Pediatric cannabis intoxication trends in the pre and post-legalization era.

INTRODUCTION: On April 13, 2017, a bill to legalize cannabis was introduced to the Canadian Parliament and presented to the public. On October 17, 2018, Canada legalized recreational cannabis use. We assessed intoxication severity, reflected by ICU admission rates, risk factors and other characteristics in children who presented to the emergency department (ED) with cannabis intoxication, before and after legalization. METHODS: A retrospective cohort study of children 0-18 years who presented to a pediatric ED between January 1, 2008 and December 31, 2019 with cannabis intoxication. The pre-legalization period was defined from January 1, 2008 to April 12, 2017 and the peri-post legalization period from April 13, 2017 to December 31, 2019. RESULTS: We identified 298 patients; 232 (77.8%) presented in the pre legalization period and 66 (22.1%) in the peri-post legalization period; median age: 15.9 years (range: 11 months-17.99 years). A higher proportion of children were admitted to the ICU in the peri-post legalization period (13.6% vs. 4.7%, respectively; p = .02). While the median monthly number of cannabis-related presentations did not differ between the time periods (2.1 [IQR:1.9-2.5] in the pre legalization period vs. 1.7 [IQR:1.0-3.0] in the peri-post legalization period; p = .69), the clinical severity did. The proportions of children with respiratory involvement (65.9% vs. 50.9%; p = .05) and altered mental status (28.8% vs. 14.2%; p < .01) were higher in the peri-post legalization period. The peri-post legalization period was characterized by more children younger than 12 years (12.1% vs. 3.0%; p = .04), unintentional exposures (14.4% vs, 2.8%; p = .002) and edibles ingestion (19.7% vs. 7.8%; p = .01). Edible ingestion was an independent predictor of ICU admission (adjusted OR: 4.1, 95%CI: 1.2-13.7, p = .02). CONCLUSIONS: The recreational cannabis legalization in Canada is associated with increased rates of severe intoxications in children. Edible ingestion is a strong predictor of ICU admission in the pediatric population.

Interventions to improve adherence to surveillance guidelines in survivors of childhood cancer: a systematic review.

PURPOSE: Many survivors of childhood cancer are at high risk of late effects of their cancer therapy, including cardiac toxicity and subsequent malignant neoplasms (SMN). Current North American guidelines recommend periodic surveillance for these late effects. We conducted a systematic review of the literature to estimate rates of adherence to recommended surveillance and summarize studies evaluating interventions intended to increase adherence. METHODS: We searched MEDLINE, Embase, Web of Science, and the Cumulative Index of Nursing and Allied Health Literature (CINAHL) for articles published between January 2000 and September 2018 that reported adherence to surveillance for cardiac toxicity and SMN (breast and colorectal cancer) and interventions implemented to improve completion of recommended testing. Risk of bias was assessed using relevant Cochrane checklists. Due to heterogeneity and overlapping study populations, we used narrative synthesis to summarize the findings. This review was registered in PROSPERO: CRD42018098878. RESULTS: Thirteen studies met our inclusion criteria for assessing adherence to surveillance, while five assessed interventions to improve rates of surveillance. No studies met criteria for low risk of bias. Completion of recommended surveillance was lowest for colorectal cancer screening (11.5-30.0%) followed by cardiomyopathy (22.3-48.1%) and breast cancer (37.0-56.5%). Factors such as patient-provider communication, engagement with the health care system, and receipt of information were consistently reported to be associated with higher rates of surveillance. Of five randomized controlled trials aimed at improving surveillance, only two significantly increase completion of recommended testing-one for echocardiography and one for mammography. Both involved telephone outreach to encourage and facilitate these tests. CONCLUSION: The majority of childhood cancer survivors at high risk of cardiac toxicity or SMN do not receive evidence-based surveillance. There is paucity of rigorous studies evaluating interventions to increase surveillance in this population. IMPLICATIONS FOR CANCER SURVIVORS: Robust trials are needed to assess whether tailored interventions, designed based on unique characteristics and needs of each survivor population, could improve adherence.

Hormone Levels in Pregnancy and Subsequent Risk of Maternal Breast and Ovarian Cancer: A Systematic Review.

OBJECTIVE: Some maternal hormone levels in pregnancy are associated with a higher risk of breast and ovarian cancer. This study systematically assessed the association between blood hormone levels measured in pregnancy and future risk of these cancers. METHODS: Two reviewers independently conducted a literature search of MEDLINE and EMBASE databases from January 1970 to August 2017. Studies were included that measured one or more serum hormone levels in pregnancy and later assessed for cancer. Cancer outcomes were considered by cancer type, each in relation to a specific maternal hormone. RESULTS: Eleven studies were included, comprising a total of 57 967 women. The interval between pregnancy and cancer onset varied from 4.1 to 20.5 years. Elevated serum chorionic gonadotropin (two of four studies) and alpha fetoprotein (two of three studies) were each associated with a lower risk of maternal breast cancer, whereas elevated estrone levels suggested a higher risk (one of three studies). Elevated testosterone (one of one study) and androstenedione (one of one study) were each associated with a significantly greater risk of sex-cord stromal ovarian tumours. Higher serum 17-hydroxyprogesterone was associated with an increased risk of sex-cord stromal (one of one study) and epithelial (one of one study) ovarian cancer. CONCLUSION: Observational studies suggest some degree of association between serum hormones measured in pregnancy and a woman's future risk of breast and ovarian cancer. More data are needed to determine sufficiently whether certain blood hormone levels measured in pregnancy are predictive of future cancer risk.

First and Second Trimester Serum sFlt-1/PlGF Ratio and Subsequent Preeclampsia: A Systematic Review.

OBJECTIVE: Angiogenic biomarkers may be predictive of preeclampsia before clinical symptoms. The objective of this review was to determine the relationship between first and second trimester soluble fms-like tyrosine kinase-1/ placental growth factor (sFlt-1/PlGF) ratio and preeclampsia. METHODS: A search algorithm using appropriate medical subject headings was developed. PubMed, EMBASE, and Cochrane were searched for publications from inception to July 4, 2017. Observational studies, including prospective and retrospective cohorts, that measured serum sFlt-1/PlGF ratio at ≤24 weeks' gestation were included. Study characteristics, study design, timing of blood samples, and outcome data were systematically extracted. Study cohorts were grouped into women with low-risk and high-risk factors for preeclampsia. RESULTS: Fifteen studies were included for analysis, including 11 779 pregnancies. In studies of women with low-risk features, four subgroups from seven studies demonstrated higher sFlt-1/PlGF ratios in women who developed preeclampsia versus those who did not. In studies of women with high-risk features, six subgroups from nine studies demonstrated a higher sFlt-1/PlGF ratio in women who later developed preeclampsia. Elevated sFlt-1/PlGF ratios were especially seen in women who had early-onset or severe preeclampsia. CONCLUSION: The serum sFlt-1/PlGF ratio measured at ≤24 weeks' gestation may be elevated in select women who later develop preeclampsia, but inconsistently so.

Dysfunctional Uterine Activity in Labour and Premature Adverse Cardiac Events: Population-Based Cohort Study.

BACKGROUND: There exist structural and physiological commonalities between myometrial and myocardial tissue, and each can become dysfunctional, such as in the presence of cardiometabolic factors. METHODS: This population-based cohort study was comprised of 1,608,720 women with ≥ 1 singleton hospital live birth at 24-41 weeks' gestation in Ontario, from 1992 to 2016. The main exposure was prolonged first stage of labour; secondary exposure was prolonged second stage of labour. The main outcome was a composite of heart failure, cardiomyopathy or dysrhythmia ≥ 1 day after the index delivery. Cox proportional hazard regression was used to generate a hazard ratio (HR), adjusted for maternal age, parity, obstructed labour or fetal malposition, preeclampsia, income quintile, rural residence, preterm birth, and infant birth weight-each at the time of delivery; time-varying drug/tobacco use, obesity, diabetes mellitus, chronic hypertension, kidney disease, dyslipidemia-each diagnosed before or at time of delivery; as well as newly diagnosed coronary artery disease or congenital heart disease arising ≥ 1 day after the index delivery. RESULTS: After a median follow-up of 10.5 and 14.0 years, respectively, there were 78 composite cardiac events (2.33 per 10,000 person-years) among women with prolonged first stage of labour vs 4114 events (2.30 per 10,000 person-years) among those without prolonged labour-a crude HR of 1.07 (95% confidence interval [CI], 0.86-1.34) and an adjusted HR of 1.09 (95% CI, 0.87-1.36). Women with prolonged second stage of labour had an adjusted HR of 0.86 (95% CI, 0.75-0.99) for the composite outcome. CONCLUSIONS: Women with prolonged labour do not appear to be at a higher short-term risk of cardiac outcomes.

Preferences and Utilities for Health States after Treatment of Olfactory Groove Meningioma: Endoscopic versus Open.

Objectives The purpose of this study is to report health utility scores for patients with olfactory groove meningiomas (OGM) treated with either the standard transcranial approach, or the expanded endonasal endoscopic approach. Design The time trade-off technique was used to derive health utility scores. Setting Healthy individuals without skull base tumors were surveyed. Main Outcome Measures Participants reviewed and rated scenarios describing treatment (endoscopic, open, stereotactic radiation, watchful waiting), remission, recurrence, and complications associated with the management of OGMs. Results There were 51 participants. The endoscopic approach was associated with higher utility scores compared with an open craniotomy approach (0.88 vs. 0.74; p < 0.001) and watchful waiting (0.88 vs.0.74; p = 0.002). If recurrence occurred, revision endoscopic resection continued to have a higher utility score compared with revision open craniotomy (0.68; p = 0.008). On multivariate analysis, older individuals were more likely to opt for watchful waiting ( p = 0.001), whereas participants from higher income brackets were more likely to rate stereotactic radiosurgery with higher utility scores ( p = 0.017). Conclusion The endoscopic approach was associated with higher utility scores than craniotomy for primary and revision cases. The present utilities can be used for future cost-utility analyses.