Diana Dawes

IMPACT OF LYMPHOEDEMA ON ARM FUNCTION AND HEALTH-RELATED QUALITY OF LIFE IN WOMEN FOLLOWING BREAST CANCER SURGERY

OBJECTIVE To estimate the extent to which the impairments associated with lymphoedema (volume increase, local oedema and sensory alteration) are linked to arm dysfunction and sub-optimal health-related quality of life. PATIENTS AND METHODS A cross-sectional study, embedded within a pilot for an epidemiologic study, was undertaken involving women who had undergone surgery for unilateral stage I or II breast cancer. Two questionnaires (a lymphoedema screening questionnaire and the Disabilities of Arm, Shoulder and Hand questionnaire) were mailed and 72 of 204 responders reported having one or more symptoms of lymphoedema (prevalence 35%). A total of 50 women with symptoms attended for further testing. RESULTS Women with self-reported symptoms of lymphoedema had a significantly higher score on the Disabilities of Arm, Shoulder and Hand questionnaire (mean difference 23.4, 95% confidence interval 19.3-27.5), indicating activity limitation and participation restriction. Pain was the only impairment directly correlated with activity limitation, participation restriction and sub-optimal health-related quality of life. CONCLUSION These findings have implications for treatment, and the outcome measures used for the assessment of lymph?oedema. Treatments focusing on decreasing arm volume without addressing issues of pain may not result in improvements in activity, participation, or health-related quality of life.

Genotype‐guided drug prescribing: a systematic review and meta‐analysis of randomized control trials

Aim Adverse drug events lead to increased morbidity, mortality and health care costs. Pharmacogenetic testing that guides drug prescribing has the potential to reduced adverse drug events and increase drug effectiveness. Our aim was to quantify the clinical effectiveness of genotype-guided prescribing. Methods Three electronic databases were searched from January 1980 through December 2013. Studies were eligible if they were RCTs comparing genotype-guided prescribing with non-genetic informed prescribing, reported drug specific adverse drug events and clinical effectiveness outcomes. Two reviewers independently screened titles and abstracts, extracted data and assessed study quality. Meta-analyses of specific outcomes were conducted where data allowed. Results Fifteen studies, involving 5688 patients and 19 drugs, met the inclusion and exclusion criteria. Eight studies had statistically significant results for their primary outcome in favour of genotype-guided prescribing. Nine studies evaluated genotype-guided warfarin dosing. Analysis of percentage of time in therapeutic international normalized ratio range (1952 individuals) showed a statistically significant benefit in favour of genotype-guided warfarin dosing (mean difference = 6.67; 95% CI 1.34, 12.0, I2 = 80%). There was a statistically significant reduction in numbers of warfarin-related minor bleeding, major bleeding and thromboembolisms associated with genotype guided warfarin dosing, relative risk 0.57 (95% CI 0.33, 0.99; I2 = 60%). It was not possible to meta-analyze genotype-guided dosing for other drugs. Of the six non-warfarin genotype-guided trials, two demonstrated a statistically significant benefit for their primary outcome, odds ratio 0.03 (95% CI 0.00, 0.62, P < 0.001) for abacavir. Conclusions There is evidence of improved clinical effectiveness associated with genotype-guided warfarin dosing.

Pedometer-facilitated walking intervention shows promising effectiveness for reducing cancer fatigue: a pilot randomized trial:

Objective: Mechanisms for cancer related fatigue suggest that exercise but “not too much and not too little” could be effective. This study aimed to investigate feasibility and estimate the potential effects of a walking exercise program in people with advanced cancer and fatigue. Design: A pilot randomized trial. Setting: McGill University Health Centre (MUHC), Montreal, Canada. Subjects: People with advanced cancer undergoing interdisciplinary assessment and rehabilitation with a fatigue level of 4 to 10 on a visual analogue scale. Interventions: An 8-week fatigue-adapted, walking intervention, facilitated using a pedometer (STEPS), and offered at the same time as or after rehabilitation. Measures: Measures of fatigue, physical function and well-being were administered at entry, and 8, 16 and 24 weeks. Generalized estimating equations (GEE) estimated the odds of response for people receiving the STEPS program in comparison to the odds of response in the controls (odds ratio, OR). Results: Twenty-six persons were randomized to three groups: during rehabilitation, after rehabilitation, and usual care. For the fatigue measures the OR for STEPS offered at any time using an intention-to-treat approach was 3.68 (95%CI: 1.05-12.88); for the physical function measures, the OR was 1.40 (95%CI: 0.41- 4.79) and 2.36 (95%CI: 0.66-8.51) for the well-being measures. Conclusion: Fifty percent of eligible people were able to participate. This small trial suggests that a personalized exercise program reduces fatigue and that 100 people are needed in a full strength trial.

Program evaluation of a model to integrate internationally educated health professionals into clinical practice

BackgroundThe demand for health professionals continues to increase, partially due to the aging population and the high proportion of practitioners nearing retirement. The University of British Columbia (UBC) has developed a program to address this demand, by providing support for internationally trained Physiotherapists in their preparation for taking the National Physiotherapy competency examinations.The aim was to create a program comprised of the educational tools and infrastructure to support internationally educated physiotherapists (IEPs) in their preparation for entry to practice in Canada and, to improve their pass rate on the national competency examination.MethodsThe program was developed using a logic model and evaluated using program evaluation methodology. Program tools and resources included educational modules and curricular packages which were developed and refined based on feedback from clinical experts, IEPs and clinical physical therapy mentors. An examination bank was created and used to include test-enhanced education. Clinical mentors were recruited and trained to provide clinical and cultural support for participants.ResultsThe IEP program has recruited 124 IEPs, with 69 now integrated into the Canadian physiotherapy workforce, and more IEPs continuing to apply to the program. International graduates who participated in the program had an improved pass rate on the national Physiotherapy Competency Examination (PCE); participation in the program resulted in them having a 28% (95% CI, 2% to 59%) greater possibility of passing the written section than their counterparts who did not take the program. In 2010, 81% of all IEP candidates who completed the UBC program passed the written component, and 82% passed the clinical component.ConclusionThe program has proven to be successful and sustainable. This program model could be replicated to support the successful integration of other international health professionals into the workforce.

Evaluation of buccal swabs for pharmacogenetics

ObjectiveA simple, non-invasive sample collection method is key for the integration of pharmacogenetics into clinical practice. The aim of this study was to gain samples for pharmacogenetic testing and evaluate the variation between dry-flocked and sponge-tipped buccal swabs in yield and quality of DNA isolated.ResultsThirty-one participants collected samples using dry-flocked swabs and sponge-tipped swabs. Samples were assessed for DNA yield, quality and genotyping performance on a qPCR OpenArray platform of 28 pharmacogenetic SNPs and a CYP2D6 TaqMan copy number variant. DNA from sponge-tipped swabs had a significantly greater yield compared to DNA collected with dry-flocked swabs (p = 4.4 × 10−7). Moreover, highest genotyping call rates across all assays and highest CNV confidence scores were observed in DNA samples collected from sponge-tipped swabs (97% vs. 54% dry-flocked swabs; 0.99 vs. 0.88 dry-flocked swabs, respectively). Sample collection using sponge-tipped swabs provides a DNA source of sufficient quantity and quality for pharmacogenetic variant detection using qPCR.