The timing of adjuvant chemotherapy in colorectal cancer:
In this meta-analysis, even a four-week increase in time to adjuvant chemotherapy was associated with a significant decrease in overall survival (hazard ratio [HR] 1.14, 95% confidence interval [CI] 1.10 to 1.17) and disease-free survival (HR 1.14, 95% CI 1.10 to 1.18). Adjuvant chemotherapy is routinely recommended after curative surgical resection of specific stages (generally stages II–III) of colon and rectal cancers. The intent is to eradicate micrometastatic deposits that may be present during surgery or spread as a result of the procedure. The authors identified 10 studies for inclusion in the review and meta-analysis; all but one were cohort or population-based. The authors stress that relative overall survival decreases by 14% for every four-week delay in starting chemotherapy after surgery and recommend that time to adjuvant chemotherapy be minimized. The study was limited by the exclusion of all studies not published in English. See JAMA 2011;305:2335–42.
Timing of IUD insertion after uterine aspiration:
Does the timing of insertion of an intrauterine device (IUD) after uterine aspiration for induced or spontaneous abortion affect the expulsion rate? Yes and no. The six-month rate of expulsion after immediate insertion was higher (5.9%) than the rate after delayed insertion (2.7% [difference, 2.3%, 95% CI −1.0 to 5.8]). However, in this randomized noninferiority trial, this result was consistent with the predefined criterion for noninferiority. Women (n = 575) undergoing uterine aspiration at 5–12 weeks’ gestation who wanted an IUD were randomized to immediate insertion (n = 258) or to delayed insertion ( n = 226) two to six weeks later. They could choose between a copper or a levonorgestrel-releasing IUD. Six-month rates of IUD use were higher in the immediate-insertion group than in the delayed-insertion group (92.3% v. 76.6%, p < 0.001.) Adverse events, such as perforation, infection and incomplete abortion were rare, with similar rates in both groups. See N Engl J Med 2011; 364:2208–17.
Dexamethasone and length of hospital stay in community-acquired pneumonia:
Dexamethasone can reduce the length of a patient’s stay in hospital when added to antibiotic treatment of community-acquired pneumonia. This is the conclusion of a double-blinded randomized trial of 304 nonimmunocompromised patients with community-acquired pneumonia presenting to two emergency departments in the Netherlands. Participants were randomized to intravenous dexamethasone (5 mg/d) or placebo for four days after admission. The median length of stay was 6.5 days in the steroid group compared with 7.5 days in the placebo group (95% CI of difference in medians 0 to 2 days, p = 0.0478) Secondary outcome measures, such as hospital mortality and rates of admission to intensive-care units, pleural effusion or empyema were similar in both groups. However, more patients (44.3%, 67 of 151) in the steroid group had hyperglycemia compared with the control group (23.1%, 35 of 151). The benefit of a reduced stay in hospital by a day needs to be balanced against the harms of using steroids. See Lancet 2011. DOI:10.1016/S0140-6736(11)60607-7.
Does interhospital transfer affect time to reperfusion in myocardial infarction?:
Patients with ST-elevation myocardial infarction (STEMI) requiring interhospital transfer for primary percutaneous coronary intervention (PCI) who had a quick turnaround (≤ 30 min) in the referring hospital had shorter times to reperfusion and lower in-hospital mortality than those experiencing delays. A retrospective cohort study of over 14 800 patients with STEMI found that the median “door-in to door-out” time at the first hospital was 68 minutes, and only 11% of patients had a turnaround of 30 minutes or less. Patients who had a quick turnaround in the referring hospital were significantly more likely to have their PCI in 90 minutes or less after initial assessment than those with a turnaround of more than 30 minutes (60% v. 13%, p < 0.001). In-hospital mortality was higher (5.9% v. 1.9%, p < 0.001) among those who experienced delays. About one-third of patients spent more than 90 minutes in the referring hospital. Those experiencing delays were more likely to be older, female and have comorbidities, such as diabetes or chronic lung disease. See JAMA 2011;305:2540–7.
Preventing falls in older people with foot pain:
A multifaceted podiatry intervention is effective in preventing falls in older community-dwelling adults with disabling foot pain. One in three people aged 65 years or older fall each year, and foot problems have been associated with falls. In this randomized study of 305 older men and women with disabling foot pain and an increased risk of falling, half were allocated to a podiatry intervention that included prefabricated foot orthoses, advice on and subsidy for footwear, a home-based foot and ankle exercise program, and an educational booklet on fall prevention. Both groups received routine podiatry care for 12 months. After one year, there were 36% fewer falls in the intervention group than in the control group (incidence rate ratio 0.64, 95% CI 0.45 to 0.91, p = 0.01), even though the proportion of those who fell was similar between the two groups. Participants in the intervention group were significantly stronger and had better balance by the end of the study, but only about half regularly wore their orthoses and did their exercises. Because the intervention is not expensive and is relatively simple to implement, the authors suggest that the program could be incorporated into routine care. See BMJ 2011;342:d3411 doi: 10.1136/bmj.d3411.