Longitudinal adherence to surveillance for late effects of cancer treatment: a population-based study of adult survivors of childhood cancer.

BACKGROUND: Adult survivors of childhood cancer are at elevated risk of morbidity and mortality compared to the general population, but their adherence to lifelong periodic surveillance is suboptimal. We aimed to examine adherence to surveillance guidelines for high-yield tests and identify risk factors for nonadherence in adult survivors of childhood cancer. METHODS: In this retrospective, population-based cohort study, we used health care administrative data from Ontario, Canada, to identify adult survivors of childhood cancer diagnosed between 1986 and 2014 who were at elevated risk of therapy-related colorectal cancer, breast cancer, or cardiomyopathy. Using a Poisson regression framework, we assessed longitudinal adherence and predictors of adherence to the Children's Oncology Group surveillance guideline. RESULTS: Among 3241 survivors, 327 (10%), 234 (7%), and 3205 (99%) were at elevated risk for colorectal cancer, breast cancer, and cardiomyopathy, respectively. Within these cohorts, only 13%, 6%, and 53% were adherent to recommended surveillance as of February 2020. During a median follow-up of 7.8 years, the proportion of time spent adherent was 14% among survivors at elevated risk for colorectal cancer, 10% for breast cancer, and 43% for cardiomyopathy. Significant predictors of adherence varied across the risk groups, but higher comorbidity was associated with adherence to recommended surveillance. INTERPRETATION: Survivors of childhood cancer in Ontario are rarely up to date for recommended surveillance tests. Tailored interventions beyond specialized clinics are needed to improve surveillance adherence.

Protocol for the ONLOOP trial: pragmatic randomized trial evaluating a province-wide system of personalized reminders for evidence-based surveillance tests in adult survivors of childhood cancer in Ontario.

BACKGROUND: Childhood cancer treatment while often curative, leads to elevated risks of morbidity and mortality. Survivors require lifelong periodic surveillance for late effects of treatment, yet adherence to guideline-recommended tests is suboptimal. We created ONLOOP to provide adult survivors of childhood cancer with detailed health information, including summaries of their childhood cancer treatment and recommended surveillance tests for early detection of cardiomyopathy, breast cancer, and/or colorectal cancer, with personalized reminders over time. METHODS: This is an individually randomized, registry-based pragmatic trial with an embedded process and economic evaluation to understand ONLOOP's impact and whether it can be readily implemented at scale. All adult survivors of childhood cancer in Ontario overdue for guideline-recommended tests will be randomly assigned to one of two arms: (1) intervention or (2) delayed intervention. A letter of information and invitation will detail the ONLOOP program. Those who sign up will receive a personalized toolkit and a screening reminder 6 months later. With the participants' consent, ONLOOP will also send their primary care clinician a letter detailing the recommended tests and a reminder 6 months later. The primary outcome will be the proportion of survivors who complete one or more of the guideline-recommended cardiac, breast, or colon surveillance tests during the 12 months after randomization. Data will be obtained from administrative databases. The intent-to-treat principle will be followed. Based on our analyses of administrative data, we anticipate allocating at least 862 individuals to each trial arm, providing 90% power to detect an absolute increase of 6% in targeted surveillance tests completed. We will interview childhood cancer survivors and family physicians in an embedded process evaluation to examine why and how ONLOOP achieved success or failed. A cost-effectiveness evaluation will be performed. DISCUSSION: The results of this study will determine if ONLOOP is effective at helping adult survivors of childhood cancer complete their recommended surveillance tests. This study will also inform ongoing provincial programs for this high-risk population. TRIAL REGISTRATION: ClinicalTrials.gov NCT05832138.

How does COVID-19 influence dynamic spillover connectedness between cryptocurrencies? Evidence from non-parametric causality-in-quantiles techniques.

This research examines the impact of the COVID-19 on cryptocurrencies' connectedness by employing two techniques: TVP-VAR-based connectedness and causality in the quantiles. First, the TVP-VAR-based connectedness unveils that cryptocurrencies act as a net receiver and transmitter of shocks, with Bitcoin, Ethereum are the highest transmitters among others. Moreover, the causality-in-quantile test shows that COVID-19 significantly causes spillover connectedness among cryptocurrencies, mainly at the quantiles ranging from 0.1 to 0.8, while an insignificant causal relationship is found in few cases. The study has implications for investors and policymakers.

Developing a Provincial Surveillance and Support System for Childhood Cancer Survivors: Multiphase User-Centered Design Study.

BACKGROUND: Survivors of childhood cancer are at lifelong risk of morbidity (such as new cancers or heart failure) and premature mortality due to their cancer treatment. These are termed late effects. Therefore, they require lifelong, risk-tailored surveillance. However, most adult survivors of childhood cancer do not complete recommended surveillance tests such as mammograms or echocardiograms. OBJECTIVE: In partnership with survivors, family physicians, and health system partners, we are designing a provincial support system for high-priority tests informed by principles of implementation science, behavioral science, and design thinking. METHODS: Our multiphase process was structured as follows. Step 1 consisted of a qualitative study to explore intervention components essential to accessing surveillance tests. Step 2 comprised a workshop with childhood cancer survivors, family physicians, and health system stakeholders that used the Step 1 findings and "personas" (a series of fictional but data-informed characters) to develop and tailor the intervention for different survivor groups. Step 3 consisted of intervention prototype development, and Step 4 involved iterative user testing. RESULTS: The qualitative study of 30 survivors and 7 family physicians found a high desire for information on surveillance for late effects. Respondents indicated that the intervention should help patients book appointments when they are due in addition to providing personalized information. Insights from the workshop included the importance of partnering with both family physicians and survivorship clinics and providing emotional support for survivors who may experience distress upon learning of their risk for late effects. In our user-testing process, prototypes went through iterations that incorporated feedback from users regarding acceptability, usability, and functionality. We sought to address the needs of survivors and physicians while balancing the capacity and infrastructure available for a lifelong intervention via our health system partners. CONCLUSIONS: In partnership with childhood cancer survivors, family physicians, and health system partners, we elucidated the barriers and enablers to accessing guideline-recommended surveillance tests and designed a multifaceted solution that will support survivors and their family physicians. The next step is to evaluate the intervention in a pragmatic randomized controlled trial.

Determinants of surveillance for late effects in childhood cancer survivors: a qualitative study using the Theoretical Domains Framework.

PURPOSE: Most adult survivors of childhood cancer do not complete the recommended surveillance tests for late effects of their treatment. We used a theory-informed method to elucidate the barriers and enablers among childhood cancer survivors to accessing such tests. METHODS: Semi-structured interviews were completed with adult survivors of childhood cancer. Participants were eligible for the surveillance tests of interest (echocardiogram, mammogram/breast MRI and/or colonoscopy) but had not attended a specialised aftercare clinic in over five years. The Theoretical Domains Framework (TDF), a tool specifically developed for implementation research to identify influences on desired behaviour(s), informed the interview guide and analysis; interview transcripts were coded line-by-line and mapped to domains in accordance with the framework. RESULTS: Thirty childhood cancer survivors were interviewed (ages 25-60). The TDF domains described by survivors included: intention to complete the tests, which was facilitated by the fear of another cancer (emotion), confidence in the benefits of early detection (beliefs about consequences), and supportive reminders (memory, attention, and decision-making). In contrast, a lack of knowledge of late effects and relevant guidelines and the burden of arranging tests (social identity) were key barriers. CONCLUSION: Interventions seeking to increase surveillance testing for late effects may be more effective if they feature components that explicitly address all the theory-informed determinants identified. IMPLICATIONS FOR CANCER SURVIVORS: Awareness about the recommendations among survivors and their physicians is a necessary (but likely not sufficient) step towards implementation of guidelines regarding surveillance for late effects.

The Feasibility of a Lifestyle Physical Activity Intervention for Black Women with Asthma.

BACKGROUND: Black women are disproportionately affected by both physical inactivity and asthma. Lifestyle physical activity (PA) interventions targeted for Black women with asthma are lacking. OBJECTIVE: To assess the feasibility and acceptability as well as preliminary effects of a lifestyle PA intervention culturally tailored for Black women with asthma. METHODS: Black women (age 18-70 years) with uncontrolled asthma (Asthma Control Test <20) were recruited. Outcome assessments at baseline and 24 weeks included measures of: feasibility and acceptability, asthma control, quality of life, health care use, and PA levels. Participants were randomized to the intervention (asthma education, Fitbit, monthly group sessions, text messages, individual step goals, and study manual) or enhanced usual care (EUC) (asthma education plus Fitbit) group. RESULTS: Of the 53 women randomized (EUC = 28; intervention = 25), 92% remained in the intervention (23 of 25) and 76% completing the 24-week outcome assessment. Overall intervention satisfaction (mean score, 6.88 of 7) and individual components were high at 24 weeks. Mean change in asthma control questionnaire between groups was not significant at 24 weeks (intervention = -0.41 vs EUC = 0.03 [P = .08]; effect size = -0.38) but approached clinical significance (0.5). At 24 weeks, more women receiving the intervention had controlled asthma compared with EUC (36.84% vs 9.52%; P = .04). Clinically significant improvements (0.5) in quality of life were found in the intervention group (mean change: intervention = 0.58 vs EUC = 0.10; P = .10) at 24 weeks. CONCLUSIONS: A culturally tailored lifestyle PA intervention is feasible and demonstrates improvements in asthma control and quality of life among Black women with asthma. These preliminary findings support the need for PA lifestyle interventions in urban Black women with asthma.

Non-linear threshold effect of financial development on renewable energy consumption: evidence from panel smooth transition regression approach.

Financial development is identified as one of the significant factors that affect energy consumption and has been widely discussed in the literature. However, the association between financial development and renewable energy consumption is still at its earlier stage and is limitedly explored. Therefore, the purpose of this study is to examine the non-linear association between financial development and renewable energy consumption in the top renewable energy consumption countries. The study utilized the newly introduced econometric technique panel smooth transition regression (PSTR) model with two regimes on annual panel data consisted of years 1997-2017. The result confirmed that all the financial development indicators increase renewable energy consumption but affect renewable energy consumption differently. Moreover, the economic growth and industrial structure showed a positive and significant association in both regimes, whereas the population showed a negative relationship with renewable energy consumption in a low growth regime but the association becomes positive in high growth regimes. The study suggested several policies for the top renewable consumption countries.

Residential energy environmental Kuznets curve in emerging economies: the role of economic growth, renewable energy consumption, and financial development.

The aim of the present paper is to determine residential energy environmental Kuznets curve (EKC) in Next-11 and BRICS countries with the specific consideration on the role of economic growth, renewable energy consumption, and financial development from an era of 1990-2015. In order to determine the cross-section independence and to control the heterogeneity between cross-sections in the paper, we have applied unique and advanced techniques of econometrics panel data. Moreover, the following tests have been applied which are the CIPS unit root test, co-integration test, fully modified ordinary least square (FMOLS), and heterogeneous panel causality technique. The outcomes revealed that in the long run, all the variables are co-integrated. Moreover, there is a significant and positive influence of residential energy consumption, economic growth, and financial development on environmental degradation. However, in the reduction of carbon dioxide (CO2) emissions, essential role is performed by renewable energy. On the other hand, findings show great support for the residential energy EKC hypothesis in emerging countries.

Testing environmental Kuznets curve hypothesis in G7 countries: the role of renewable energy consumption and trade.

This study has been conducted to examine the impact of trade, economic growth, and renewable energy on environmental degradation in G7 countries. The data consist of the years 1991-2016. We employed the panel unit root test and co-integration test, along with cross-sectional dependence and cross-sectionally augmented IPS unit root test by Pesaran (J Appl Econ 22:265-312, 2007). We also employed dynamic ordinary least squares, fully modified ordinary least squares, and fixed effect ordinary least squares regression. The result concluded that all the variables are co-integrated in the long run and all the variables create a significant effect on CO2 emission. This study implies that economic growth and trade increases the CO2 emission in the long run whereas the renewable energy consumption reduces the CO2 emission in the long run. The result also provides support for the Environmental Kuznets curve hypothesis in G7 countries.

Obturator Nerve Block in Transurethral Resection of Bladder Tumor: A Comparison of Ultrasound-guided Technique versus Ultrasound with Nerve Stimulation Technique.

BACKGROUND: Obturator nerve (ON) stimulation during transurethral resection of lateral and posterolateral bladder wall tumor under spinal anesthesia may lead to obturator reflex, adductor contraction, and leg jerking with complications such as bleeding, bladder perforation, or incomplete tumor resection. Our study was carried out to obtain successful block of ON using ultrasound (US)-guided technique with or without nerve stimulation in patients undergoing transurethral resection of bladder tumor (TURBT) under spinal anesthesia. AIMS: The aim of the study was to compare the effectiveness of two different techniques in blocking ON and adductor spasm during TURBT. SETTINGS AND DESIGN: Prospective, randomized, double-blind study. SUBJECTS AND METHODS: Sixty patients with American Society of Anesthesiologists Status II and III scheduled to undergo TURBT for lateral and posterolateral bladder wall tumor were enrolled. Group I (US group, n = 30) patients received 5 ml of bupivacaine 0.5% each at anterior, and posterior division of ON under real-time US visualization and Group II (US-NS group, n = 30) received the same amount of bupivacaine 0.5% for each division using US-guidance with nerve stimulation-assisted technique. Motor block onset time, block success and performance time, ease of performance of block, and complications were measured besides assessing patient and surgeon satisfaction into two groups. STATISTICAL METHODS USED: SPSS using two sample independent t-test and Pearson's Chi-square/Fisher's exact test. RESULTS: Motor block onset was significantly faster in Group II (6.67 ± 2.40) than in Group I (12.39 ± 2.55). A success rate of 90% was achieved in Group II as compared to 76.7% in Group I with increased block performance time in Group II (4.47 ± 0.73 min) versus (2.10 ± 0.51 min) in Group I. A better patient and surgeon satisfaction were seen in Group II with combination of US and nerve stimulation technique. No complications were encountered. CONCLUSION: We conclude that both techniques are safe and easy to perform; however, nerve stimulation as an adjunct to US results in a faster onset of block with a higher success rate.

Effectiveness of sodium thiopentone, propofol, and etomidate as an ideal intravenous anesthetic agent for modified electroconvulsive therapy.

INTRODUCTION: Electroconvulsive therapy (ECT) is a well-established psychiatric treatment in which seizures are electrically induced in patients for therapeutic effects. ECT can produce severe disturbances in the cardiovascular system and a marked increase in cerebral blood flow and intracranial pressure. These cardiovascular changes may be altered using various anesthetic drugs. AIM AND OBJECTIVES: This study was undertaken to compare the effects of intravenous (IV) sodium thiopentone, propofol, and etomidate, used as IV anesthetic agents in modified ECT as regards, induction time and quality of anesthesia, alteration of hemodynamics, seizure duration, and recovery time. MATERIALS AND METHODS: A total of 90 patients in the age group of 16-60 years of either sex, who had to undergo ECT therapy were divided randomly into three equal groups. Group A received propofol 1% - 1.5 mg/Kg, Group B received etomidate - 0.2 mg/Kg, and Group C received thiopentone 2.5% - 5 mg/Kg. All the patients were monitored for changes in heart rate, systolic blood pressure, diastolic blood pressure, and oxygen saturation at basal, after induction and 1 min, 2 min, 3 min, 5 min, 10 min, 20 min, and 30 min following ECT. Quality of anesthesia, seizure duration, and recovery times were also recorded. CONCLUSION: We found that propofol had the advantage of smooth induction, stable hemodynamic parameters and rapid recovery as compared to etomidate and thiopentone. Thiopentone had the advantage over propofol of having longer seizure duration at the cost of a relatively prolonged recovery period. Etomidate had a definite advantage of longer seizure duration.