Long-term follow-up of surgical outcomes for patients with Wilms tumor and neuroblastoma.

BACKGROUND: There are minimal data on long-term surgical outcomes of patients who have undergone resection for Wilms tumor (WT) and neuroblastoma (NB). METHODS: A retrospective review of patients in a long-term survivor clinic between the years 1967 and 2016 in a pediatric tertiary care hospital (>5 years posttreatment) was performed. RESULTS: Eighty-six survivors of WT and 86 survivors of NB who had ongoing follow-up in the survivors' clinic were identified. The median age at diagnosis was 2.5 years (range, 0.4-15.7 years) with a mean follow-up of 22.3 years (±10.4 years) for WT. The median age at diagnosis for patients with NB was 0.9 years (range, 0.1-8.6 months); mean follow-up of 21.7 years (±7.9 years). Twelve patients with WT (14.0%) had at least 1 repeat laparotomy, 11.1% for bowel obstruction, at a median of 3 months from initial surgery. Twelve patients (14.0%) with NB required laparotomy and 8.1% for bowel obstruction, at a median of 12 years after initial surgery. The incidence of hypertension in patients with WT who had undergone nephrectomy was not outside of population norms. Patients who underwent thoracotomy for a NB have a higher incidence of scoliosis and Horner syndrome. CONCLUSIONS: Small bowel obstruction requiring laparotomy is significantly higher than the literature norms for both tumor patient populations and typically occurs in the early postoperative period for patients with WT and remotely in patients with NB. The long-term surgical complications of patients who underwent resection for NB and WT clearly merit follow-up and patient education within multidisciplinary long-term survivorship clinics.

Transitional care practices, services, and delivery in childhood cancer survivor programs: A survey study of U.S. survivorship providers.

PURPOSE: There are limited reports describing transition of young adult childhood cancer survivors (CCS) from pediatric to adult-focused survivorship care. The purpose of this study was to characterize current transitional care practices in the United States. PROJECT DESCRIPTION: An online survey was sent to one preselected respondent at 163 Children's Oncology Group member institutions in the United States. Data were collected about (i) the availability and type of long-term follow-up services for adult CCS and (ii) policies and procedures for transitioning. Logistic regression was used to evaluate factors related to care for CCS. RESULTS: The response rate was 60% (97/163). Eighty-one respondents (84%) represented centers with specialized pediatric-focused CCS programs. Thirty-nine percent (38/97) of programs delivered specialized transitional care for adult CCS. Adult-centered care was delivered in both pediatric (39%, 15/38) and adult oncology clinics (39%, 15/38). The most common perceived transition barriers were lack of available partnering adult providers and adult providers' lack of knowledge regarding CCS. The larger the program in terms of new diagnoses, the more likely they were to offer formal transitional care (<50 vs >200: odds ratios [OR] 20.0; 95% CI 3.2, 100.0, P = 0.004). CONCLUSIONS: A variety of models are utilized for delivering care to adult CCS. Our results suggest that interventions to establish effective partnerships with adult providers on appropriate care of CCS may facilitate expanded availability of these services.

Near-Real-Time Surveillance of Illnesses Related to Shellfish Consumption in British Columbia: Analysis of Poison Center Data.

BACKGROUND: Data from poison centers have the potential to be valuable for public health surveillance of long-term trends, short-term aberrations from those trends, and poisonings occurring in near-real-time. This information can enable long-term prevention via programs and policies and short-term control via immediate public health response. Over the past decade, there has been an increasing use of poison control data for surveillance in the United States, Europe, and New Zealand, but this resource still remains widely underused. OBJECTIVE: The British Columbia (BC) Drug and Poison Information Centre (DPIC) is one of five such services in Canada, and it is the only one nested within a public health agency. This study aimed to demonstrate how DPIC data are used for routine public health surveillance in near-real-time using the case study of its alerting system for illness related to consumption of shellfish (ASIRCS). METHODS: Every hour, a connection is opened between the WBM software Visual Dotlab Enterprise, which holds the DPIC database, and the R statistical computing environment. This platform is used to extract, clean, and merge all necessary raw data tables into a single data file. ASIRCS automatically and retrospectively scans a 24-hour window within the data file for new cases related to illnesses from shellfish consumption. Detected cases are queried using a list of attributes: the caller location, exposure type, reasons for the exposure, and a list of keywords searched in the clinical notes. The alert generates a report that is tailored to the needs of food safety specialists, who then assess and respond to detected cases. RESULTS: The ASIRCS system alerted on 79 cases between January 2015 and December 2016, and retrospective analysis found 11 cases that were missed. All cases were reviewed by food safety specialists, and 58% (46/79) were referred to designated regional health authority contacts for follow-up. Of the 42% (33/79) cases that were not referred to health authorities, some were missing follow-up information, some were triggered by allergies to shellfish, and some were triggered by shellfish-related keywords appearing in the case notes for nonshellfish-related cases. Improvements were made between 2015 and 2016 to reduce the number of cases with missing follow-up information. CONCLUSIONS: The surveillance capacity is evident within poison control data as shown from the novel use of DPIC data for identifying illnesses related to shellfish consumption in BC. The further development of surveillance programs could improve and enhance response to public health emergencies related to acute illnesses, chronic diseases, and environmental exposures.

Long-term morbidity after staging laparotomy for Hodgkin lymphoma.

BACKGROUND: A large cohort of Hodgkin lymphoma (HL) survivors exist. With patients transitioning from pediatric to adult care, practitioners should be aware of potential complications. The aim of this study was to describe the long-term complications of patients who had staging laparotomy for the treatment of HL. METHODS: After institutional review board approval, a retrospective review of hospital records at our institution was performed. Data extracted included demographics, treatment course and long-term postoperative complications. RESULTS: 24 patients with HL underwent staging laparotomy from 1971 to 1994 with median follow-up of 27.9years. Six (33%) had intraabdominal disease. Three patients (17%) required four repeat laparotomies for bowel obstruction. Of these, one had radiation to the inguinal region for local control, one had mantle radiation. Five patients developed a second malignancy. There were no documented cases of postsplenectomy sepsis. Other late effects that were unlikely related to surgery included pulmonary fibrosis (4), heart failure (2), hypothyroidism (4), and dysphagia (3). One patient died of metastatic adenocarcinoma. CONCLUSIONS: Long-term follow-up of patients who underwent staging laparotomy for HL revealed an increased incidence of repeat laparotomy and secondary malignancy. This underscores the importance of a high index of suspicion and screening in this population. LEVEL OF EVIDENCE: Level III.

Calls to the British Columbia Drug and Poison Information Centre: A summary of differences by health service areas.

OBJECTIVES: Poison control centres provide information on the management of poisoning incidents. The British Columbia (BC) Drug and Poison Information Centre recently implemented an electronic database system for recording case information, making it easier to use case data as a potential source of population-based information on health services usage and health status. This descriptive analysis maps poisoning case rates in BC, highlighting differences in patient age, substance type, medical outcome, and caller location. METHODS: There were 50,621 human exposure cases recorded during 2012 and 2013. Postal code or city name was used to assign each case to a Health Service Delivery Area (HSDA). Case rates per 1,000 person-years were calculated, including crude rates, age-standardized rates, age-specific rates, and rates by substance type, medical outcome, and caller location. RESULTS: The lowest case rate was observed in Richmond, a city where many residents do not speak English as a first language. The highest rate was observed in the Northwest region, where the economy is driven by resource extraction. Pharmaceutical exposures were elevated in the sparsely populated northern and eastern areas. Calls from health care facilities were highest in the Northwest region, where there are many remote Aboriginal communities. CONCLUSIONS: Case rates were generally highest in the primarily rural northern and eastern areas of the province. Considering these results alongside contextual factors informs further investigation and action: addressing cultural and language barriers to accessing poison centre services, and developing a public health surveillance system for severe poisoning events in rural and remote communities.

Reduced cardiorespiratory fitness in adult survivors of childhood acute lymphoblastic leukemia.

BACKGROUND: Adult survivors of childhood acute lymphoblastic leukemia (ALL) are at increased cardiovascular risk. Studies of factors including treatment exposures that may modify risk of low cardiorespiratory fitness in this population have been limited. PROCEDURE: To assess cardiorespiratory fitness, maximal oxygen uptake (VO2 max) was measured in 115 ALL survivors (median age, 23.5 years; range 18-37). We compared VO2 max measurements for ALL survivors to those estimated from submaximal testing in a frequency-matched (age, gender, race/ethnicity) 2003-2004 National Health and Nutritional Examination Survey (NHANES) cohort. Multivariable linear regression models were constructed to evaluate the association between therapeutic exposures and outcomes of interest. RESULTS: Compared to NHANES participants, ALL survivors had a substantially lower VO2 max (mean 30.7 vs. 39.9 ml/kg/min; adjusted P < 0.0001). For any given percent total body fat, ALL survivors had an 8.9 ml/kg/min lower VO2 max than NHANES participants. For key treatment exposure groups (cranial radiotherapy [CRT], anthracycline chemotherapy, or neither), ALL survivors had substantially lower VO2 max compared with NHANES participants (all comparisons, P < 0.001). Almost two-thirds (66.7%) of ALL survivors were classified as low cardiorespiratory fitness compared with 26.3% of NHANES participants (adjusted P < 0.0001). In multivariable models including only ALL survivors, treatment exposures were modestly associated with VO2 max. Among females, CRT was associated with low VO2 max (P = 0.02), but anthracycline exposure was not (P = 0.58). In contrast, among males, anthracycline exposure ≥ 100 mg/m(2) was associated with low VO2 max (P = 0.03), but CRT was not (P = 0.54). CONCLUSION: Adult survivors of childhood ALL have substantially lower levels of cardiorespiratory fitness compared with a similarly aged non-cancer population.

Contribution of diet and physical activity to metabolic parameters among survivors of childhood leukemia.

PURPOSE: Determine the relationship between diet and metabolic abnormalities among adult survivors of childhood acute lymphoblastic leukemia (ALL). METHODS: We surveyed 117 adult survivors of childhood ALL using the Harvard Food Frequency Questionnaire. Physical activity energy expenditure (PAEE) was measured with the SenseWear Pro2 Armband. Insulin resistance was estimated using the Homeostasis Model for Insulin Resistance (HOMA-IR). Visceral and subcutaneous adiposity were measured by abdominal CT. Adherence to a Mediterranean diet pattern was calculated using the index developed by Trichopoulou. Subjects were compared using multivariate analysis adjusted for age and gender. RESULTS: Greater adherence to a Mediterranean diet pattern was associated with lower visceral adiposity (p = 0.07), subcutaneous adiposity (p < 0.001), waist circumference (p = 0.005), and body mass index (p = 0.04). For each point higher on the Mediterranean Diet Score, the odds of having the metabolic syndrome fell by 31 % (OR 0.69; 95 % CI 0.50, 0.94; p = 0.019). Higher dairy intake was associated with higher HOMA-IR (p = 0.014), but other individual components of the Mediterranean diet, such as low intake of meat or high intake of fruits and vegetables, were not significant. PAEE was not independently associated with metabolic outcomes, although higher PAEE was associated with lower body mass index. CONCLUSIONS: Adherence to a Mediterranean diet pattern was associated with better metabolic and anthropometric parameters in this cross-sectional study of ALL survivors.

Atherogenic low density lipoprotein phenotype in long-term survivors of childhood acute lymphoblastic leukemia.

Survivors of childhood acute lymphoblastic leukemia (ALL) have an increased risk of cardiovascular disease. Small density lipoproteins are atherogenic but have not been studied in this population. We conducted a cross-sectional analysis of 110 ALL survivors (mean age, 24.3 years) to determine prevalence of small dense LDL (pattern B) phenotype in ALL survivors and identify associated factors. Lipid subfractions were measured using Vertical Auto Profile-II. Participants with greater than 50% of LDL-cholesterol (LDL-c) in small dense LDL fractions (LDL(3+4)) were classified as LDL pattern B. Visceral and subcutaneous adipose tissue (VAT, SAT) volumes were also measured by computed tomography. While the mean LDL-c level of ALL survivors was 108.7 ± 26.8 mg/dl, 36% (40/110) of survivors had atherogenic LDL pattern B. This pattern was more common in males (26/47; 55%) than in females (14/63; 22%, P = 0.001) and more common in survivors treated with cranial radiotherapy (15/33; 45%) than in those who were treated with chemotherapy alone (25/77; 33%; P = 0.04, adjusted for age, gender, history of hypertension, and smoking history). VAT was associated with atherogenic lipids: LDL pattern B and LDL(3+4) levels. This association was independent of other measures of body fat. We conclude that a substantial proportion of ALL survivors had an atherogenic LDL phenotype despite normal mean LDL-c levels. An atherogenic LDL phenotype may contribute to the increase in cardiovascular mortality and morbidity in this population.

Hereditary cancer risk assessment in a pediatric oncology follow-up clinic.

BACKGROUND: Pediatric cancer survivors are at risk for multiple late effects including second malignancies, some a direct consequence of genetic susceptibility. Appropriate surveillance and management for the survivor and at-risk family members can often be established if the genetic predisposition is recognized and/or diagnosed. Numerous published guidelines outline which adult cancer patients and survivors should be referred for hereditary cancer risk assessment. In the pediatric oncology setting, minimal guidance exists for healthcare providers to determine which patients and families to refer for genetic evaluation. PROCEDURE: The aim of this project was to determine what percentage of childhood cancer survivors are appropriate for further evaluation in a hereditary cancer program or genetics clinic and characterize indications for referral. Participants included pediatric cancer survivors seen for follow-up in a large cancer survivor center. Medical and family histories were obtained and reviewed by a certified genetic counselor at the survivor's annual visit. Eligibility for genetics referral was determined based on personal/family medical history and published literature. RESULTS: Of 370 survivors of childhood cancer, 109 (29%) were considered eligible for genetics follow-up or referral. Family history of cancer is the most prevalent reason identified for eligibility for further genetics evaluation (61%) followed by tumor type (18%), medical history (16%), and family history of another condition (6%). CONCLUSIONS: This project provides evidence that inclusion of genetic evaluation is feasible and relevant in the care of childhood cancer survivors. Further study is warranted to determine optimal timing and clinical utility of this multidisciplinary and family-centered approach.

Cancer survivorship practices, services, and delivery: a report from the Children's Oncology Group (COG) nursing discipline, adolescent/young adult, and late effects committees.

PURPOSE: To describe survivorship services provided by the Children's Oncology Group (COG), an assessment of services was undertaken. Our overall aims were (1) to describe survivorship services, including the extent of services provided, resources (personnel, philanthropy, and research funding), billing practices, and barriers to care and 2) to describe models of care that are in use for childhood cancer survivors and adult survivors of childhood cancer. METHODS: One hundred seventy-nine of 220 COG institutions (81%) completed an Internet survey in 2007. RESULTS: One hundred fifty-five (87%) reported providing survivorship care. Fifty-nine percent of institutions provide care for their pediatric population in specialized late effects programs. For adult survivors, 47% of institutions chose models of care, which included transitioning to adult providers for risk-based health care, while 44% of institutions keep survivors indefinitely at the treating institution (Cancer Center Based Model without Community Referral). Sixty-eight percent provide survivors with a copy of their survivorship care plan. Only 31% of institutions provide a detailed summary of results after each clinic visit, and 41% have a database to track survivor health outcomes. Minimal time required for initial and annual survivorship visits is estimated to be approximately 120 and 90 min, respectively. The most prevalent barriers to care were the lack of dedicated time for program development and a perceived insufficient knowledge on the part of the clinician receiving the transition referral. CONCLUSIONS: Not all COG institutions provide dedicated survivorship care, care plans, or have databases for tracking outcomes. Transitioning to adult providers is occurring within the COG. Survivorship care is time intensive.

Childhood cancer survivorship educational resources in North American pediatric hematology/oncology fellowship training programs: a survey study.

BACKGROUND: Childhood cancer survivors require life-long care by clinicians with an understanding of the specific risks arising from the prior cancer and its therapy. We surveyed North American pediatric hematology/oncology training programs to evaluate their resources and capacity for educating medical trainees about survivorship. PROCEDURE: An Internet survey was sent to training program directors and long-term follow-up clinic (LTFU) directors at the 56 US and Canadian centers with pediatric hematology/oncology fellowship programs. Perceptions regarding barriers to and optimal methods of delivering survivorship education were compared among training program and LTFU clinic directors. RESULTS: Responses were received from 45/56 institutions of which 37/45 (82%) programs require that pediatric hematology/oncology fellows complete a mandatory rotation focused on survivorship. The rotation is 4 weeks or less in 21 programs. Most (36/45; 80%) offer didactic lectures on survivorship as part of their training curriculum, and these are considered mandatory for pediatric hematology/oncology fellows at 26/36 (72.2%). Only 10 programs (22%) provide training to medical specialty trainees other than pediatric hematology/oncology fellows. Respondents identified lack of time for trainees to spend learning about late effects as the most significant barrier to providing survivorship teaching. LTFU clinic directors were more likely than training program directors to identify lack of interest in survivorship among trainees and survivorship not being a formal or expected part of the fellowship training program as barriers. CONCLUSIONS: The results of this survey highlight the need to establish standard training requirements to promote the achievement of basic survivorship competencies by pediatric hematology/oncology fellows.

Increasing rates of breast cancer and cardiac surveillance among high-risk survivors of childhood Hodgkin lymphoma following a mailed, one-page survivorship care plan.

BACKGROUND: Hodgkin lymphoma (HL) survivors face substantially elevated risks of breast cancer and cardiovascular disease. They and their physicians are often unaware of these risks and surveillance recommendations. PROCEDURE: A prospective one-arm study was conducted among a random sample of 72 HL survivors, ages 27-55 years, participating in the Childhood Cancer Survivor Study (CCSS) who were at increased risk for breast cancer and/or cardiomyopathy and had not had a screening mammogram or echocardiogram, respectively, within the prior 2 years. A one-page survivorship care plan with recommendations for surveillance was mailed to participants. In addition, survivors' primary physicians were contacted and provided patient-specific information and a web-based Virtual Information Center was made available for both survivors and physicians. Outcomes were assessed by telephone 6 months after the intervention. RESULTS: The survivor participation (62/72; 86%) and 6-month retention (56/61; 92%) rates were high. Tension and anxiety, measured by the Profile of Mood States, did not increase following risk notification; 91% of survivors described their reactions to receiving the information in positive terms. At 6 months, 41% of survivors reported having completed the recommended mammogram; 20% reported having an echocardiogram (females 30%, males 10%). Only 29% of survivors visited the website. Nine physicians enrolled, and none used the study resources. CONCLUSION: A mailed, personalized survivorship care plan was effective in communicating risk and increasing compliance with recommended medical surveillance. Internet- and telephone-based strategies to communicate risk were not utilized by survivors or physicians.

Transitioning survivors of central nervous system tumors: challenges for patients, families, and health care providers.

Survivors of central nervous system tumors (SCNST) are a growing group of cancer survivors who require risk-based, long-term health care due to the chemotherapy, surgery, and radiation they have received.Although treatment strategies are being developed to reduce morbidity and mortality, ultimately this subgroup of pediatric cancer survivors often faces moderate to severe late effects of their treatment.As a result, they will need lifelong health care that includes risk-based health care due to cancer treatment exposures as well as primary adult health care, including primary and secondary preventative care. The best way to accomplish lifelong health care for SCNST as they enter adulthood is not clearly defined. In this article, the authors plan to (1) present an overview of the complexities of health care problems that make transition challenging for SCNST; (2) review the evolving transition literature; (3) explore the barriers to successful transition; (4) discuss methods to facilitate transition; (5) describe approaches, strategies, and models for survivorship care in SCNST; (6) present issues for consideration when transitioning SCNST; and (7) provide information on transition-related resources.

Insulin resistance and risk factors for cardiovascular disease in young adult survivors of childhood acute lymphoblastic leukemia.

PURPOSE: To determine the prevalence of insulin resistance and other risk factors for cardiovascular disease (CVD) in young adult survivors of childhood acute lymphoblastic leukemia (ALL). PATIENTS AND METHODS: In this cross-sectional evaluation of 118 survivors of childhood ALL (median age, 23.0 years; range, 18 to 37 years), insulin resistance was estimated using the homeostasis model for assessment of insulin resistance (HOMA-IR). Sex-specific comparisons were made with a cohort of 30- to 37-year-old individuals from the same region participating in the Dallas Heart Study (DHS, N = 782). ALL survivors were stratified by treatment with and without cranial radiotherapy (CRT). RESULTS: Female ALL survivors had a significantly higher HOMA-IR (CRT, mean 4.6, 95% CI, 3.6 to 5.7; no CRT, mean 3.3, 95% CI, 2.8 to 3.8) in comparison with DHS women (mean 2.4, 95% CI, 2.2 to 2.7). Eighty percent of women treated with CRT had at least three of six CVD risk factors, and they were significantly more likely to have three or more risk factors compared with DHS women (odds ratio [OR], 5.96; 95% CI, 2.15 to 16.47). Male ALL survivors had a significantly higher HOMA-IR (CRT, mean 4.0, 95% CI, 2.8 to 5.6; no CRT, mean 3.4, 95% CI, 2.9 to 3.9) in comparison with DHS men (mean 2.3, 95% CI, 2.1 to 2.6), but were not more likely to have multiple CVD risk factors. CONCLUSION: ALL survivors had an increased prevalence of insulin resistance in comparison with a cohort of older individuals from the same community. Importantly, women treated with CRT seem to have an increased prevalence of multiple CVD risk factors, warranting close monitoring and risk-reducing strategies.

Adequacy of antidote stocking in British Columbia hospitals: the 2005 Antidote Stocking Study.

BACKGROUND: Inadequate hospital stocking and the unavailability of essential antidotes is a worldwide problem with potentially disastrous repercussions for poisoned patients. Research indicates minimal progress has been made in the resolution of this issue in both urban and rural hospitals. In response to this issue the British Columbia Drug and Poison Information Centre developed provincial antidote stocking guidelines in 2003. We sought to determine the compliance with antidote stocking in BC hospitals and any factors associated with inadequate supply. METHODS: A 2-part survey, consisting of hospital demographics and antidote stocking information, was distributed in 2005 to all acute care hospital pharmacy directors in BC. The 32 antidotes examined (21 deemed essential) and the definitions of adequacy were based on the 2003 BC guidelines. Availability was reported as number of antidotes stocked per hospital and proportion of hospitals stocking each antidote. For secondary purposes, we assessed factors potentially associated with inadequate stocking. RESULTS: Surveys were completed for all 79 (100%) hospitals. A mean of 15.6+/-4.9 antidotes were adequately stocked per hospital. Over 90% of hospitals had adequate stocks of N-acetylcysteine, activated charcoal, naloxone, calcium salts, flumazenil and vitamin K; 71%-90% had adequate dextrose 50% in water (D50W), ethyl alcohol or fomepizole, polyethylene glycol electrolyte solution, protamine sulfate, and cyanide antidotes; 51%-70% had adequate folic acid, glucagon, methylene blue, atropine, pralidoxime, leucovorin, pyridoxine, and deferoxamine; and <50% had adequate isoproterenol and digoxin immune Fab. Only 7 (8.9%) hospitals sufficiently stocked all 21 essential antidotes. Factors predicting poor stocking included small hospital size (p < 0.0001), isolation (p = 0.01) and rural location (p < 0.0001). CONCLUSION: Although antidote stocking has improved since the implementation of the 2003 guidelines, essential antidotes are absent in many BC hospitals. Future research should focus on determining the reasons for this situation and the effects of corrective interventions.

Recruitment strategies for minority participation: challenges and cost lessons from the POWER interview.

BACKGROUND: The importance of recruiting and retaining women from diverse populations is well recognized; however, the recruitment process often presents greater challenges at higher costs than initially anticipated. OBJECTIVES: To describe recruitment strategies and costs from a study evaluating women's preferences regarding tamoxifen use for primary prevention of breast cancer. DESIGN: Description and analysis of recruitment strategies, outcomes, and costs for a cross-sectional interview study. SETTING: University hospital and community sites. PARTICIPANTS: 932 racially and ethnically diverse women respondents, of whom 771 completed the screening process (aged 27-87). INTERVENTION: Women were recruited and screened by using the Breast Cancer Risk Assessment Program (BCRA version 1, National Cancer Institute). Eligibility required an estimated five-year breast cancer risk of at least 1.7%. Recruitment goals targeted a high percentage of ethnic minorities. METHODS: Recruitment strategies included direct mail, flyers, newspapers, media advertising, and community outreach. RESULTS: Of the 771 screened women, 341 (44%) met eligibility criteria and 255 (33%) completed interviews (76.9% White, 10.6% Latina, 7.0% Asian, 3.9% African American, 1.6% Native American). Recruitment costs averaged US $113/screened participant. Direct mail and community contact yielded the largest number of participants (312 screened, 205 eligible). Radio advertising provided few participants (one screened, one eligible) at high cost. CONCLUSIONS: Recruiting an ethnically diverse sample presented multiple challenges. We recommend that future studies budget adequately for recruitment time and costs, develop ongoing relationships with key community leaders, evaluate recruitment strategies closely, and report detailed recruitment findings to the research community.

Delayed dystonia following pimozide overdose in a child.

BACKGROUND: Pimozide overdose has rarely been reported in children. In adults, pimozide intoxication may cause seizures, extrapyramidal and anticholinergic effects, hypotension, QTc prolongation and torsades de pointes. We report dystonia, hypotension and drowsiness following pimozide ingestion in a child. CASE REPORT: An alert 18-month-old presented to hospital 40 minutes after ingesting up to 6 mg (0.5 mg/kg) of pimozide. Vital signs: BP 91/62 mmHg, HR 130/min, RR 26/min, temperature 97.2 degrees F (36.2 degrees C). She received gastric lavage and activated charcoal. One hour later, her QTc interval was 420 msec, HR 150. She remained asymptomatic until 12 hours post-ingestion, when she developed drooling, tongue thrusting and drowsiness. BP was 75/40, HR 150, QTc 440 msec. BP increased to 95/50 after a bolus of normal saline. Her dystonia subsided over the next 12 hours without treatment. Drowsiness and tachycardia persisted until 40 hours post-ingestion. QTc interval at this time was 370 msec. Patient recovered without sequelae. CONCLUSION: Pimozide overdose in children may be associated with delayed onset of symptoms, including dystonia.

Salty broth for salicylate poisoning? Adequacy of overdose management advice in the 2001 Compendium of Pharmaceuticals and Specialties.

BACKGROUND: The Compendium of Pharmaceuticals and Specialties (CPS) is a collection of monographs written by pharmaceutical companies and published by the Canadian Pharmacists Association. The CPS is widely available and is consulted frequently by Canadian physicians. We examined overdose management advice contained in the CPS to see whether it reflects current standards. METHODS: We restricted our review to 10 classes of medication for which an overdose is frequently fatal: acetaminophen, beta-blockers, calcium-channel blockers, digoxin, lithium, opioids, salicylates, tricyclic antidepressants, theophylline and valproic acid. A panel of 3 toxicologists arrived at a consensus on indicated, contraindicated and futile interventions for each of these classes of drug. Monographs were then rated for their inclusion of essential interventions as excellent (listed all interventions and unique supportive care issues and gave correct and complete indications), good (listed the key interventions and gave correct and complete indications), fair (listed the key indications but failed to give proper indications) or poor (failed to list the key interventions). Monographs were also rated on how well they warned against contraindicated interventions as excellent (did not advocate any futile or contraindicated treatments and warned against contraindicated treatments), good (did not advocate any futile or contraindicated treatments), fair (did not advocate any contraindicated treatments but did list some simple futile treatments) or poor (advocated contraindicated or complicated futile treatments, such as unnecessary hemodialysis). We also considered whether the monograph would allow a clinician to manage an overdose, whether it served to refresh one's memory and whether it was simply misleading or dangerous. RESULTS: We reviewed 119 monographs, of which 25 (21%) were adequate to allow a clinician to manage an overdose. Another 25 monographs were not adequate to allow a clinician to manage an overdose but would serve to refresh the memory regarding key management points. Sixty monographs (50%) contained misleading or dangerous advice. Nine monographs (8%) did not fall into any of these categories. In terms of listing essential interventions, 61 monographs (51%) were poor, 35 (29%) were fair, 22 (18%) were good, and 1 (1%) was excellent. For warning against contraindicated interventions, 57 monographs (48%) were poor, 9 (8%) were fair, 51 (43%) were good, and 2 (2%) were excellent. INTERPRETATION: Overdose management advice in the CPS is inadequate in most cases and is misleading or dangerous in half of the monographs examined. These sections should be omitted or rewritten to reflect current standards of care. Physicians should refer to authoritative sources (e.g., current toxicology texts, computerized databases or local poison control centres) for poisoning management advice.