis because of late presentation at an advanced stage of disease. If diagnosed at an early stage, it is a curable disease. Four strategies will systematically help to improve outcomes for gastric cancer: (i) early detection by screening of high-risk groups; (ii) clarification of the hypothesis that Helicobacter pylori eradication in endemic areas with a high incidence of gastric cancer is an effective primary prevention strategy; (iii) improvement of treatment by well-designed clinical trials, coupled with molecular characterization of tumors; and (iv) improving our biological understanding of gastric carcinogenesis.     

Can bone quality be assessed non-invasively?--Imaging--

Properties of "bone quality" contain "structural property" and "material property" . Most components of "material properties" cannot be visualized by current technology. Mineralization, one of material properties, can be evaluated using synchrotron radiation CT or contact microradiography with high spatial and density resolution, but they are invasive examinations. On the other hand, "structural property" can be radiographically delineated, even though only a few methods are available non-invasively. Assessments of macrostructure of bone by radiograms or CT, and trabecular microstructure by high resolution CT or MR can be done non-invasively, and provide valuable results in clinical studies. Bone scintigram provides limited but useful information of bone turnover.     

Can bisphosphonates improve outcomes in patients with newly diagnosed multiple myeloma?

Preclinical and clinical evidence suggests that bisphosphonates have anticancer activities both within and outside bone. Early clinical trials of bisphosphonates provided evidence for antimyeloma effects in exploratory analyses in high-risk subsets, and recent trials of zoledronic acid (ZOL) have provided further support of antimyeloma activity The MRC Myeloma IX trial is an innovative 2 x 2 factorial trial comparing ZOL and clodronate (CLO) in patients with newly diagnosed multiple myeloma receiving either intensive or non-intensive therapy regimens. Results showed that ZOL significantly reduced skeletal morbidity and significantly improved both progression-free and overall survival versus CLO. Notably, the survival benefit with ZOL remained significant after adjustment for skeletal-related events, consistent with clinically meaningful antimyeloma activity. Further analyses of these data will provide greater insight into ZOL interactions with primary treatment regimens for multiple myeloma.     

How do platelets prevent bleeding?

A new study presented by Goerge and colleagues in this issue of Blood demonstrates that platelets preserve vascular integrity in inflamed tissue independently of classic adhesion mechanisms.     

Could targeting bone delay cancer progression? Potential mechanisms of action of bisphosphonates

Although dissemination may occur early in the course of many cancers, the development of overt metastases depends upon a variety of factors inherent to the cancer cells and the tissue(s) they colonize. The time lag between initial dissemination and established metastases could be several years, during which period the bone marrow may provide an unwitting sanctuary for disseminated tumor cells (DTCs). Survival in a dormant state within the bone marrow may help DTCs weather the effects of anticancer therapies and seed posttreatment relapses. The importance of the bone marrow for facilitating DTC survival may vary depending on the type of cancer and mechanisms of tumor cell dissemination. By altering the bone microenvironment, bisphosphonates may reduce DTC viability. Moreover, some bisphosphonates have demonstrated multiple anticancer activities. These multiple mechanisms may help explain the improvement in disease outcomes with the use of zoledronic acid in malignancies like breast cancer and multiple myeloma.     

How to improve efficacy of onychomycosis treatment?

Onychomycosis is a public health concern because of its high world wide prevalence, and its potential for spread of fungal elements to others. About one half of all patients presenting to dermatologists' offices for nail disorders have onychomycosis. This kind of infection may impact upon physical, functional, and emotional aspects of life. Onychomycosis can be treated with the new generation of oral antifungals. Efficacy rates for fingernail onychomycosis are high; however, for toenail onychomycosis, efficacy rates may range from 60% to 80%. Relapse rates have been estimated to be 15% to 20% measured at 2 years following therapy initiation. Because many factors may be associated with a suboptimal clinical response, consideration to measures that reflect the most appropriate pharmacologic and supportive regimens must be made in order to meet the challenge of onychomycosis cure. In some situations supplemental therapy consisting of extra antifungal or adjunctive (topical/surgical) therapy may be beneficial.     

How can we improve junior doctor prescribing?

The large number of medications available has complicated the learning of drug therapy for medical students at a time when pharmacology training has been substantially reduced. Attempts to remedy this include: improving the pharmaco‐therapeutics curriculum; interactive web‐based learning and students developing a personal formulary. The approach adopted by the University of Wollongong Medical School is to integrate clinical pharmacology throughout the course, with the Student Preferred‐drugs Formulary linking pharmacology and common diseases. Evidence from other countries suggests this should enhance prescribing by medical graduates.     

How we can measure quality in colonoscopy?

Measuring quality is a current need of medical services either to assess their cost-effectiveness or to identify discrepancies requiring refinement. With the advent of bowel cancer screening and increasing patient awareness of bowel symptoms, there has been an unprecedented increase in demand for colonoscopy. Consequently, there is an expanding open-discussion on missed rates of cancer or precancerous polyps during diagnostic/screening colonoscopy and on the rate of adverse events related to therapeutic colonoscopy. Delivering a quality colonoscopy service is therefore a healthcare priority. Colonoscopy is a multi-step process and therefore assessment of all aspects of the procedure must be addressed. Quality in colonoscopy refers to a combination of many patient-centered technical and non-technical skills and knowledge aiming to patient’s safety and satisfaction through a continuous effort for improvement. The benefits of this endless process are hiding behind small details which can eventually make the difference in colonoscopy. Identifying specific quality metrics help to define and shape an optimal service and forms a secure basis of improvement. Τhis paper does not aim to give technical details on how to perform colonoscopy but to summarize what to measure and when, in accordance with the current identified quality indicators and standards for colonoscopy.