Unmasking the Struggle: A Scoping Review Exploring Post-Traumatic Stress Symptoms in Caregivers of Individuals with Neurodevelopmental, Psychiatric and Neurocognitive Disorders

The impact of caregiving on caregivers' mental health is typically considered within the caregiver stress and burden literature; however, more recently, research has investigated the experience of post-traumatic stress symptoms (PTSS) in caregivers. As an emerging area of research, it is timely to conduct a scoping review to map the existing literature in relation to PTSS among adult caregivers of children and adults with neurodevelopmental disorders (NDD), neurocognitive disorders, and psychiatric disorders. The scoping review was conducted using Preferred Reporting Items of Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guidelines and Arksey and O'Malley's five-stage methodology framework. Published and unpublished gray literature between 2005 and 2022 was included in the scoping review. Nine thousand one hundred and twenty-five studies were originally identified for screening and 22 studies were selected for inclusion in the final review. Trauma and PTSS experienced by NDD caregivers were related to news breaking, NDD diagnosis, and behavioral issues, whereas caregivers of individuals with psychosis reported aggression and violence as traumatic events. Studies showed that up to half of caregivers reported PTSS, although no conclusions could be drawn about prevalence rates. A wide variety of tools measuring PTSS were used across the 22 studies. Many symptoms of PTSS were reported by caregivers, and cognitive appraisals were associated with PTSS in caregivers. The findings highlight the importance of recognizing the impact of trauma in caregiver mental health and the potential value of using traumatic stress frameworks with these populations. Research should be expanded to establish prevalence rates and to examine the long-term impact of trauma on caregiving as caregivers and care recipients age.

Comprehensive whole-genome sequence analyses provide insights into the genomic architecture of cerebral palsy

We performed whole-genome sequencing (WGS) in 327 children with cerebral palsy (CP) and their biological parents. We classified 37 of 327 (11.3%) children as having pathogenic/likely pathogenic (P/LP) variants and 58 of 327 (17.7%) as having variants of uncertain significance. Multiple classes of P/LP variants included single-nucleotide variants (SNVs)/indels (6.7%), copy number variations (3.4%) and mitochondrial mutations (1.5%). The COL4A1 gene had the most P/LP SNVs. We also analyzed two pediatric control cohorts (n = 203 trios and n = 89 sib-pair families) to provide a baseline for de novo mutation rates and genetic burden analyses, the latter of which demonstrated associations between de novo deleterious variants and genes related to the nervous system. An enrichment analysis revealed previously undescribed plausible candidate CP genes (SMOC1, KDM5B, BCL11A and CYP51A1). A multifactorial CP risk profile and substantial presence of P/LP variants combine to support WGS in the diagnostic work-up across all CP and related phenotypes.

Management of Malignant Bowel Obstruction: An Innovative Proactive Outpatient Nurse-Led Model of Care for Patients With Advanced Gynecologic Cancer

BACKGROUND

Malignant bowel obstruction (MBO) in patients with advanced gynecologic cancer (GyCa) can negatively impact clinical outcomes and quality of life. Oncology nurses can support these patients with adequate tools/processes.

PROBLEM

Patients with GyCa with/at risk of MBO endure frequent emergency or hospital admissions, impacting patient care.

APPROACH

Optimizing oncology nurses' role to improve care for patients with GyCa with/at risk of MBO, the gynecology oncology interprofessional team collaborated to develop a proactive outpatient nurse-led MBO model of care (MOC).

OUTCOMES

The MBO MOC involves a risk-based algorithm engaging interdisciplinary care, utilizing standardized tools, risk-based assessment, management, and education for patients and nurses. The MOC has improved patient-reported confidence level of bowel self-management and decreased hospitalization. Following education, nurses demonstrated increased knowledge in MBO management.

CONCLUSIONS

An outpatient nurse-led MBO MOC can improve patient care and may be extended to other cancer centers, fostering collaboration and best practice.

341 Is CT Imaging Mandated for Confirming the Diagnosis of Acute Appendicitis in Patients Over the Age of 40?

Aim

Acute appendicitis remains a largely clinical diagnosis, with clinical scoring systems such as the Alvarado score calculated to give a quantitative assessment of the diagnostic probability. It remains common practice amongst surgeons to rely on CT scanning to confirm the diagnosis however, especially in older patients. Our aim was to assess the diagnostic performance of CT scanning compared with that of the Alvarado score in patients aged over 40 years old.

Method

We conducted a retrospective observational study of 149 patients greater than 40 years old who had a diagnosis of acute appendicitis and had undergone an appendicectomy with subsequent histological analysis. Data was extracted from patients’ electronic medical records. This was recorded in Microsoft Excel and analysed using NCSS.

Results

When using an Alvarado score cut-off point of ≥7, the sensitivity and specificity were 44.1% and 60.0% respectively. The sensitivity of the test improved to 80.3% when using a cut-off point of ≥ 5, however the specificity decreased to 50%. The accuracy improved to 78.1% from 45.3%, when using ≥ 5 as a cut-off point. On the other hand, the sensitivity of the CT scan was 84.9% and the specificity was 45.5%. The accuracy of CT scanning was 81.8%.

Conclusions

When comparing performance, pre-operative CT scanning did not show a statistically significant improvement in the diagnosis of acute appendicitis relative to Alvarado score. We recommend using an Alvarado score cut-off point of ≥ 5 to aid in diagnosing appendicitis in patients older than 40, as it accounts for a higher sensitivity.

809 USE OF NEW MOBILITY SCORE AND A TRANS-DISCIPLINARY APPROACH TO REDUCE HOSPITAL LOS, RETURN TO ORIGINAL RESIDENCE, AND MORTALITY

Introduction

The National Hip Fracture Database indicated Guy’s and St Thomas’ Trust ranked in the fourth quartile nationally with reference to hospital length of stay (LOS), return to original residence (ROR), and mortality in hip fracture patients in 2018. This quality improvement project aimed to improve and maintain these key factors via a two-stage process.

Methods

Stage one involved implementation of four key interventions through a trans-disciplinary focus group, comprising ortho-geriatricians, orthopaedic surgeons, physiotherapists (PT), occupational therapists (OT), nursing staff, and a transfer of care navigator (TCN). Firstly, the New Mobility Score (NMS) was employed as a tool to guide estimated length of stay. Secondly, use of preoperative OT assessment allowed early evaluation of patient expectations concerning discharge planning. Third, facilitation of the discharge process was optimised by the recruitment of a TCN. Lastly, attendance of a senior orthogeriatrician during the daily board round was established. Stage two involved education of new members of the trans-disciplinary team to ensure that the key interventions listed above were maintained on hip fracture patients.

Results

Following stage one, average acute hospital LOS and overall LOS decreased from 20.1 to 15.1 days and 22.4 to 18.3 days, respectively. Rate of ROR within 120 days of discharge improved from 72.4% to 86.9%, while mortality rates fell from 7.1 to 3.4. Following stage two, overall LOS improved to 17.1 days, while acute LOS and mortality were maintained at 15.6 and 3.9 days, respectively. While ROR fell to 82.8%, this remained higher than the national average at 69.9%.

Conclusions

Utilisation of NMS and multi-disciplinary input effectively improved ROR, while reducing length of hospital stay and mortality rates in hip fracture patients. Education of new members of the trans-disciplinary team allowed sustained improvement despite challenges faced during the COVID-19 pandemic.

Epilepsy in children with cerebral palsy: a data linkage study

AIM

To compare the prevalence of epilepsy in children with cerebral palsy (CP) to peer controls and their differences in healthcare utilization.

METHOD

The Quebec CP registry was linked to the provincial administrative health database. Two CP cohorts were identified from the registry (n=302, 168 males, 1y 2mo-14y) and administrative data (n=370, 221 males, 2y 2mo-14y). A control cohort (n=6040, 3340 males, 10-14y) was matched by age, sex, and region to the CP registry cohort. Administrative data algorithms were used to define epilepsy cases. Data on hospitalizations and emergency department presentations were obtained.

RESULTS

Using the most sensitive epilepsy definition, prevalence was 42.05% in the CP registry, 43.24% in the CP administrative data, and 1.39% in controls. Prevalence rose with increasing Gross Motor Function Classification System level. Children with CP and epilepsy had increased number and length of hospitalizations and emergency department presentations compared to children with CP or epilepsy alone. Epilepsy accounted for approximately 5% of emergency department presentations and 10% of hospitalizations in children with epilepsy, with and without CP.

INTERPRETATION

Children with CP have an increased risk of epilepsy compared to their peers. Children with CP and coexisting epilepsy represent a unique subset with complex developmental disability and increased healthcare service utilization.

Interobserver Reliability for Identifying Specific Patterns of Placental Injury as Defined by the Amsterdam Classification

CONTEXT.—

Placental pathology is an essential tool for understanding neonatal illness. The recent Amsterdam international consensus has standardized criteria and terminology, providing harmonized data for research and clinical care.

OBJECTIVE.—

To evaluate the interobserver reliability of these criteria between pathologists at different levels of experience using digitally scanned slides from placentas in a birth population including a large proportion of normal deliveries.

DESIGN.—

This was a secondary analysis of selected placentas from a large case-control study of placental lesions associated with neonatal encephalopathy. Histologic slides from 80 placentas were digitally scanned and blindly evaluated by 6 pathologists. Interobserver reliability was assessed by positive and negative agreement, Fleiss κ, and interrater correlation coefficients.

RESULTS.—

Overall agreement on the diagnosis, grading, and staging of acute chorioamnionitis and villitis of unknown etiology was moderate to good for all observers and good to excellent for a subset of 4 observers. Agreement on the diagnosis and subtyping of fetal vascular malperfusion was poor to fair for all observers and fair to moderate for the subset of 4 pathologists. Agreement on accelerated villous maturation was poor.

CONCLUSIONS.—

This study critically evaluates interobserver reliability for lesions defined by the Amsterdam consensus using scanned images with a low frequency of pathologic lesions. Although reliability was good to excellent for inflammatory lesions, lower reliability for vascular lesions emphasizes the need to more explicitly define the specific histologic features and boundaries for these patterns.

Significantly Minimizing Drug Wastage and the Cost of Cabazitaxel Used to Treat Metastatic Castration-Resistant Prostate Cancer

Cabazitaxel is used to treat patients with metastatic castration-resistant prostate cancer progressing after docetaxel. It is prepackaged in 60 mg single-dose vials, a quantity much higher than the average prescribed dose, which leads to, substantial drug wastage (DW) and associated costs. To minimize DW we implemented a cost-saving, cohorting strategy where multiple patients scheduled to receive cabazitaxel (at a dose of 20mg/m² every 3 wks) were cohorted and treated on a single weekday whenever possible. Excess drug from each vial was then saved and used for subsequent patients treated on the same day. The drug cost with cohorting was calculated from the actual number of vials used, and the drug cost without cohorting was estimated by assumingthat one vial was used per treatment. The cost of DW was determined based on the amount of drug that was discarded. All cost calculations also accounted for the discount incentives offered by Sanofi-Aventis. Over a 3-yr period, 74 patients received 402 treatments of cabazitaxel. Multiple patients were treated on 67.4% of the treatment days, and grouping of three patients on one day saved one vial. The estimated total drug cost saved was $394 536 CAD (21.1%). Pending further studies on safety and efficacy, this strategy could potentially be adopted to mitigate DW for cabazitaxel and similarly for other oncology drugs. This would significantly decrease the overall financial burden on patients, institutions, and stakeholders. PATIENT SUMMARY: Cabazitaxel chemotherapy is associated with substantial drug wastage and associated costs. By cohorting patients scheduled to receive cabazitaxel on a single weekday, the total drug cost was decreased by $394 536 CAD (21.1%) over a 3-yr period. Similar strategies could be considered to overcome the prohibitory costs associated with drug wastage for cabazitaxel and other cancer drugs.

Congenital Malformations in Children With Cerebral Palsy: Is Prematurity Protective?

BACKGROUND

Congenital malformations are more common in children who are born prematurely, and prematurity is the leading risk factor for cerebral palsy. The primary objective of this study was to describe the profile of congenital malformations in a Canadian cohort of children with cerebral palsy. The secondary objectives were to compare the profiles of children with cerebral palsy with and without a congenital malformation and explore the possible role of prematurity.

METHODS

This retrospective cohort study utilized data from the Canadian Cerebral Palsy Registry, a population based registry of children with a confirmed diagnosis of cerebral palsy. Differences between groups were compared using Pearson's chi-square and Student t test as appropriate. Odds ratios and 95% confidence intervals were calculated RESULTS: Congenital malformations were present in 23% participants. In term-born children, brain malformations were the most common, whereas heart and gastrointestinal malformations were more common in children born prematurely. Children with a malformation had higher odds of being born at term (odds ratio 1.57, 95% confidence interval 1.20 to 2.04); having hypotonic, ataxic, or dyskinetic cerebral palsy (odds ratio 1.92, 95% confidence interval 1.35 to 2.72; being nonambulatory (odds ratio 1.70, 95% confidence interval 1.29 to 2.25); and having cerebral palsy-associated comorbidities.

CONCLUSIONS

One in four children with cerebral palsy have an associated congenital malformation. Their profile of term birth, higher Apgar scores, and lower frequency of perinatal seizures suggests a distinct causal pathway.

Reducing dexamethasone antiemetic prophylaxis during the COVID-19 pandemic: recommendations from Ontario, Canada

Purpose

People with cancer face an elevated risk of infection and severe sequelae from COVID-19. Dexamethasone is commonly used for antiemetic prophylaxis with systemic therapy for cancer. However, dexamethasone is associated with increased risk of viral and respiratory infections, and causes lymphopenia, which is associated with worse outcomes during COVID-19 infections. Our purpose was to minimize dexamethasone exposure during antiemetic prophylaxis for systemic therapy for solid tumors during the COVID-19 pandemic, while maintaining control of nausea and emesis.

Methods

We convened an expert panel to systematically review the literature and formulate consensus recommendations.

Results

No studies considered the impact of dexamethasone-based antiemetic regimens on the risk and severity of COVID-19 infection. Expert consensus recommended modifications to the 2019 Cancer Care Ontario Antiemetic Recommendations.

Conclusion

Clinicians should prescribe the minimally effective dose of dexamethasone for antiemetic prophylaxis. Single-day dexamethasone dosing is recommended over multi-day dosing for regimens with high emetogenic risk excluding high-dose cisplatin, preferably in combination with palonosetron, netupitant, and olanzapine. For regimens with low emetogenic risk, 5-HT₃ antagonists are recommended over dexamethasone.

Acute kidney injury associated with immune checkpoint inhibitor therapy: incidence, risk factors and outcomes

BACKGROUND

Immune checkpoint inhibitors (ICPi) are a novel and promising anti-cancer therapy. There are limited data on the incidence, risk factors and outcomes of acute kidney injury (AKI) in patients receiving ICPi.

METHODS

We conducted a cohort study of patients receiving ICPi at our center between 2010 and 2017 via electronic health record. The primary outcome was AKI (increase of >50% from baseline serum creatinine (sCr)). Risk factors for AKI were assessed using logistic regression. Survival among those with and without AKI was compared using the Kaplan-Meier method.

RESULTS

Among 309 patients on ICPi, 51 (16.5%) developed AKI (Kidney Disease Improving Global Outcomes (KDIGO) stages 1: 53%, 2: 22%, 3: 25%). AKI was associated with other immune-related adverse events (IRAE) (OR 3.2, 95% CI 1.6 to 6; p<0.001), hypertension (OR 4.3, 95% CI 1.8 to 6.1; p<0.001) and cerebrovascular disease (OR 9.2; 95% CI 2.1 to 40; p<0.001). Baseline sCr, cancer, and ICPi type was not associated with AKI. Use of angiotensin-converting enzyme inhibitors/angiotensin-receptor blockers (OR 2.9; 95% CI 1.5 to 5.7; p=0.002), diuretics (OR 4.3; 95% CI 1.9 to 9.8; p<0.001), and corticosteroid treatment (OR 1.9; 95% CI 1.1 to 3.6; p=0.03) were associated with AKI. In the multivariable analysis, AKI was associated only with other IRAE (OR 2.82; 95% CI 1.45 to 5.48; p=0.002) and hypertension (OR 2.96; 95% CI 1.33 to 6.59; p=0.008). AKI was not associated with increased risk of mortality (HR 1.1; 95% CI: 0.8 to 1.6; p=0.67). ICPi nephrotoxicity was attributed via biopsy or nephrologist assessment in 12 patients (six interstitial nephritis, two membranous nephropathy, two minimal change disease, and two thrombotic microangiopathy). Subsequent doses of ICPi were administered to 12 patients with prior AKI, with one (8.3%) having recurrent AKI.

CONCLUSION

AKI is a common complication in patients receiving ICPi treatment. The development of other IRAE and previous diagnosis of hypertension were associated with increased AKI risk. AKI was not associated with worse survival. Distinguishing kidney IRAE from other causes of AKI will present a frequent challenge to oncology and nephrology practitioners. Kidney biopsy should be considered to characterize kidney lesions and guide potential therapy.

Safety of two-hour intermittent intravenous infusions of tacrolimus in the allogeneic hematopoietic stem cell transplantation unit

At our institution, tacrolimus is used as a second-line agent for the prevention and treatment of graft-versus-host-disease in the allogeneic hematopoietic stem cell transplantation (HSCT) unit after patients have experienced a serious or intolerable adverse event to cyclosporine. As per our standard practice, tacrolimus is administered via 2-h intermittent IV infusions (IIVs) every 12 h rather than continuous IV infusion. Shorter infusion times are cautioned due to concerns of higher rates of nephrotoxicity, neurotoxicity and infusion-related reactions, although there is a paucity of data to support this claim. Our primary objective was to evaluate the safety of a 2-h IIV of tacrolimus in an adult HSCT population. We retrospectively reviewed the charts of 104 patients who received tacrolimus by IIV (3574 doses; median = 22, range 1-158, IQR = 28) from 2002 to 2016. Primary outcomes collected include rates of nephrotoxicity, neurotoxicity and infusion-related reactions. One (0.9%) grade 2 infusion-related reaction occurred and resolved without discontinuation of tacrolimus. Of 16 incidences (13.6%) of nephrotoxicity, all but 10 (8.5%) cases resolved. Precipitating factors for nephrotoxicity unrelated to tacrolimus were identified in all 10 cases. There were 41 incidences (35%) of neurotoxicity, of which, 8 (6.8%) were considered serious. All neurotoxicity reverted to baseline or resolved completely. We propose that a 2-h IIV of tacrolimus is a safe method of administration in the adult HSCT setting.

480 Successful anticoagulation treatment of an ascending aortic thrombus associated with myocardial infarction and systemic embolism

Background

The ascending aorta is an uncommon site for non-infective mural thrombus. The detection of such a thrombus is of particular importance, given the risk of systemic and coronary embolisation. We present a case of a 60-year-old female with an ascending aortic thrombus complicated by non-ST-elevation myocardial infarction (NSTEMI), and associated systemic embolism in the form of renal and splenic infarcts.

Case Report

A 60-year-old female was admitted to a local secondary hospital with a 4-day history of crampy abdominal pain and intermittent bilateral arm pain associated with nausea and vomiting. Past medical history included known hypertrophic cardiomyopathy, gastroesophageal reflux disease, carpal tunnel syndrome, hepatic steatosis, but no known thrombophilia or coronary artery disease. Computer tomography (CT) scan of the abdomen revealed subacute infarction of the right kidney and spleen in keeping with a thrombo-embolic event. A CT pulmonary angiogram revealed a small pulmonary embolus in the right lower lobe. Troponin I level was elevated at 11 mg/L (normal &lt;0.04 mg/L). She was treated with aspirin, clopidogrel and therapeutic enoxaparin for a NSTEMI, and transferred to a metropolitan tertiary centre for ongoing investigation. A transthoracic echocardiogram performed showed known hypertrophic cardiomyopathy, but negative for intracardiac shunting via bubble study. Coronary angiography revealed an acutely occluded distal left anterior descending (LAD) artery with no collaterals, and mild irregularities in all other coronary arteries. A transoesophageal echocardiogram performed to exclude any intracardiac sources of emboli showed a pedunculated and mobile non-calcific mass measuring 1.0cm X 0.5cm in the posterior aspect of the ascending aorta, associated with atheroma in the aortic arch. A laboratory workup for antiphospholipid syndrome, antithrombin III, protein S and protein C deficiency were negative.

After discussion with the multidisciplinary Heart team, the consensus was that the aortic mass was likely thrombus formation relating to erosion of aortic atheroma. It was hypothesised that this may have resulted in distal embolisation to the left kidney and spleen, and possibly also caused embolisation to the LAD artery, although the cause of the pulmonary embolism was still unknown. The patient was then discharged on rivaroxaban and aspirin.

A repeat transoesophageal echocardiogram was performed 4 months after discharge to assess the ascending aortic mass. It showed complete resolution of the mass in the ascending aorta, with no change in any other cardiac structures.

Discussion

Although thrombus formation is uncommon in the ascending aorta, certain conditions, such as pregnancy and thrombophilia increase its risk. Several case reports of ascending aortic thrombus were found in the literature, but this will be the first to report complete resolution with treatment using a direct oral anticoagulant.

Abstract 480 Figure. Ascending Aortic Thrombus + Resolution

Optimizing the Care of Malignant Bowel Obstruction in Patients With Advanced Gynecologic Cancer

PURPOSE:

Malignant bowel obstruction (MBO) is a common and distressing complication in women with advanced gynecologic cancer. A pilot, interprofessional MBO program was launched in 2016 at a large Canadian tertiary cancer center to integrate these patients’ complex care needs across multiple disciplines and support women with MBO.

METHOD:

Retrospective analysis to evaluate the outcomes of women with advanced gynecologic cancer who were admitted to hospital because of MBO, before (2014 to 2016: baseline group) and after (2016 to 2018) implementation of the MBO program.

RESULTS:

Of the 169 women evaluated, 106 and 63 were in the baseline group and MBO program group, respectively. Most had ovarian cancer (n = 124; 73%) and had small-bowel obstruction (n = 131; 78%). There was a significantly shorter cumulative hospital length of stay (LOS_sum) within the first 60 days of MBO diagnosis in the MBO program group compared with the baseline group (13 v 22 days, respectively; adjusted P = .006). The median overall survival for women treated in the MBO program was also significantly longer compared with the baseline group (243 v 99 days, respectively; adjusted P = .002). Using the interprofessional MBO care platform, a greater proportion of patients received palliative chemotherapy (83% v 56%) and less surgery (11% v 21%) in the MBO program group than in the baseline group, respectively. A subgroup of women (n = 11) received total parenteral nutrition for longer than 6 months.

CONCLUSION:

Implementation of a comprehensive, interprofessional MBO program significantly affects patient care and may improve outcomes. Unique to this MBO program is an integrated outpatient model of care and education that empowers patients to recognize MBO symptoms for early intervention.

Ataxic-hypotonic cerebral palsy in a cerebral palsy registry: Insights into a distinct subtype

Objective

To specifically report on ataxic-hypotonic cerebral palsy (CP) using registry data and to directly compare its features with other CP subtypes.

Methods

Data on prenatal, perinatal, and neonatal characteristics and gross motor function (Gross Motor Function Classification System [GMFCS]) and comorbidities in 35 children with ataxic-hypotonic CP were extracted from the Canadian Cerebral Palsy Registry and compared with 1,804 patients with other subtypes of CP.

Results

Perinatal adversity was detected significantly more frequently in other subtypes of CP (odds ratio [OR] 4.3, 95% confidence interval [CI] 1.5-11.7). The gestational age at birth was higher in ataxic-hypotonic CP (median 39.0 weeks vs 37.0 weeks, p = 0.027). Children with ataxic-hypotonic CP displayed more intrauterine growth restriction (OR 2.6, 95% CI 1.0-6.8) and congenital malformation (OR 2.4, 95% CI 1.2-4.8). MRI was more likely to be either normal (OR 3.8, 95% CI 1.4-10.5) or to show a cerebral malformation (OR 4.2, 95% CI 1.5-11.9) in ataxic-hypotonic CP. There was no significant difference in terms of GMFCS or the presence of comorbidities, except for more frequent communication impairment in ataxic-hypotonic CP (OR 4.2, 95% CI 1.5-11.6).

Conclusions

Our results suggest a predominantly genetic or prenatal etiology for ataxic-hypotonic CP and imply that a diagnosis of ataxic-hypotonic CP does not impart a worse prognosis with respect to comorbidities or functional impairment. This study contributes toward a better understanding of ataxic-hypotonic CP as a distinct nosologic entity within the spectrum of CP with its own pathogenesis, risk factors, clinical profile, and prognosis compared with other CP subtypes.

Is Cerebral Palsy Changing in High Resource Settings? Data From the Quebec Cerebral Palsy Registry

Advances in maternal and perinatal care in developed countries have led to improved health outcomes for children. These changes may have impacted the profile of children with a cerebral palsy (CP) and groups at risk for CP over time. Using data from the Canadian CP Registry, the objectives of this retrospective cohort study were to describe the profile of children with CP in Quebec born between 1999 and 2010 and identify possible temporal variation in CP risk factors and phenotypic profile. Our sample consisted of 662 children with CP in Quebec. No change in profile or associated risk factors was observed across the birth cohorts 1999 to 2010. Prematurity remains the largest risk factor for CP in Quebec, and children with CP have multiple comorbidities that contribute to overall CP burden. CP registries offer a unique platform to study spectrum disorders and their longitudinal changes over time.

Minimizing drug wastage (DW) and cost of cabazitaxel used to treat metastatic castrate-resistant prostate cancer (mCRPC)

6550

Background: Cabazitaxel is indicated for mCRPC, but is associated with substantial DW and financial strain on hospital budgets. It is only available in single-dose 60mg vials and has short reconstituted drug stability of < 24 hours. We aimed to determine feasibility and cost savings of an aggressive batching strategy to facilitate vial sharing of Cabazitaxel. Methods: Our mitigation strategy was to administer Cabazitaxel 20mg/m2 q3-weekly (without prophylactic G-CSF) on a single weekday whenever possible. Drug was prepared after patient (pt) arrival. Remaining amount from each vial was saved for subsequent pts on the same day. Amount administered, discarded and number of (#) vials used were obtained from pharmacy records. We estimated drug cost without batching by assigning 1 vial/treatment, and drug cost with batching from the actual # vials used. Cost of DW was determined from the amount discarded. All cost calculations were based on market price ($96.7CAD/mg) accounting for Sanofi’s discount incentive (5 vials for the price of 4), allowing a real-world cost assessment. Results: Between 09/2015 and 09/2018, 74 pts received 404 Cabazitaxel treatments on 164 days using 319 vials. Multiple pts were batched on 68% treatment days. Every 3 pts batched saved 1 vial. Average dose/treatment was 37mg (20-45mg). Among 10 treatment cancellations, prepared drug was administered for subsequent pts in 9 cases. Drug and DW costs over the 3-year period with and without batching are shown in Table. Conclusions: Batching ≥3 pts on a single weekday was feasible and significantly lowered drug cost of Cabazitaxel by reducing wastage. This strategy could help mitigate costs associated with wastage for other oncology drugs. [Table: see text]

Family-centred health care for children with cerebral palsy

AIM

To identify characteristics of young children with cerebral palsy (CP), and intrinsic and extrinsic factors, that may be associated with parental perceptions regarding family-centred health care services.

METHOD

We conducted a cross-sectional study, drawing our sample from the Canadian Cerebral Palsy Registry (CCPR). Parents rated the extent of family-centred care provided by their child's health care teams using the 56-item Measures of Process of Care (MPOC) questionnaire. Environmental and CP phenotypic variables were extracted from the CCPR for group comparisons. Low and high MPOC-56 raters were also compared.

RESULTS

Valid responses were obtained from 282 families (90%). All MPOC-56 subscales were highly rated (median ≥6.0), indicating satisfaction with health care services, with the exception of the Providing General Information subscale (median 4.8, interquartile range 3.2-6.0). Parents from Nova Scotia rated all subscales significantly higher than parents from other regions. CP subtype and severity were not significantly associated with MPOC-56 subscale scores. Higher socio-economic status was associated with lower MPOC-56 subscale scores. Higher paternal educational attainment and household income were significantly associated with lower scores on the Providing General Information and Providing Specific Information about the Child subscales respectively.

INTERPRETATION

Participants affirmed the provision of family-centred services from Canadian pediatric rehabilitation centres. Sociodemographic factors were associated with parental perceptions of family-centred services.

WHAT THIS PAPER ADDS

Sociodemographic factors were associated with parental perceptions of family-centred care. Factors intrinsic to the child's cerebral palsy were not associated with parental perceptions.

The Placenta in Neonatal Encephalopathy: A Case-Control Study

OBJECTIVE

We assessed whether specific histologic placental lesions were associated with risk for neonatal encephalopathy, a strong predictor of death or cerebral palsy.

STUDY DESIGN

Case-control study of singletons with gestational ages ≥35 weeks. Data were abstracted from a prospectively collected database of consecutive births at a hospital in which placental samples from specified sites are collected and stored for all inborn infants. Placentas of infants with neonatal encephalopathy were compared with randomly selected control infants (ratio of 1:3). Placental histologic slides were read by a single experienced perinatal pathologist unaware of case status, using internationally recommended definitions and terminology. Findings were grouped into inflammatory, maternal, or fetal vascular malperfusion (FVM) and other lesions.

RESULTS

Placental samples were available for 73 of 87 (84%) cases and 253 of 261 (97%) controls. Delivery complications and gross placental abnormalities were more common in cases, of whom 4 died. Inflammation and maternal vascular malperfusion did not differ, and findings consistent with global FVM were more frequent in case (20%) than control (7%) placentas (P = .001). There was a trend toward more segmental FVM and high-grade FVM (fetal thrombotic vasculopathy) among cases. Some type of FVM was observed in 24% of placentas with neonatal encephalopathy. In infants with both neonatal encephalopathy and placental FVM, more often than in infants with neonatal encephalopathy without FVM, electronic fetal monitoring tracings were considered possibly or definitely abnormal (P = .028).

CONCLUSIONS

Vascular malperfusion of subacute or chronic origin on the fetal side of the placenta was associated with increased risk of neonatal encephalopathy.

PAEDIATRIC SCHOOL OUTREACH: DEMOGRAPHICS AND CLINICAL NEEDS OF A UNIQUE INNER-CITY STUDENT POPULATION

BACKGROUND

Paediatric School Outreach (PSO) clinic is a school-based health centre housed in a Kindergarten-Grade 8 public school. It serves an inner-city community impacted by the social determinants of health, such as language and income, which are barriers to accessing health care. This clinic focuses on developmental/behavioural, mental health and educational concerns.

OBJECTIVES

To characterize demographics, social determinants of health and some clinical characteristics of patients accessing services at PSO. By gaining a better understanding of the challenges of patients, services may be tailored to better suit patient/family needs.

DESIGN/METHODS

We conducted a retrospective chart review of children enrolled at PSO from November 2015 to March 2017. Data were obtained from demographic questionnaires and the electronic medical record. Analyses were performed in Microsoft Excel and SPSS (version 23) and are primarily descriptive. This work was funded by a faculty of medicine student research program and approved by research ethics boards at our hospital and school board.

RESULTS

138 children, between the ages of 2 and 15 years (average birth year 2008) enrolled at PSO during the study period. 73% were male. 70% of patients were in Grade 1 or above at enrolment. Children tended to be Canadian born to immigrant mothers; 74% of children were born in Canada but only 34% of mothers were also Canadian-born. After Canada, Hungary was the second common maternal place of birth (12%). English was the most common language spoken by patients (71%), followed by Hungarian, Tibetan, Portuguese and Spanish. 58% of patients’ families had a household annual income (HAI) of <$30,000 and 18% a HAI of $30,000–49,999.

84% of 138 patients reported having a family physician. Referrals were made by school support team (54%), teacher (36%) or principal (28%). The common presenting concerns were behaviour (81%), school performance (60%), followed by social communication (51%) and emotional presentation (49%).

Among 132 patients with clinical records, 13% were on any medication at enrolment; and 3% (4/132) on psychostimulants. 14% of patients were started on medication during the study period, most frequently psychostimulants (11%, 15/132).

CONCLUSION

PSO patients are culturally diverse and at least three quarters have HAIs below our city’s median of $65,829 (2015). The majority reported having a family physician but accessed our clinic for educational/behavioural concerns, suggesting PSO may be a stream-lined approach. With knowledge of maternal languages, we can begin to translate questionnaires and clinic materials. Further data analyses will better describe diagnoses and referrals made at the clinic.

A case–control study analyzing mannitol dosing for prevention of cisplatin-induced acute nephrotoxicity

Background

Mannitol is an osmotic diuretic given routinely as part of cisplatin regimens to prevent nephrotoxicity, but there are limited data on the ideal dosage. At our center, three different doses of mannitol are used: 12, 20, and 40 g per cycle for cisplatin doses of ≥50 mg/m2. The primary objective was to determine if variations in mannitol dosing significantly influence the incidence of cisplatin-induced acute nephrotoxicity.

Methods

A case–control study was performed. Electronic records of 1462 consecutive outpatients who received cisplatin at ≥ 50 mg/m2 per cycle between January 2010 and December 2014 were reviewed. Patients experiencing nephrotoxicity of any grade within 30 days of last cisplatin dose, as defined by NCI CTCAE 4.0, were matched to a minimum of two and maximum of five controls based on the following criteria: age ± 5 years, baseline estimated glomerular filtration rate ± 10 ml/min/1.73 m2, cisplatin dose per cycle, and presence of diabetes. Conditional logistic regression was used to identify baseline predictors of cisplatin-induced acute nephrotoxicity.

Results

Of the 1245 included patients, 237 had nephrotoxicity and 1008 were matched controls. Median baseline estimated glomerular filtration rate for cases and controls were 83 and 80 ml/min/1.73 m2, respectively. A total of 3.8% of cases experienced ≥ grade 3 nephrotoxicity. Univariable analysis showed that diabetes, lymphoma, low baseline estimated glomerular filtration rate, and low baseline magnesium level were significantly associated with nephrotoxicity, whereas mannitol dosing did not show any association (odds ratio 1.08; p = 0.29). In multivariable analysis, diabetes and lymphoma retained statistical significance, but baseline estimated glomerular filtration rate and baseline magnesium level showed nonsignificant associations with nephrotoxicity.

Conclusions

Cisplatin-induced acute nephrotoxicity remains common in patients with good baseline renal function despite preventive measures. Diabetes and lymphoma are predictors of nephrotoxicity, whereas mannitol dosing has no significant influence, suggesting that doses may be standardized across cisplatin regimens.

The Association Between Maternal Age and Cerebral Palsy Risk Factors

BACKGROUND

Advanced maternal age is associated with higher frequencies of antenatal and perinatal conditions, as well as a higher risk of cerebral palsy in offspring. We explore the association between maternal age and specific cerebral palsy risk factors.

METHODS

Data were extracted from the Canadian Cerebral Palsy Registry. Maternal age was categorized as ≥35 years of age and less than 20 years of age at the time of birth. Chi-square and multivariate logistic regressions were performed to calculate odds ratios and their 95% confidence intervals.

RESULTS

The final sample consisted of 1391 children with cerebral palsy, with 19% of children having mothers aged 35 or older and 4% of children having mothers below the age of 20. Univariate analyses showed that mothers aged 35 or older were more likely to have gestational diabetes (odds ratio 1.9, 95% confidence interval 1.3 to 2.8), to have a history of miscarriage (odds ratio 1.8, 95% confidence interval 1.3 to 2.4), to have undergone fertility treatments (odds ratio 2.4, 95% confidence interval 1.5 to 3.9), and to have delivered by Caesarean section (odds ratio 1.6, 95% confidence interval 1.2 to 2.2). These findings were supported by multivariate analyses. Children with mothers below the age of 20 were more likely to have a congenital malformation (odds ratio 2.4, 95% confidence interval 1.4 to 4.2), which is also supported by multivariate analysis.

CONCLUSIONS

The risk factor profiles of children with cerebral palsy vary by maternal age. Future studies are warranted to further our understanding of the compound causal pathways leading to cerebral palsy and the observed greater prevalence of cerebral palsy with increasing maternal age.

Neonatal Infection in Children With Cerebral Palsy: A Registry-Based Cohort Study

BACKGROUND

The goal of this study was to explore the association between neonatal infection and outcomes in children with cerebral palsy.

METHODS

We conducted a retrospective cohort study using the Canadian CP Registry. Neonatal infection was defined as meeting one of the following criteria: (1) septicemia, (2) septic shock, or (3) administration of antibiotics for ≥10 days. Phenotypic profiles of children with cerebral palsy with and without an antecedent neonatal infection were compared. Subgroup analysis was performed, stratified by gestational age (term versus preterm).

RESULTS

Of the 1229 registry participants, 505 (41.1%) were preterm, and 192 (15.6%) met the criteria for neonatal infection with 29% of preterm children having a neonatal infection compared with 6.5% in term-born children. Children with prior neonatal infection were more likely to have a white matter injury (odds ratio 2.2, 95% confidence interval 1.5 to 3.2), spastic diplegic neurological subtype (odds ratio 1.6, 95% confidence interval 1.1 to 2.3), and sensorineural auditory impairment (odds ratio 2.1, 95% confidence interval 1.4 to 3.3). Among preterm children, neonatal infection was not associated with a difference in phenotypic profile. Term-born children with neonatal infection were more likely to have spastic triplegia or quadriplegia (odds ratio 2.4, 95% confidence interval 1.3 to 4.3), concomitant white matter and cortical injury (odds ratio 4.1, 95% confidence interval 1.6 to 10.3), and more severe gross motor ability (Gross Motor Function Classification System IV to V) (odds ratio 2.6, 95% confidence interval 1.4 to 4.8) compared with preterm children.

CONCLUSIONS

Findings suggest a role of systemic infection on the developing brain in term-born infants, and the possibility to develop targeted therapeutic and preventive strategies to reduce cerebral palsy morbidity.

A Comparison of Ketoprofen and Diclofenac for Acute Musculoskeletal Pain Relief: a Prospective Randomised Clinical Trial

Objectives

To compare the efficacy and adverse effects of Ketoprofen and Diclofenac in the treatment of acute musculoskeletal pain.

Methods

In a prospective randomised clinical trial, patients admitted to an emergency department with acute musculoskeletal injuries requiring intramuscular (IM) injection for pain treatment were enrolled. The target study patients were Chinese adults who suffered from any musculoskeletal injuries of less than 12 hours. They received either 100 mg of Ketoprofen or 75 mg of Diclofenac. Pain was assessed by a 10-point visual analog score (VAS) and evaluations were performed at 30-minute intervals from treatment. Rescue analgesic was given if insufficient analgesia was achieved by one hour. The outcomes and the adverse effects were recorded.

Results

We recruited 77 cases in the Diclofenac group and 74 cases in the Ketoprofen group. The demographic data with regards to age, sex and patterns of injury were comparable in both groups. Following the administration of treatment, both groups showed highly statistically significant (P<0.001) reduction in pain level at 30-minute and 60-minute intervals. Comparing the mean decrease of pain level, there was no statistically significant difference between the two groups at 30-minute interval (P=0.6) and 60-minute interval (P=0.5). In each group, there was one patient experiencing skin rash after treatment. Four patients in the Ketoprofen group and one in Diclofenac group required rescue medicine. With respect to the number of admission following treatment, there was no statistically significant difference between the two groups.

Conclusions

Ketoprofen and Diclofenac are equally effective and safe in the treatment of acute musculoskeletal pain in Hong Kong Chinese population.

A Study of Orotracheal Intubation in Emergency Departments of Five District Hospitals in Hong Kong

Objective

To study the success rates and complications of orotracheal intubation in emergency departments of five district hospitals in Hong Kong in order to identify ways for improvement.

Method

This was a prospective observational study. The emergency department doctors performing the intubation were asked to complete an intubation study form immediately after the procedure over a period of four months. Data collected included vital signs, experiences of intubators, method of intubation and complications.

Results

A total of 347 cases were collected and 93% of them were non-trauma cases. Fifty-two percent (52%) of the cases were in cardiac arrest before intubation. Rapid sequence intubation (RSI) was applied in 36% of the cases. Junior doctors first intubated about 72% of the patients. Successful intubation was achieved in 1 and 2 attempts in 70% and 89% of the cases respectively. In 10 cases (3%), secondary methods such as laryngeal mask airway, Combitube, Trachlight or cricothyroidotomy were needed. The overall complication rate was 7.8% and the complication rate in the RSI group was 15.3%. The complication rate was even higher (20%) if intubation without medication was used in non-cardiac arrest patients. Significant drop in blood pressure was the most common complication and it could be attributed to the use of midazolam as induction medication. The success rate was found to correlate with the experience of the first intubator (p<0.05) and the laryngeal view (p<0.001). The complication rate increased with repeated attempts (p<0.001) and was higher among junior doctors (p<0.05). Early use of elastic gum bougie was associated with lower complication and higher success rates.

Conclusion

Orotracheal intubation in the emergency department was associated with high complication rate. Many complications came from junior intubators. Hypotension was the most common complication. Potentially avoidable complications may be a result of failure to use RSI in non-cardiac arrest patients and failure to use bougie in cases of poor laryngeal view.

Two Pregnant Women Presenting with Umbilical Cord Prolapse

Cord prolapse is an obstetric emergency as delay in management is associated with significantly increased neonatal morbidity and mortality. If the accident occurred outside the hospital, many babies would be dead or severely asphyxiated upon arrival in the hospital. The role of Accident & Emergency (A&E) department is to arrive at this diagnosis promptly and deliver appropriate intervention. Immediate cesarean delivery is the treatment of choice. The clinical presentations of two cases with umbilical cord prolapse presenting to our A&E department within two weeks were described. The pathophysiology, risk factors, diagnosis, management as well as outcome were discussed.

A Review on the Management of Acute Gastroenteritis in Children

Acute gastroenteritis represents a frequent cause of morbidity among children in Hong Kong. Despite the large number of potential etiologic agents, principles of management of gastroenteritis are uniform and aim to prevent the two major complications - dehydration and malnutrition. A review of the literature was performed. Selected articles were appraised, graded, and synthesised qualitatively. Statements on recommendations were generated. Current evidence emphasises the use of oral rehydration and the early reintroduction of age-appropriate foods. Apart from these two, important aspects of management reviewed included laboratory investigations, role of anti-diarrhoeal agents, and use of antimicrobial agents. Criteria for admission of high-risk children are also addressed.

Novel malignant bowel obstruction (MBO) management program for women with advanced gynecological cancer

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Background: Malignant bowel obstruction (MBO) is a common and challenging clinical predicament in women with advanced gynecological cancers. However, there is a lack of evidence-based guidelines or innovative approaches to improve patient care and quality of life. We implemented an inter-professional MBO management program incorporating a nurse-led ambulatory symptom management algorithm and multidisciplinary care conferences (MCC) as hallmarks of this program. Methods: Princess Margaret Cancer Centre has piloted an inter-professional MBO management program that supports women with advanced gynecological cancers who are at risk of/have developed MBO. The MBO team includes oncologists (medical, surgical, gynecologic and radiation), palliative care physicians, diagnostic and interventional radiologists, home parenteral nutrition physicians, specialized oncology nurses, dietitians, pharmacists and social workers. Complex MBO cases are discussed at regular MCC to derive treatment consensus. A symptom-driven MBO management algorithm has been devised and all patients are educated with a personalized bowel symptom management and dietary plan. For outpatient care, patients with MBO are proactively monitored by our specialized oncology nurses via phone or an eHealth bowel application to facilitate communication of symptoms and early intervention. Access to community services and home palliative care services are utilized to support care at home. All patients are enrolled into a prospective database to assess care impact and quality. Results: A total of 145 patients have been followed through the MBO management program over 12 months. At time of data cutoff, 14 had MBO (3 inpatients and 11 outpatients) and 22 were deemed at risk of MBO. Majority patients are managed as an outpatient and avoided unnecessary emergency department episodes. Detailed methodology and data analyses will be presented. Conclusions: A successful novel MBO program incorporating inter-professional care model and nurse-led ambulatory symptom management algorithm optimizes patient care in this vulnerable population and foster collaboration in implementing best practice clinical processes.

The impact of CT head scans on ED management and length of stay in bizarre behavior patients

METHODS

A 5-year retrospective chart review was conducted at 3 EDs. Inclusion criteria were patients ≥18years old triaged as "mental health - bizarre behavior" (deviation from normal cognitive behaviour with no obvious cause) with a CT head scan ordered in the ED. Exclusion criteria were focal neurologic deficits on exam, alternative medical etiology (i.e. delirium, trauma) and/or pre-existing CNS disease. Clinical, demographic and administrative data were extracted with 10% of charts independently reviewed by an Emergency Physician for inter-rater reliability.

RESULTS

266 cases met study criteria. Population demographics: 49% percent female, average age 51years old, 28% homeless, 58% arrived by police or ambulance. CT head results: 1 (0.4%) case with possible acute findings, 105 (39%) with incidental findings (i.e. cerebral atrophy) that did not impact clinical management. Average time to physician assessment was 1:48 (hour:min) (sd 1:11), time to CT completion was 5:05 (sd 7:28) and an average delay of 3:17 awaiting results. Subgroup analysis revealed a net increase in ED length of stay (ED LOS) of 5:02 from obtaining neuroimaging. 85% of patients were referred to a consultant, 92% were to psychiatry.

CONCLUSIONS

CT head results prolonged ED LOS, delayed patient disposition and did not change the patient's clinical management. A prospective trial for ordering CT head scans in these patients is warranted.

Accuracy of administrative claims data for cerebral palsy diagnosis: a retrospective cohort study

BACKGROUND

Cerebral palsy is the most common cause of childhood physical disability, with multiple associated comorbidities. Administrative claims data provide population-level prevalence estimates for cerebral palsy surveillance; however, their diagnostic accuracy has never been validated in Quebec. This study aimed to assess the accuracy of administrative claims data for the diagnosis of cerebral palsy.

METHODS

We conducted a retrospective cohort study of children with cerebral palsy born between 1999 and 2002 within 6 health administrative regions of Quebec. Provincial cerebral palsy registry data (reference standard) and administrative physician claims were linked. We explored differences between true-positive and false-negative cases using subgroup sensitivity analysis.

RESULTS

A total of 301 children were identified with confirmed cerebral palsy from the provincial registry, for an estimated prevalence of 1.8 (95% confidence interval [CI] 1.6-2.1) per 1000 children 5 years of age. The sensitivity and specificity of administrative claims data for cerebral palsy were 65.5% (95% CI 59.8%-70.8%) and 99.9% (95% CI 99.9%-99.9%), respectively, yielding a prevalence of 2.0 (95% CI 1.9-2.3) per 1000 children 5 years of age. The positive and negative predictive values were 58.8% (95% CI 53.3%-64.1%) and 99.9% (95% CI 99.9%-99.9%), respectively. The κ value was 0.62 (95% CI 0.57-0.67). Administrative claims data were more sensitive for children from rural regions, born preterm, with spastic quadriparesis and with higher levels of motor impairment.

INTERPRETATION

Administrative claims data do not capture the full spectrum of children with cerebral palsy. This suggests the need for a more sensitive case definition and caution when using such data without validation.

Recurrent Body Rash Warranted Second Desensitization With Acyclovir in a Myeloma Patient: A Case Report

A 75-year-old woman developed a moderately severe rash about a week and a half after the start of bortezomib (Btb)-based chemotherapy for IgG lambda multiple myeloma; at the time, she was also receiving acyclovir as antiviral prophylaxis in addition to herpes zoster (HZ) vaccination. HZ reactivation rate is high in Btb recipients; therefore, the timing of antiviral prevention is critical in relation to Btb. Attempts were made to identify the offending agent based on the timing of drugs administered and the appearance of skin lesions in relation to other drugs. Both Btb and acyclovir were potential culprits. However, the timing of rash presented on days 9 - 10 revealed the offending agent when the corticosteroid was weaned off while acyclovir continued. A decision was made to administer acyclovir rapid desensitization program (RDP) for our patient.

Financial Impact of Cancer Drug Wastage and Potential Cost Savings From Mitigation Strategies

Purpose:

Cancer drug wastage occurs when a parenteral drug within a fixed vial is not administered fully to a patient. This study investigated the extent of drug wastage, the financial impact on the hospital budget, and the cost savings associated with current mitigation strategies.

Methods:

We conducted a cross-sectional study in three University of Toronto–affiliated hospitals of various sizes. We recorded the actual amount of drug wasted over a 2-week period while using current mitigation strategies. Single-dose vial cancer drugs with the highest wastage potentials were identified (14 drugs). To calculate the hypothetical drug wastage with no mitigation strategies, we determined how many vials of drugs would be needed to fill a single prescription.

Results:

The total drug costs over the 2 weeks ranged from $50,257 to $716,983 in the three institutions. With existing mitigation strategies, the actual drug wastage over the 2 weeks ranged from $928 to $5,472, which was approximately 1% to 2% of the total drug costs. In the hypothetical model with no mitigation strategies implemented, the projected drug cost wastage would have been $11,232 to $149,131, which accounted for 16% to 18% of the total drug costs. As a result, the potential annual savings while using current mitigation strategies range from 15% to 17%.

Conclusion:

The financial impact of drug wastage is substantial. Mitigation strategies lead to substantial cost savings, with the opportunity to reinvest those savings. More research is needed to determine the appropriate methods to minimize risk to patients while using the cost-saving mitigation strategies.

Risk-stratified multidisciplinary ambulatory management of malignant bowel obstruction (MAMBO) program for women with advanced gynecological cancer

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Background: Malignant bowel obstruction (MBO) in gynecologic oncology patients is associated with poor prognosis, debilitating symptoms and compromises quality of life. Management of MBO poses a clinical challenge with prolonged hospitalization. Evidence based guidelines for surgical intervention, use of chemotherapy, total parenteral nutrition or best supportive care in this patient population is lacking. Surgical correction may improve survival in selected patients. Retrospective analysis to assess impact of MBO show variable range of MBO-related admissions up to 60 days, and is associated with significant morbidity. Methods: A risk stratified MAMBO program for gynecologic patients has been implemented at Princess Margaret Cancer Centre to define a systematic approach for MBO management and build multidisciplinary consensus for personalized treatment of our patients. The program is novel and includes a nurse-led ambulatory management algorithm with an eHealth application designed to monitor bowel symptoms. A symptom-driven classification system has been devised to objectively define risk using a MBO management algorithm. Complex MBO cases are discussed in designated MBO rounds for consensus treatment recommendation. All patients with MBO are enrolled into a prospective database. Patients undergoing surgical procedures for MBO are consented for opportunistic tissue collection for translational research. MBO patient education materials have been developed to improve awareness and encourage proactive bowel symptom management. Results: Seventy nine patients have been followed through this risk stratified MAMBO program for ambulatory care over 6 months. The MBO program integrates diet, laxatives/stool softeners and drug therapy. Designated MBO rounds are now established for complex case discussion. A prospective MBO database will evaluate treatment and patient-reported outcomes. Conclusions: Risk stratified model of care for multidisciplinary MBO program facilitates decision-making between disciplines and optimize patient care in a vulnerable population with support for ambulatory care.

Strategies to minimize wastage of expensive drugs in expensive times: Cabazitaxel, a single center experience

e18297

Background: Although approved for metastatic castrate-resistant prostate cancer (mCRPC), the use of cabazitaxel has been limited due to concerns over drug wastage. In Canada, Cabazitaxel costs $96.7/mg and comes prepackaged in 60 mg single-dose vials, a quantity higher than the average prescribed and provincially reimbursed dose based on body size. Despite a discount offered by Sanofi to help cover the costs of drug wastage, many centers still cannot afford to administer it. We investigated whether aggressively batching patients (pts) on the same day, and allowing for excess drug to be used for subsequent pts can result in cost-savings. Methods: Between 09/2015 and 09/2016, all mCRPC pts receiving cabazitaxel at Princess Margaret Cancer Center were only treated on Mondays. Left over drug in opened vials was used for subsequent pts treated on the same day. Pts were dosed according to clinical parameters and BSA, at a dose of 20mg/m2 every 3 weeks. We calculated the total number of vials used daily and the amount of drug (mg) wasted. We then compared costs of the new batching system to the standard practice of opening one vial per treatment session. Results: During the trial period, 28 patients, mean age 72.3 (range 45-91) received cabazitaxel as 2nd line (23 pts) or 3rd line (5pts) therapy until disease progression or toxicity. In total, they required 117 individual treatment sessions, administered on 53 treatment days. With the batching system, 91 cabazitaxel vials were used, in comparison to 117 vials required with standard practice. As a result, 26 vials were unopened, $149,760 CAD were saved, equating to a 22.2% cost reduction over a year. In terms of wastage, $121,154 CAD of Cabazitaxel was wasted compared to $251,808 CAD wasted without batching, a difference of $130,656 CAD. Conclusions: Batching of mCRPC pts receiving cabazitaxel on the same day was feasible at a single center and significantly reduced drug wastage. This approach could be applied to centers with adequate patient volumes to save costs and reduce a key barrier to the use of cabazitaxel. A similar strategy can also be applied to other drugs across the field of oncology and has similar implications for cost-savings.

Physician driven variation in the care of children with spinal muscular atrophy type 1

BACKGROUND

Increasing numbers of families are requesting active supportive management for their child with spinal muscular atrophy type 1 (SMA1), leading to longer survival and greater prevalence of affected children. Strong opinions exist among physicians for and against the provision of care measures prolonging life.

OBJECTIVE

To describe current practice in the care of SMA1 in Canada, and explore the factors underlying inter-physician variability.

METHODS

A cross-sectional survey of Canadian hospital-based pediatric neurologists and pediatric respirologists was performed in 2015. Odds ratios and 95% confidence intervals were calculated to compare proportions between groups.

RESULTS

There was a 54% completion rate (99 physicians). Over half of participants believed that a disease modifying therapy was likely within 10 years. Quebec respirologists were 50 times less likely to offer long-term non-invasive ventilation (NIV) than respirologists in other provinces (OR 50.6, 95% CI 2.4-1075.3), and 20 times less likely to discuss tracheostomy with families (OR 20.4, 95% CI 2.0-211.8). High raters of perceived happiness of affected children were more likely to find NIV an acceptable measure for acute (OR 6.7, 95% CI 1.7-26.0) and chronic (OR 13.7, 95% CI 4.0-46.4) respiratory failure and prophylactic use (OR 5.8, 95% CI 2.2-15.6).

CONCLUSION

Physician knowledge, opinions, subjective perception of child happiness, and regional factors, all influence physicians' practices and the shared decision-making process. Parents may not be informed or offered all the services available to their child. Knowledge translation initiatives are needed to enhance SMA1 care. Pediatr Pulmonol. 2017;52:662-668. © 2016 Wiley Periodicals, Inc.

SCOPE of Pain: An Evaluation of an Opioid Risk Evaluation and Mitigation Strategy Continuing Education Program

OBJECTIVE

Due to the high prevalence of prescription opioid misuse, the US Food and Drug Administration (FDA) mandated a Risk Evaluation and Mitigation Strategy (REMS) requiring manufacturers of extended-release/long-acting (ER/LA) opioid analgesics to fund continuing education based on a FDA Blueprint. This article describes the Safe and Competent Opioid Prescribing Education (SCOPE of Pain) program, an ER/LA opioid analgesic REMS program, and its impact on clinician knowledge, confidence, attitudes, and self-reported clinical practice.

METHOD

Participants of the 3-h SCOPE of Pain training completed pre-, immediate post- and 2-month post-assessments.

SUBJECTS

The primary target group (n = 2,850), and a subset (n = 476) who completed a 2-month post-assessment, consisted of clinicians licensed to prescribe ER/LA opioid analgesics, who care for patients with chronic pain and who completed the 3-h training between February 28, 2013 and June 13, 2014.

RESULTS

Immediately post-program, there was a significant increase in correct responses to knowledge questions (60% to 84%, P ≤ 0.02) and 87% of participants planned to make practice changes. At 2-months post-program, there continued to be a significant increase in correct responses to knowledge questions (60% to 69%, P ≤ 0.03) and 67% reported increased confidence in applying safe opioid prescribing care and 86% reported implementing practice changes. There was also an improvement in alignment of desired attitudes toward safe opioid prescribing.

CONCLUSIONS

The SCOPE of Pain program improved knowledge, attitudes, confidence, and self-reported clinical practice in safe opioid prescribing. This national REMS program holds potential to improve the safe use of opioids for the treatment of chronic pain.

Prevention of carboplatin-induced hypersensitivity reactions in women with ovarian cancer

Background

Carboplatin-based chemotherapy offers high response rates and improved overall survival for women with epithelial ovarian cancer, but its use is limited by the occurrence of hypersensitivity reactions. To evaluate the efficacy of prophylactic diphenhydramine for hypersensitivity reaction prevention, we reviewed the incidence of hypersensitivity reactions and identified patients at high risk of hypersensitivity reactions.

Methods

Women receiving ≥6 cycles of carboplatin-based chemotherapy for epithelial ovarian cancer were identified from our institutional database at the Princess Margaret Cancer Centre. Institutional policy was changed in 2009 to introduce diphenhydramine prophylaxis for patients receiving ≥6 cycles of carboplatin. Additional clinical data were abstracted from the patient record.

Results

Between 2006 and 2012, 450 women received ≥6 cycles of carboplatin-based chemotherapy for epithelial ovarian cancer. Two hundred and ninety-one women received prophylaxis with diphenhydramine. Carboplatin-induced hypersensitivity reactions occurred in 41 of 449 patients (9%). Univariable predictors of carboplatin-induced hypersensitivity reactions included administration of 8 to 10 cycles of carboplatin, history of other drug allergies and a platinum-free interval >12 months. BRCA mutational status was not predictive. In a multivariable analysis, the number of cycles of carboplatin and a platinum-free interval >12 months were independent predictors of hypersensitivity reactions. There was a trend towards diphenhydramine prophylaxis reducing the incidence of hypersensitivity reactions in women with a platinum-free interval compared to continuous delivery; this was most marked when the platinum-free interval was >12 months (n = 64) (OR: 0.2 (95% CI: 0.046–0.83), p = 0.03).

Conclusions

The administration of diphenhydramine to women who have a platinum-free interval may reduce the risk of hypersensitivity reaction, but prospective evaluation is required.

Long-term, high-level hepatic secretion of acid α-glucosidase for Pompe disease achieved in non-human primates using helper-dependent adenovirus

Pompe disease (glycogen storage disease type II (GSD-II)) is a myopathy caused by a genetic deficiency of acid α-glucosidase (GAA) leading to lysosomal glycogen accumulation causing muscle weakness, respiratory insufficiency and death. We previously demonstrated in GSD-II mice that a single injection of a helper-dependent adenovirus (HD-Ad) expressing GAA resulted in at least 300 days of liver secretion of GAA, correction of the glycogen storage in cardiac and skeletal muscles and improved muscle strength. Recent reports suggest that gene therapy modeling for lysososomal storage diseases in mice fails to predict outcomes in larger animal models. We therefore evaluated an HD-Ad expressing GAA in non-human primates. The baboons not only tolerated the procedure well, but the results also confirmed that a single dose of the HD-Ad allowed the livers of the treated animals to express and secrete large amounts of GAA for at least 6 months, at levels similar to those achieved in mice. Moreover, we detected liver-derived GAA in the heart, diaphragm and skeletal muscles of the treated animals for the duration of the study at levels that corrected glycogen accumulation in mice. This work validates our proof-of-concept studies in mice, and justifies future efforts using Ad-based vectors in Pompe disease patients.