Trial of Dexamethasone for Chronic Subdural Hematoma

BACKGROUND: Chronic subdural hematoma is a common neurologic disorder that is especially prevalent among older people. The effect of dexamethasone on outcomes in patients with chronic subdural hematoma has not been well studied. METHODS: We conducted a multicenter, randomized trial in the United Kingdom that enrolled adult patients with symptomatic chronic subdural hematoma. The patients were assigned in a 1:1 ratio to receive a 2-week tapering course of oral dexamethasone, starting at 8 mg twice daily, or placebo. The decision to surgically evacuate the hematoma was made by the treating clinician. The primary outcome was a score of 0 to 3, representing a favorable outcome, on the modified Rankin scale at 6 months after randomization; scores range from 0 (no symptoms) to 6 (death). RESULTS: From August 2015 through November 2019, a total of 748 patients were included in the trial after randomization - 375 were assigned to the dexamethasone group and 373 to the placebo group. The mean age of the patients was 74 years, and 94% underwent surgery to evacuate their hematomas during the index admission; 60% in both groups had a score of 1 to 3 on the modified Rankin scale at admission. In a modified intention-to-treat analysis that excluded the patients who withdrew consent for participation in the trial or who were lost to follow-up, leaving a total of 680 patients, a favorable outcome was reported in 286 of 341 patients (83.9%) in the dexamethasone group and in 306 of 339 patients (90.3%) in the placebo group (difference, -6.4 percentage points [95% confidence interval, -11.4 to -1.4] in favor of the placebo group; P = 0.01). Among the patients with available data, repeat surgery for recurrence of the hematoma was performed in 6 of 349 patients (1.7%) in the dexamethasone group and in 25 of 350 patients (7.1%) in the placebo group. More adverse events occurred in the dexamethasone group than in the placebo group. CONCLUSIONS: Among adults with symptomatic chronic subdural hematoma, most of whom had undergone surgery to remove their hematomas during the index admission, treatment with dexamethasone resulted in fewer favorable outcomes and more adverse events than placebo at 6 months, but fewer repeat operations were performed in the dexamethasone group. (Funded by the National Institute for Health Research Health Technology Assessment Programme; Dex-CSDH ISRCTN number, ISRCTN80782810.)

A population-based study of Kurdish breast cancer in northern Iraq: Hormone receptor and HER2 status. A comparison with Arabic women and United States SEER data

<p>Abstract</p> <p>Background</p> <p>Hormone receptor (HR) and HER2 expression predict the therapeutic response and prognosis of breast cancer. In the Middle-East, breast cancer is diagnosed at a young age, and Arabic women are reported to have a low frequency of HR positive tumors. This study investigates HR and HER2 expression among Kurdish and Arabic women.</p> <p>Methods</p> <p>During 2008–2010, the Sulaimaniyah Directorate of Health records identified 514 Sulaimaniyah Kurdish women, 227 Kurdish women of other Governates, and 83 Arabic women with a first diagnosis of breast cancer. The breast cancers of 432 women had immunohistochemistry (IHC) performed for estrogen and progesterone receptors (ER and PR) and HER2. Age specific and age standardized incidence rates were calculated for Sulaimaniyah Kurds. Results were compared with Egypt and with United States (US) SEER data.</p> <p>Results</p> <p>The median patient age was 46 years and 60.4% were < 50 years old. Tumors of 65.2% of women were ER+/HER2- with the rate increasing to 78.3% in patients ≥ 60 years old in proportions similar to US whites. The total annual age standardized incidence for breast cancer among Sulaimaniyah Kurds was 40.5/100,000 women, a rate similar to Egypt but much lower than the US. By HR/HER2 subtype, the highest age specific incidence rates were 16.4 and 45.4/100,000 for ER+/PR+/HER2- tumors in women < 50 or ≥ 50 years old, respectively (US whites: 37.7 and 226.1/100,000). Tumors of 20.4% of Sulaimaniyah women were HER2+ with annual incidence rates for ER-/PR-/HER2+ tumors of women <50 or ≥ 50 years old being 4.0 and 6.3/100,000 (US whites: 3.2 and 14.4/100,000). No significant differences in ER or HER2 status were found between Kurdish and Arabic patients.</p> <p>Conclusions</p> <p>Compared to the US, low age standardized and age specific breast cancer incidence rates were found in Kurdish women; nevertheless, the proportional expression of HR and HER2 for both Kurds and Arabs was comparable to that of US white women. The great majority of the breast cancer was ER+/HER2- and should respond to anti-estrogen therapy.</p