State of the art in aspiration assessment and the idea of a new non invasive predictive test for the risk of aspiration in stroke

BACKGROUND

Dysphagia is a common but severe complication in acute stroke. New bedside tests are necessary to assess the risk of aspiration and avoid unnecessary alimentary restrictions but they must be completed by evaluated instruments.

OBJECTIVE

We evaluated the prognostic validity of the recognition of forms (rf) test related to the assessment by speech and language therapists (SLT).

DESIGN

Double blinded screening tests.

SETTING

Geriatric department of general hospital.

SUBJECTS

50 patients with acute stroke admitted consecutively.

METHODS

All patients were assessed by SLT, mini mental status test, short test for assessing deficits of memory and attention and abilities of daily living-test. The rf-test was performed twice with a two week interval.

RESULTS

Assessment by SLT demonstrated aspiration in 29 of 50 patients. 18 patients failed the rf-test, giving a specificity of 90% (positive predictive value 89%), a sensitivity of 55% (negative predictive value 59%). 5 of 7 patients with aspiration pneumonia failed the test. Test-retest-correlation was 0,827. Performance in the rf-test was related significantly to results of the activities of daily living-test.

CONCLUSIONS

Bedside tests to exclude aspiration in patients with acute stroke are necessary. No test so far combines high sensitivity with acceptable specificity. Compared to other bedside tests the rf-test has a high specificity while sensitivity is low. On behalf of good predictivity rf-test may be an interesting supplement to swallow tests in case of stroke and seems to be a candidate for more extended studies.

Comprehensive geriatric assessment in the elderly cancer patient

The proportion of older cancer patients is increasing due to demographic and disease-specific reasons. However, this group of patients is severely underrepresented in research and clinical therapy. Limitation in physical and functional capacity with considerable interindividual heterogeneity remains one of the important problems in the treatment decision process. One approach to this problem is the use of a Comprehensive Geriatric Assessment (CGA) to describe and classify these deficits with high validity and reliability. The different domains of CGA are described with special respect to the instruments applied, as CGA has also a key role in the decision process.

[Therapy of elderly patients with colorectal carcinoma]

Treating elderly patients with colorectal cancer is a challenging task for which many aspects have to be taken into account. Almost 70% of patients with colorectal cancer are 65 years or older and the number of elderly patients is expected to increase. As elderly patients frequently exhibit adverse physical or socio-economic conditions, a thorough geriatric assessment of the patient's suitability for therapy is essential before making a decision. The first line treatment for colorectal cancer is surgery. Complete resection of the tumor should also be attempted in elderly patients, as there are little differences in cancer--specific survival in selected elderly patients compared to younger patients. Surgery with palliative intention can be attempted for symptom control or to prevent later local complications caused by the primary tumor. At present, adjuvant 5-FU based chemotherapy (in colon cancer) and adjuvant radio-chemotherapy (in rectal cancer) in the elderly is recommended for locally advanced or node positive tumor after tumor resection, since the benefit seems to be comparable to that achieved in younger patients. There is also enough data to support the use of 5-FU based chemotherapy in elderly patients in the palliative setting. New drugs have recently been added to the armentarium for the treatment of metastatic colorectal cancer. However, there is as yet not sufficient data to guide the use of these new drugs (such as oxaliplatin or irinotecan) in elderly patients. However, first clinical studies seem to indicate a comparable efficacy and toxicity in elderly patients to that observed in younger patients. Further clinical trials of chemotherapy in elderly patients with colorectal cancer are necessary to gain information about treatment recommendations. It is the aim of this manuscript to summarize the current knowledge about the management of colorectal cancer in elderly patients.

Driving in vitro selection of anti-HIV-1 TAR aptamers by magnesium concentration and temperature

In vitro selection with either DNA or RNA libraries was performed against the TAR RNA element of HIV-1. The role of the selection conditions on the outcome of the selection was evaluated by varying the magnesium concentration and the temperature. The selection stringency was demonstrated to determine i) the affinity of the best identified aptamers for the TAR target, and ii) the type of interaction between the two partners. Selections performed with a DNA library under low (4 degrees C, 10 mM magnesium) and high stringency (23 degrees C, 3 mM magnesium) led to the emergence of "kissing aptamers"; but even if the motif interacting directly with the TAR loop were identical in the two kinds of aptamers, the consensus was extended from eight to thirteen nucleotides when the Mg(2+) concentration was decreased from 10 to 3 mM. Similar kissing aptamers were selected at 23 degrees C and 37 degrees C starting with two different RNA libraries under identical ionic conditions. In addition, selection performed at 37 degrees C yielded a significant proportion of antisense sequences. Only antisense RNAs complementary to the TAR loop competitively inhibited the association of a Tat peptide with TAR.

Use of hematopoietic growth factors in elderly patients receiving cytotoxic chemotherapy

Myelosuppression is a common side effect in elderly patients undergoing chemotherapy. Neutropenia and anemia cause considerable morbidity, may increase mortality, and can result in a worse outcome of treatment in elderly patients compared to younger patients with comparable type and stage of disease. The availability and proven efficacy of hematopoietic growth factors such as granulocyte colony-stimulating factor (G-CSF) or granulocyte-macrophage colony-stimulating factor (GM-CSF) and erythropoietin (EPO) have had a considerable impact on supportive care in cancer patients: Several randomized trials have demonstrated a reduction of neutropenia and the frequency of severe infections in elderly patients treated with G-CSF following myelotoxic chemotherapy compared with patients without growth factor support. Both for G-CSF and for recombinant human erythropoietin (rHu-EPO) several studies have demonstrated the safety and effectiveness of these molecules in elderly patients with regard to increasing hemoglobin concentrations, improving quality of life (rHu-EPO), and neutrophil recovery. Although a positive effect of the use of growth factors on overall survival in elderly cancer patients is not yet proven, a reduction of chemotherapy-induced side effects could clearly be shown. The National Comprehensive Cancer Network (NCCN) of cancer centers has recommended that all patients aged 70 years and older treated with CHOP or cytotoxic chemotherapy of comparable intensity should receive prophylactic G-CSF administration, and that the hemoglobin concentration be maintained at >or=12 g/dl in elderly patients undergoing chemotherapy.

[Chemotherapy of colorectal cancer--which therapy is justified for elderly patients?]

Treating elderly patients with colorectal cancer is a challenging task for which many aspects have to be taken into account. 70% of patients with colorectal cancer are 65 years or older and the number of elderly patients is expected to increase. As elderly patients frequently exhibit adverse physical or socio-economic conditions, a thorough geriatric assessment of the patient's suitability for therapy is essential before making a decision. At present, adjuvant 5-FU based chemotherapy (in colon cancer) and adjuvant radio-chemotherapy (in rectal cancer) in the elderly is recommended for locally advanced or node positive tumor after tumor resection, since the benefit may be comparable to that achieved in younger patients. There is enough data to support the use of 5-FU based chemotherapy in elderly patients in the palliative setting. New substances have recently been added to the armentarium for metastatic colorectal cancer. However, there is as yet not sufficient data to guide the use of these new drugs (such as oxaliplatin or irinotecan) in elderly patients. However, first clinical studies seem to indicate a comparable efficacy and toxicity in elderly patients to that observed in younger patients. Further clinical trials of chemotherapy in elderly patients with colorectal cancer are necessary to gain information about treatment recommendations.