Breast Cancer-Related Financial Toxicity in Sri Lanka: Insights From a Lower Middle-Income Country With Free Universal Public Healthcare.

Financial toxicity (FT) describes either objective or perceived excess financial strain due to a cancer diagnosis on the well-being of patients, families, and society. The consequences of FT have been shown to span countries of varied economic tiers and diverse healthcare models. This study attempts to describe FT and its effects in a lower- to middle-income country delivering predominantly public nonfee-levying healthcare. This was a cross-sectional study involving 210 patients with breast cancer of any stage (I to IV), interviewed between 6 and 18 months from the date of diagnosis. Financial toxicity was highly prevalent with 81% reporting 3 or more on a scale of 1 to 5. Costs incurred for travelling (94%), out-of-hospital investigations (87%), and consultation fees outside the public system (81%) were the most common contributors to FT. Daily compromises for food and education were made by 30% and 20%, respectively, with loss of work seen in over one-third. Greater FT was seen with advanced cancer stage and increasing distance to the nearest radiotherapy unit (P = .008 and .01, respectively). Family and relatives were the most common form of financial support (77.6%). In conclusion, FT is substantial in our group, with many having to make daily compromises for basic needs. Many opt to visit the fee-levying private sector for at least some part of their care, despite the availability of an established public nonfee-levying healthcare.

Demographic, tumour, and treatment characteristics of female patients with breast cancer in Sri Lanka; results from a hospital-based cancer registry.

BACKGROUND: Although breast cancer is the most common cancer among Sri Lankan women, there is little published data on patient characteristics and treatment in the local context. We aimed to describe disease characteristics and management in a large contemporary cohort of women with breast cancer at the National Cancer Institute of Sri Lanka (NCISL). METHODS: All women with invasive primary breast cancers diagnosed during 2016-2020 were identified from the NCISL breast cancer registry. The NCISL sees approximately 40% of all cancer patients in Sri Lanka. Cancer stage at diagnosis was defined according to the Tumour, Node, and Metastasis (TNM) staging system and the Estrogen (ER) and progesterone (PR) receptor status was determined based on the results of immunohistochemistry tests. Descriptive statistics were used to describe the study cohort and treatment patterns. RESULTS: Over 5100 patients were diagnosed with breast cancer during the study period at the NCISL. The mean age of the women was 56 (SD 12) years. Common co-morbidities were hypertension (n = 1566, 30%) and diabetes mellitus (n = 1196, 23%). Two thirds (66%) of the cancers were early stage (stage I & II) at diagnosis. ER/PR positivity rate was 72% and HER-2 positivity rate was 22%. Two thirds of the women had undergone mastectomy while 68% had undergone axillary clearance. The rate of chemotherapy delivery was 91% for women with node positive disease while 77% of eligible women (i.e., after wide local excision or with > 3 positive lymph nodes) had received adjuvant radiotherapy. Endocrine therapy was initiated in 88% of eligible women with hormone receptor positive disease while rate of trastuzumab use was 59% among women with HER2 positive breast cancer. CONCLUSIONS: High percentage of advanced breast cancer at diagnosis and high prevalence of comorbidities are some of the major challenges faced in the management of breast cancer in Sri Lanka. Given that stage at diagnosis is the most important prognostic factor determining survival, greater efforts are needed to promote early diagnosis of breast cancer. Considerable lapses in the concordance between guideline recommendations and the delivery of cancer care warrants closer assessment and intervention.

Strategies to Prevent Readmissions to Hospital for COPD: A Systematic Review.

Patients with chronic obstructive pulmonary disease (COPD) experience high rates of hospital readmissions, placing substantial clinical and economic strain on the healthcare system. Therefore, it is essential to implement evidence-based strategies for preventing these readmissions. The primary objective of our systematic review was to identify and describe the domains of existing primary research on strategies aimed at reducing hospital readmissions among adult patients with COPD. We also aimed to identify existing gaps in the literature to facilitate future research efforts. A total of 843 studies were captured by the initial search and 96 were included in the final review (25 randomized controlled trials, 37 observational studies, and 34 non-randomized interventional studies). Of the included studies, 72% (n = 69) were considered low risk of bias. The majority of included studies (n = 76) evaluated patient-level readmission prevention strategies (medication and other treatments (n = 25), multi-modal (n = 19), follow-up (n = 16), telehealth (n = 8), education and coaching (n = 8)). Fewer assessed broader system- (n = 13) and policy-level (n = 7) strategies. We observed a trend toward reduced all-cause readmissions with the use of medication and other treatments, as well as a trend toward reduced COPD-related readmissions with the use of multi-modal and broader scale system-level interventions. Notably, much of this evidence supported shorter-term (30-day) readmission outcomes, while little evidence was available for longer-term outcomes. These findings should be interpreted with caution, as considerable between-study heterogeneity was also identified. Overall, this review identified several evidence-based interventions for reducing readmissions among patients with COPD that should be targeted for future research.Supplemental data for this article is available online at https://doi.org/10.1080/15412555.2021.1955338 .

Screening and Management Recommendations for Type 2 Diabetes in Women With Breast Cancer.

Breast cancer increases the risk of type 2 diabetes 1.07- to 4.27-fold, depending on patient and treatment characteristics, such as postmenopausal status, hormone therapy, and treatment with adjuvant chemotherapy. We evaluated the current evidence and considered the role of increased screening for type 2 diabetes in this at-risk population. This narrative review was conducted using Embase and MEDLINE databases. Keywords including diabetes and breast cancer were used. Articles were limited to those published in English between 2000 and 2022. It appears that the increased risk of diabetes begins at or just after breast cancer diagnosis, and remains elevated for at least 10 to 15 years, with greatest risk in the first 2 years after diagnosis. Subsets of patients with breast cancer appear to be at higher risk of developing type 2 diabetes, including those who were treated with adjuvant chemotherapy or hormone therapy. Further investigation is needed to develop specific screening recommendations for this population. If screening is performed with a glycated hemoglobin test during breast cancer treatment, then hemoglobin should be measured at the same time given the association of breast cancer therapy with anemia. Presence of breast cancer should not be a major factor when choosing among available antihyperglycemic agents. Overall, patients with breast cancer appear to be at an increased risk of developing type 2 diabetes. This increased risk suggests the need for further investigation to develop specific screening recommendations for this at-risk population.

Five practical strategies to get a grip on large group cooperative virtual learning in medical education.

The COVID-19 pandemic has led to the rapid replacement of in-person classroom learning with virtual large group learning. Done well, virtual large group learning can be an effective tool that provides flexibility, accessibility, and collaboration between learners. However, despite its potential benefits, human and technological challenges limit engagement and overall efficacy of large group virtual learning. The following account provides an evidence-based framework to maximize cooperative learning, learner engagement and retention of medical education in the virtual setting.

La pandémie de la COVID-19 a rapidement entraîné le remplacement de l'apprentissage en classe en personne par l'apprentissage virtuel en grand groupe. Bien conçu, l'apprentissage virtuel en groupe peut être un outil efficace qui offre souplesse, accessibilité et possibilités de collaboration entre apprenants. Malgré ces avantages potentiels, les défis humains et technologiques limitent la participation à l'apprentissage virtuel en grand groupe et son efficacité générale. L'exposé suivant propose un cadre fondé sur des données probantes permettant de maximiser l'apprentissage coopératif, la participation des apprenants et la rétention des connaissances enseignées virtuellement dans les programmes de médecine.

Videoconferencing interventions and COPD patient outcomes: A systematic review.

INTRODUCTION: Videoconferencing circumvents various physical and financial barriers associated with in-person care. Given this technology's potential benefits and timely nature, we conducted a systematic review to understand how videoconferencing for chronic obstructive pulmonary disease (COPD) follow-up care affects patient-related outcomes. METHODS: We included primary research evaluating the use of bidirectional videoconferencing for COPD patient follow-up. The outcomes of interest were resource utilization, mortality, lifestyle factors, patient satisfaction, barriers, and feasibility. We searched MEDLINE, EMBASE, EBM Reviews, and CINAHL databases for articles published from January 1, 2010, to August 2, 2021. Relevant information was extracted and presented descriptively and common themes and patterns were identified. The risk of bias for each study was assessed using design-specific validated tools. RESULTS: We included 39 studies of 18,194 patients (22 quantitative, 12 qualitative, and 5 mixed methods). The included studies were grouped by type of intervention; 18 studies explored videoconferencing for exercise, 19 explored videoconferencing for clinical assessment/monitoring, and 2 examined videoconferencing for education. Generally, videoconferencing was associated with high levels of patient satisfaction. There were mixed results in terms of its effects on resource utilization and lifestyle-related factors. Additionally, 12 studies were at high risk of bias, indicating that these results should be interpreted with caution. CONCLUSIONS: The videoconferencing interventions resulted in high levels of patient satisfaction, despite facing technological issues. Overall, more research is needed to better understand the effects of videoconferencing interventions on resource utilization and other patient outcomes, quantifying their advantages over in-person care.

A systematic review of eHealth technologies for breast cancer supportive care.

Breast cancer places a substantial burden on patient physical and mental wellbeing, and the delivery of high-quality supportive care is essential at all stages of the disease. Given the increased uptake of technology in recent years, eHealth interventions may be a convenient and accessible method for supportive care. Within this context, we conducted a systematic review to describe and quantify the use of eHealth for breast cancer supportive care. We searched MEDLINE, EMBASE, and CINAHL databases for primary research studies published from 2016 to 2021 (present) that assessed the effects of eHealth interventions on adult patients with breast cancer. We explored the effects of the interventions on patient symptoms, lifestyle, satisfaction, and barriers, as well as factors related to feasibility and implementation. The risk of bias of each study was also assessed. Findings were presented according to stage of cancer care. We identified 43 relevant studies capturing n = 6,285 patients (30 randomized controlled trials and 13 non-randomized interventional studies); 5 evaluated patients who were newly diagnosed, 16 evaluated patients undergoing active treatment, and 22 evaluated patients in post-treatment follow-up. A total of 19 studies used mobile apps, 18 used online patient portals, 5 used text messaging, and 1 used both a patient portal and text messaging. We found that patients were broadly satisfied with the eHealth interventions; however, findings were less consistent for symptom and lifestyle-related outcomes. Eight studies were judged as high risk of bias. There was substantial between-study heterogeneity, which made it challenging to discern consistent trends. Overall, future research should continue to explore the use of eHealth for breast cancer supportive care, with a focus on improving patient symptoms.

Patient Satisfaction With Breast Cancer Care Delivery at the National Cancer Institute of Sri Lanka: Does Language Play a Role?

PURPOSE: This study sought to examine whether there was an association between language barriers and patient satisfaction with breast cancer care in Sri Lanka. METHODS: A telephone-based survey was conducted in the three official languages (Sinhala, Tamil, or English) among adult women (older than 18 years) who had been treated for breast cancer within 6-12 months of diagnosis at the National Cancer Institute of Sri Lanka. The European Organisation for Research and Treatment of Cancer Satisfaction with Cancer Care core questionnaire was adapted to assess three main domains (physicians, allied health care professionals, and the organization). All scores were linearly transformed to a 0-100 scale, and subscores for domains were summarized using means and standard deviations. These were also calculated for the Sinhalese and Tamil groups and compared. RESULTS: The study included 72 participants (32 ethnically Tamil and 40 Sinhalese, with 100% concordance with preferred language). The most commonly reported best aspect of care (n = 25) involved affective behaviors of the physicians and nurses. Ease of access to the hospital performed poorest overall, with a mean satisfaction score of 54 (30.5). Clinic-related concerns were highlighted as the worst aspect of the care (n = 10), including long waiting times during clinic visits. Sixty-three percent of Tamil patients reported receiving none of their care in Tamil and 18% reported experiencing language barriers during their care. Tamil patients were less satisfied overall and reported lower satisfaction with care coordination (P = .005) and higher financial burden (P = 0.014). CONCLUSION: Ethnically Tamil patients were significantly less satisfied than their Sinhalese counterparts and experienced more language barriers, suggesting there is a need to improve access to language-concordant care in Sri Lanka.

Malignant Superior Vena Cava Syndrome: A Scoping Review.

Malignant superior vena cava syndrome (SVCS) is a clinical problem that results from the obstruction of blood flow in the superior vena cava by an underlying malignancy. This may occur due to external compression, neoplastic invasion of the vessel wall, or internal obstruction with bland or tumor thrombus. Although symptoms are typically mild, SVCS can cause neurologic, hemodynamic, and respiratory compromise. Classic management options include supportive measures, chemotherapy, radiation therapy, surgery, and endovascular stenting. New targeted therapeutics and techniques have also recently been developed, which may have a role in management. Nevertheless, few evidence-based guidelines exist to guide treatment of malignant SVCS, and these recommendations are typically restricted to individual disease sites. Furthermore, there are no recent systematic literature reviews that address this question. Here, we present a theoretical case to frame this clinical problem and synthesize updated evidence published in the past decade relating to the management of malignant SVCS through a comprehensive literature review.

Efficacy and safety of JAK inhibitors in the treatment of psoriasis and psoriatic arthritis: a systematic review and meta-analysis.

BACKGROUND: JAK inhibitors are a relatively new class of medications that may be useful in the treatment of moderate-to-severe psoriasis and psoriatic arthritis (PsA). The objective of this study was to determine the efficacy of several JAK inhibitors in treating psoriasis and PsA and examine safety concerns. METHODS: MEDLINE, Cochrane and EMBASE were searched for randomized controlled trials and observational studies comparing any JAK inhibitor to placebo. The primary outcomes were a 75% improvement in the Psoriasis Area and Severity Index (PASI75) and a 20% improvement in the American College of Rheumatology composite score (ACR20). A secondary outcome was the proportion of patients achieving a "0" or "1" on the static Physician Global Assessment scale. Odds ratios were used to compare the proportion of patients reaching these targets in the max dose intervention group vs. the placebo group. A random effects model was used to account for heterogeneity. RESULTS: In total, 15 RCTs were included in the study and no observational studies. This encompassed 6757 patients in total. When the results were combined, the calculated odds ratio for PASI75 amongst tofacitinib vs. placebo was OR 14.35 [95%CI 7.65, 26.90], for PASI75 amongst non-tofacitinib JAK inhibitors vs. placebo it was OR 6.42 [95%CI 4.89, 8.43], for ACR20 amongst all JAK inhibitors versus placebo was OR 5.87 [95%CI 4.39, 7.85]. There was no significant difference in prevalence of serious adverse events between intervention and control in any of these studies. CONCLUSION: JAK inhibitors show promise for safely treating moderate-to-severe psoriasis and psoriatic arthritis.

Cancer and cardiovascular disease: can understanding the mechanisms of cardiovascular injury guide us to optimise care in cancer survivors?

Cancer and cardiovascular disease (CVD) are the leading causes of morbidity and mortality. Therefore, CVD deaths in cancer survivors remain a major challenge in improving cancer outcomes, especially in low and middle income countries (LMICs). Cancer and CVD share many common risk factors, both modifiable risk factors (obesity, diabetes and smoking) and non-modifiable factors such as inflammation. Additionally, some cancer therapies are associated with cardiac toxicity. These mechanisms drive increased CVD outcomes in cancer survivors, and understanding this relationship allows us to target therapies to combat such risks. Several commonly used pharmacotherapies for CVD demonstrate promise in cancer survivors for both primary and secondary prevention. Beta blockers and Angiotensin converting enzyme (ACE)-inhibitors have been shown in several studies to improve left ventricular ejection fraction (LVEF) in patients with already established LVEF decline following cancer therapy. Statin use during chemotherapy was associated with lower risk of heart failure and smaller declines in LVEF. Recent studies into the effects of anti-inflammatory medications on cardiovascular events in the non-cancer population have demonstrated promising results and may prove to be an area of further investigation and possible benefit in the cancer population [Canakinumab Anti-Inflammatory Thrombosis Outcomes Study (CANTOS) and Colchicine Cardiovascular Outcomes Trial (COLCOT)]. Additionally, several other medications including PCSK9 inhibitors, sodium-glucose cotransporter-2 inhibitors (SGLT2i) and glucagon-like peptide 1 (GLP-1) agonists have been shown to modify inflammation, and therefore may provide cardiovascular benefits. While common pharmacotherapies used in CVD show promise in cancer survivors, their exact mechanisms remain poorly understood. Few studies evaluate their clinical effectiveness specifically in cancer survivors, as this patient population is excluded from most studies. Further investigation is warranted with more representation of cancer survivors before cost-effective recommendations are made. This is especially true in LMICs where resources are sparse for primary and secondary prevention in order to optimise care in this unique, high-risk population for CVD.

Colorectal Cancer Treatment Characteristics and Concordance With Guidelines in Sri Lanka: Results From a Hospital-Based Cancer Registry.

PURPOSE: Colorectal cancer (CRC) ranks among the top five incident cancers in Sri Lanka (SL). Here, we describe disease characteristics and treatment patterns of patients with CRC in SL. METHODS: All adult patients (age > 18 years) diagnosed with CRC during 2016-2020 were identified from the National Cancer Institute SL cancer registry. Cancer stage at diagnosis was defined according to the seventh edition of the TNM staging system. Concordance between recommendations for adjuvant therapy and actual rates of delivery was also analyzed. Descriptive statistics were used to describe the study cohort and treatment patterns. RESULTS: A total of 1,578 patients were diagnosed with CRC during the study period, 53% (n = 830) with colon cancer and 47% (n = 748) with rectal cancer. Mean age was 61 (range, 18-91) years. Stage distribution was 13%, 28%, 46%, and 12% for stage I, II, III, and IV cancers, respectively. Adjuvant chemotherapy was delivered to 82% of patients with stage III colon cancer. There was a lack of concordance with delivery of neoadjuvant chemoradiotherapy, which was only delivered to 50% of patients with stage III rectal cancer for whom this treatment was indicated. CONCLUSION: Aging population and advanced stage of CRC at diagnosis will continue to challenge the provision of high-quality CRC care in SL. Further quantitative and qualitative research may help better understand the nonconcordance with treatment guidelines. Such information would help ease the burden of advanced-stage CRC in SL.

Using health administrative data to identify patients with pulmonary hypertension: A single center, proof of concept validation study in Ontario, Canada.

Real-world identification of pulmonary hypertension (PH) is largely based on the use of administrative databases identified by ICD codes. This approach has not been validated. The aim of this study was to validate a diagnosis of PH and its comorbidities using ICD 9/10 codes. Health records from Kingston Health Sciences Centre (2010 to 2012) were abstracted to identify a diagnosis of PH. Cohort 1 patients (n = 300) were selected because they had attended a cardiology or respirology clinic without knowledge of PH status. Cohort 2 patients (n = 200) were patients with a diagnosis of PH, identified using International Classification of Diseases (ICD) codes at the time of hospitalizations (CIHI-DAD) or emergency department (ED) visits (CIHI-NACRS). These cohorts were combined and reviewed to validate the diagnosis of PH. These data were securely transferred to the Institute of Clinical Evaluative Sciences (ICES). The diagnosis of PH from chart abstraction was used as the gold standard. The classification of PH into WHO groups, based on chart abstraction, was also compared to classification based on ICD code-defined comorbidities. Cohort 1 and Cohort 2 were merged to yield 449 unique patients in the combined cohort. In the combined cohort, 248 of 449 (55.2%) had a diagnosis of PH by ICD code criteria. The mean age of this PH group was 70 years, and the majority were females (65.5%). One hospitalization or ED visit resulting in a diagnostic code for PH had a sensitivity of 73% and a specificity of 99% for a confirmed PH diagnosis on chart abstraction. When WHO classification by chart abstraction and ICD codes for comorbidities were compared, there was 87% agreement. Identification of PH and its comorbidities using ICD codes is a valid approach, and this single-center study supports its application to identify PH.

Cannabis and its derivatives for the use of motor symptoms in Parkinson's disease: a systematic review and meta-analysis.

BACKGROUND: Recent changes to the legal status of cannabis across various countries have renewed interest in exploring its use in Parkinson's disease (PD). The use of cannabinoids for alleviation of motor symptoms has been extensively explored in pre-clinical studies. OBJECTIVE: We aim to systematically review and meta-analyze literature on the use of medical cannabis or its derivatives (MC) in PD patients to determine its effect on motor function and its safety profile. METHODS: We reviewed and analyzed original, full-text randomized controlled trials (RCTs) and observational studies. Primary outcomes were change in motor function and dyskinesia. Secondary outcomes included adverse events and side effects. All studies were analyzed for risk of bias. RESULTS: Fifteen studies, including six RCTs, were analyzed. Of these, 12/15 (80%) mention concomitant treatment with antiparkinsonian medications, most commonly levodopa. Primary outcomes were most often measured using the Unified Parkinson Disease Rating Scale (UPDRS) among RCTs and patient self-report of symptom improvement was widely used among observational studies. Most of the observational data lacking appropriate controls had effect estimates favoring the intervention. However, the controlled studies demonstrated no significant motor symptom improvement overall. The meta-analysis of three RCTs, including a total of 83 patients, did not demonstrate a statistically significant improvement in UPDRS III score variation (MD -0.21, 95% CI -4.15 to 3.72; p = 0.92) with MC use. Only one study reported statistically significant improvement in dyskinesia (p < 0.05). The intervention was generally well tolerated. All RCTs had a high risk of bias. CONCLUSION: Although observational studies establish subjective symptom alleviation and interest in MC among PD patients, there is insufficient evidence to support its integration into clinical practice for motor symptom treatment. This is primarily due to lack of good quality data.

Seven ways to get a grip on facilitating bedside team rounding.

Although classically considered a cornerstone of inpatient care, rounding at patients' bedsides is increasingly being replaced by rounding in workrooms. Workroom rounds may provide a sense of efficiency and comfort, however bedside rounds have multiple benefits for patients, trainees, and staff physicians. Alongside its benefits, there are human and institutional challenges when incorporating bedside rounding. This article aims to draw on our own experience of implementing bedside rounding at Kingston Health Sciences Centre, to guide staff physicians and institutions on how to implement bedside rounding effectively while overcoming its challenges. The following seven tips provide a framework to avoid pitfalls when implementing bedside team rounding on inpatient services.

Bien que classiquement considéré comme la pierre angulaire des soins aux patients hospitalisés, les tournées médicales au chevet des patients sont de plus en plus remplacées par les tournées dans les salles d'enseignement. Bien que Les tournées en salle de travail puissent procurer un sentiment d'efficacité et de confort, les tournées au chevet présentent de multiples avantages pour les patients, les apprenants et les médecins superviseurs. Parallèlement à ses avantages, il existe des défis humains et institutionnels lors de l'intégration des tournéesau chevet du patient. Cet article vise à tirer parti de notre propre expérience de la mise en œuvre des tournéesau chevet au Kingston Health Sciences Centre, pour guider les médecins superviseurs et les institutions sur la façon de mettre en œuvre efficacement les tournées au chevet tout en surmontant ses défis. Les sept conseils suivants fournissent un cadre pour éviter les pièges lors de la mise en œuvre des tournées en équipes au chevet des patients hospitalisés.

Text Messaging in Cancer-Supportive Care: A Systematic Review.

The global cancer disease burden is substantial, resulting in increased economic and clinical strain on our healthcare systems. A proposed solution is text-based communication, which can be used for cancer-supportive care. We conducted a systematic review to synthesize and describe the use of text-based communications for cancer-supportive care. Our population of interest included adult patients with cancer. A total of 18 studies were included in the review: 9 RCTs and 9 non-randomized interventional/observational studies. Patients were largely satisfied with text-based communication during their cancer care. Compared to controls, results for other outcomes including symptoms and quality of life were largely mixed; however, no harms were observed. Furthermore, positive outcomes were seen for specific interventions, such as text message medication reminders. These findings should be considered with caution due to the considerable heterogeneity observed between studies regarding their design and reported outcomes and the high risk of bias associated with 6/18 studies. Overall, this review suggests that text-based communication may be a complementary tool for cancer-supportive care; however, more research is needed to examine the feasibility of implementation and use.

Clinical Oncology Workload in Sri Lanka: Infrastructure, Supports, and Delivery of Clinical Care.

PURPOSE: Sri Lanka is a lower middle-income country undergoing a demographic transition with an increasing aging population. This has given rise to a higher burden of noncommunicable diseases including cancer. A well-trained oncology workforce is essential to address this growing public health challenge. Understanding the baseline status of the clinical oncology workforce is an essential step to improving cancer care delivery in Sri Lanka. METHODS: In this cross-sectional study, we distributed a web-based survey to all clinical oncologists in Sri Lanka. The survey captured data regarding clinical workload, demographic details, practice setting, and perceived barriers to quality patient care. RESULTS: A total of 41 of 54 oncologists responded to the survey, and all participants had training in clinical oncology. Thirty-seven (90%) of 41 oncologists treated both solid and hematologic malignancies, and the median duration of independent practice was 5 years. Almost two thirds of the oncologists (26 of 41, 63%) work at an academic center, and two thirds of the oncologists (27 of 41, 66%) work in both public and private sectors. A majority of the oncologists (26 of 41, 63%) were on-call 7 days per week. More than half of the oncologists saw over 400 new patient consults per year. With regard to barriers to quality patient care, most of the concerns relate to the scarcity of resources. CONCLUSION: This study sheds significant light about the clinical oncology workload landscape in Sri Lanka. Compared with other low- and middle-income countries, Sri Lankan clinical oncologists are faced with a very high workload, which may affect delivery or care.

Healthcare delivery for non-communicable diseases among breast cancer survivors in Sri Lanka: Is there a missed opportunity?

PURPOSE: Breast cancer is the most common cancer globally as well as in Sri Lanka. Improvements in cancer care have allowed patients to live to an older age. With advancing age, incidence of non-communicable diseases (NCDs) increases. Cancer diagnoses tend to take attention away from the treatment of other comorbidities, given its importance. The objective of this study was to describe healthcare delivery for NCDs among female breast cancer survivors treated at the National Cancer Institute of Sri Lanka (NCISL) and identify opportunities to optimise non-cancer medical care in this cohort. METHODS: A total of 420 women were identified from the breast cancer database at the NCISL, who were 50-80 years at the time of their breast cancer diagnosis, were within 12-24 months from the date of diagnosis, had completed their active cancer treatment and were in complete remission. Of this population, 228 (54%) women who had documented NCDs at the time of diagnosis were identified and were followed-up via telephone to collect details regarding existing comorbidities and the screening and development of new comorbidities. RESULTS: At the time of cancer diagnosis, 216/228 (95%) of patients had hypertension, 104/228 (46%) had type 2 diabetes and 17/228 (8%) had ischaemic heart disease (IHD). The prevalence of other comorbidities was very low. During the post diagnosis period, 11 patients developed type 2 diabetes, while 2 developed IHD. Osteoporosis screening using dual-energy X-ray absorptiometry scanning was very low at diagnosis 21/228 (9%) but improved in post cancer treatment follow-up 112/228 (49%, p < 0.001). Only 95/228 (42%) were screened for other cancers. CONCLUSIONS: Hypertension was the most prevalent comorbidity while type 2 diabetes and dyslipidaemia were the most common diagnoses post-treatment. In these patients, screening for osteoporosis and other cancers remains very low, emphasising a missed opportunity.

Ixekizumab Associated New-Onset Inflammatory Bowel Disease.

Ixekizumab is a monoclonal antibody targeting interleukin-17 approved for the treatment of psoriasis. In a recent post hoc meta-analysis of Phase-I to Phase-III clinical trials of anti-interleukin-17 agents for the treatment of plaque psoriasis, there was a rare association (<1%) with induction or exacerbation of inflammatory bowel disease. We report a case of new-onset ileal Crohn's disease in a 48-year-old woman on ixekizumab for psoriasis.

Polysulfonate Resins in Hyperkalemia: A Systematic Review.

BACKGROUND: Hyperkalemia is a potentially life-threatening electrolyte abnormality defined as a serum potassium above the lab reference range (usually >5.0-5.5 mEq/L). Polystyrene resins, including sodium polystyrene sulfonate (SPS) and calcium polystyrene sulfonate (CPS), have long been used to treat hyperkalemia. Sodium polystyrene sulfonate/calcium polystyrene sulfonate act by exchanging a cation for potassium within the intestinal lumen. While SPS and CPS have been available since the 1960s, there are rising concerns about the validity of the data supporting its use and about serious adverse gastrointestinal effects. OBJECTIVE: The objective of this systematic review was to quantify the efficacy and safety of polystyrene sulfonate resins (SPS/CPS) in the treatment of adults with hyperkalemia. This review focuses on the randomized control trial (RCT), interventional non-RCT, and observational data available on SPS/CPS use. DESIGN: Systematic review. SETTING: Any country of origin. Both inpatient and outpatient settings. PATIENTS: Adults with hyperkalemia treated with polystyrene sulfonate resins. MEASUREMENTS: The primary outcome was change in serum potassium. The secondary outcomes included adverse effects of SPS/CPS and prevention of recurrent hyperkalemia. METHODS: We conducted a systematic review using Cochrane Library, EMBASE (1947-2019), and Medline (1946-2019) databases. Literature reviews, systematic reviews, case studies, case series, and editorial pieces were excluded. Included studies were assessed for risk of bias. RESULTS: Four RCTs, 21 observational studies, and 5 quasi-experimental trials were included. A total of 212 351 patients were included. Two thousand and fifty-eight patients were studied for the primary outcome and 210 293 patients were studied for the secondary outcomes. Study designs were heterogeneous and not amenable to meta-analysis. Most studies included nonhemodialysis outpatients older than 65 years. Of the included studies, 22/25 (88%) demonstrated a reduction of serum potassium >0.5 mEq/L over the study period. The magnitude of reduction in serum potassium of potassium resin compared with placebo or matched controls in the 3 low-risk studies identified was 0.14 to 1.04 mEq/L. However, each study used different dosing regimens. Ten of 22 studies reported the effects of polystyrene resins on serum potassium within 24 hours. A few high-quality observational studies suggest an increased risk of serious adverse gastrointestinal events with a relative risk of 2.10 and a hazard ratio of 1.25 to 1.94; however, the absolute risk remains low. The incidence of adverse gastrointestinal events is 16 to 23 events per 1000 person-years. LIMITATIONS: We acknowledge several limitations in this study. Case studies and case series were excluded from the search results. Large case series may have been excluded despite having comparable sample sizes to studies included due to lack of a comparator and calculated estimates. Due to the heterogeneity of the studies, the data were unable to be meta-analyzed and as such the potassium-lowering effect of polystyrene sulfonate resins remains founded on small studies with potential confounders. CONCLUSIONS: This systematic review demonstrates a continued lack of high-quality evidence for the use of SPS/CPS in hyperkalemia. Studies investigated highly variable timelines and the most robust evidence for SPS/CPS use is in chronic hyperkalemia. While the absence of high-quality evidence does not exclude the possibility of benefit, prescribers must understand that the use of SPS/CPS in acute hyperkalemia is not supported by high-quality evidence. TRIAL REGISTRATION: The protocol for this systematic review was not registered.

CONTEXTE: L'hyperkaliémie est un déséquilibre électrolytique potentiellement mortel qui se définit par une concentration sérique en potassium supérieure aux valeurs de référence (généralement supérieure à 5,0-5,5 mEq/L). Les résines polystyréniques, le sulfonate de polystyrène sodique (SPS) et le sulfonate de polystyrène calcique (SPC), sont depuis longtemps utilisées pour traiter l'hyperkaliémie. Le SPS et le SPC agissent dans la lumière intestinale en échangeant un cation contre du potassium. Bien que ces résines soient disponibles depuis les années 1960, la validité des données justifiant leur utilisation et le risque d'effets indésirables graves qu'elles posent pour le système gastro-intestinal suscitent de plus en plus d'inquiétudes. OBJECTIF: Cette revue systématique visait à quantifier l'efficacité et l'innocuité des résines SPS/SPC dans le traitement de l'hyperkaliémie chez les adultes. Cette revue se concentre sur les données issues d'essais contrôlés randomisés, d'études interventionnelles non randomisées et d'études observationnelles portant sur cette utilisation. TYPE D'ÉTUDE: Revue systématique. CADRE: Les études étaient incluses peu importe le pays d'origine. Patients traités en ambulatoire ou en milieu hospitalier. SUJETS: Des adultes atteints d'hyperkaliémie traités avec les résines de sulfonate de polystyrène. MESURES: Le principal résultat était une modification de la kaliémie. Les résultats secondaires incluaient les effets indésirables des SPS/SPC et la prévention de l'hyperkaliémie récurrente. MÉTHODOLOGIE: Nous avons procédé à une revue systématique des bases de données Cochrane Library, EMBASE (1947 à 2019) et Medline (1946 à 2019). Les revues de littérature, revues systématiques, études de cas, séries de cas et éditoriaux ont été exclus. Les études incluses ont fait l'objet d'une évaluation du risque de biais. RÉSULTATS: Quatre essais contrôlés randomisés, vingt-et-une études observationnelles et cinq essais quasi expérimentaux ont été inclus, pour un total de 212 351 patients étudiés. Plus précisément, 2 058 patients ont été examinés pour le résultat principal et 210 293 patients pour les résultats secondaires. L'hétérogénéité des plans d'étude n'a pas permis de procéder à une méta-analyse. La plupart des études comprenaient des patients non hémodialysés de plus de 65 ans et traités en ambulatoire. Parmi les études incluses, 88 % (22/25) ont démontré une réduction de la kaliémie supérieure à 0,5 mEq/L au cours de la période étudiée. Dans les trois études jugées à faible risque, l'ampleur de la réduction de la kaliémie observée avec les résines par rapport au placebo ou aux témoins appariés s'établissait entre 0,14 et 1,04 mEq/L. Chaque étude avait cependant utilisé des schémas posologiques différents. Dix études sur vingt-deux rapportaient un effet des résines de polystyrène sur la kaliémie en moins de 24 heures. Quelques études observationnelles de grande qualité suggéraient un risque accru d'événements gastro-intestinaux graves (risque relatif de 2,10 et rapport de risque entre 1,25 et 1,94), mais le risque absolu demeure faible. L'incidence des événements indésirables gastro-intestinaux s'établissait entre 16 et 23 événements par 1 000 années-personnes. LIMITES: Nous reconnaissons que cette étude comporte plusieurs limites. Les études de cas et les séries de cas ont été exclues de nos résultats de recherche. De vastes séries de cas ont été exclues faute de comparateur et d'estimations calculées, bien que leurs échantillons étaient comparables à ceux d'études incluses. L'hétérogénéité des études n'a pas permis de procéder à une méta-analyse. Par conséquent, l'effet de réduction du potassium par les résines de sulfonate de polystyrène demeure fondé sur les résultats de petites études comportant de possibles variables confusionnelles. CONCLUSION: Cette revue systématique démontre l'insuffisance constante de données probantes de grande qualité appuyant l'utilisation des résines SPS et SPC pour le traitement de l'hyperkaliémie. Les études portaient sur des périodes de temps très variables et les preuves les plus robustes en faveur de l'utilisation des résines SPS et SPC concernent l'hyperkaliémie chronique. Si l'absence de données probantes de qualité n'exclut pas la possibilité de bienfaits, les médecins doivent comprendre que l'utilisation des résines SPS/SPC pour traiter l'hyperkaliémie aiguë n'est pas étayée par des preuves robustes. ENREGISTREMENT DE L'ESSAI: Le protocole de cette revue systématique n'a pas été enregistré.