The diagnosis of colorectal cancer in patients with symptoms: finding a needle in a haystack

Patients often see primary care physicians with symptoms that might signal colorectal cancer but are also common in adults without cancer. Physicians and patients must then make a difficult decision about whether and how aggressively to evaluate the symptom. Favoring referral is that missed diagnoses lead to unnecessary testing, prolonged uncertainty, and continuing symptoms; also, the physician will suffer chagrin. It is not clear that diagnostic delay leads to progression to a more advanced stage. Against referral is that proper evaluation includes colonoscopy, with attendant inconvenience, discomfort, cost, and risk. The article by Hamilton et al, published this month in BMC Medicine, provides strong estimates of the predictive value of the various symptoms and signs of colorectal cancer and show how much higher predictive values are with increasing age and male sex. Unfortunately, their results also make clear that most colorectal cancers present with symptoms with low predictive values, < 1.2%. Models that include a set of predictive variables, that is, risk factors, age, sex, screening history, and symptoms, have been developed to guide primary prevention and clinical decision-making and are more powerful than individual symptoms and signs alone. Although screening for colorectal cancer is increasing in many countries, cancers will still be found outside screening programs so primary care physicians will remain at the front line in the difficult task of distinguishing everyday symptoms from life-threatening cancer

Neuroplasticity-based technologies and interventions for restoring motor functions in multiple sclerosis

Motor impairments are very common in multiple sclerosis (MS), leading to a reduced Quality of Life and active participation. In the past decades, new insights into the functional reorganization processes that occur after a brain injury have been introduced. Specifically, the motor practice seems to be determinant to induce neuroplastic changes and motor recovery. More recently, these findings have been extended to multiple sclerosis, in particular, it has been hypothesized that disease progression, functional reorganization and disability are mutually related. For this reason, neuroplasticity-based technologies and interventions have been rapidly introduced in MS rehabilitation. Constraint-induced movement therapy (CIMT), robotics and virtual reality training are new rehabilitative interventions that deliver an intensive e task-specific practice, which are two critical factors associated with functional improvements and cortical reorganization. Another promising strategy for enhancing neuroplastic changes is non-invasive brain stimulation that can be used with a priming effect on motor training. The aims of this chapter are to review the evidence of neuroplastic changes in multiple sclerosis and to present technologies and interventions that have been tested in clinical trials