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Background Radiation therapy is a mainstay of treatment for brain tumors, but delayed complications include secondary malignancy which may occur months to years after treatment completion. Methods We reviewed the medical records of a 41-year-old female treated with 60 Gy of radiation for a recurrent astrocytoma, who 6 years later developed a locally advanced sinonasal teratocarcinosarcoma. We searched MEDLINE, Embase, and Web of Science to conduct a scoping review of biopsy-proven sinonasal malignancy in patients who previously received cranial irradiation for a brain tumor. Results To our knowledge, this is the first report of a patient to present with a sinonasal teratocarcinosarcoma after receiving irradiation for a brain tumor. Our scoping review of 1,907 studies produced 14 similar cases of secondary sinonasal malignancy. Median age of primary cancer diagnosis was 39.5 years old (standard deviation [SD]: 21.9), and median radiation dose was 54 Gy (SD: 20.3). Median latency time between the primary cancer and secondary sinonasal cancer was 9.5 years (SD: 5.8). Olfactory neuroblastoma was the most common sinonasal cancer ( n = 4). Fifty percent of patients died from their sinonasal cancer within 1.5 years. Conclusion Patients who receive radiation exposure to the sinonasal region for treatment of a primary brain tumor, including low doses or scatter radiation, may be at risk of a secondary sinonasal malignancy later in life. Physicians who monitor at-risk patients must be vigilant of symptoms which may suggest sinonasal malignancy, and surveillance should include radiographic review with careful monitoring for a secondary malignancy throughout the entire irradiated field.
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BACKGROUND: Dentists serve a crucial role in managing treatment complications for patients with head and neck cancer, including post-radiation caries and oral infection. To date, dental services for head and neck cancer patients in Ontario, Canada have not been well characterized and considerable disparities in allocation, availability, and funding are thought to exist. The current study aims to describe and assess the provision of dental services for head and neck cancer patients in Ontario. METHODS: A mixed methods scoping assessment was conducted. A purposive sample of dentist-in-chiefs at each of Ontario's 9 designated head and neck cancer centres (tertiary centres which meet provincially-set quality and safety standards) was invited to participate. Participants completed a 36-item online survey and 60-minute semi-structured interview which explored perceptions of dental services for head and neck cancer patients at their respective centres, including strengths, gaps, and inequities. If a centre did not have a dentist-in-chief, an alternative stakeholder who was knowledgeable on that centre's dental services participated instead. Thematic analysis of the interview data was completed using a mixed deductive-inductive approach. RESULTS: Survey questionnaires were completed at 7 of 9 designated centres. A publicly funded dental clinic was present at 5 centres, but only 2 centres provided automatic dental assessment for all patients. Survey data from 2 centres were not captured due to these centres' lack of active dental services. Qualitative interviews were conducted at 9 of 9 designated centres and elicited 3 themes: (1) lack of financial resources; (2) heterogeneity in dentistry care provision; and (3) gaps in the continuity of care. Participants noted concerning under-resourcing and limitations/restrictions in funding for dental services across Ontario, resulting in worse health outcomes for vulnerable patients. Extensive advocacy efforts by champions of dental services who have sought to mitigate current disparities in dentistry care were also described. CONCLUSIONS: Inequities exist in the provision of dental services for head and neck cancer patients in Ontario. Data from the current study will broaden the foundation for evidence-based decision-making on the allocation and funding of dental services by government health care agencies.
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Cárie Dentária , Neoplasias de Cabeça e Pescoço , Doenças da Boca , Humanos , Ontário , Atenção à Saúde , Cárie Dentária/terapia , Assistência OdontológicaRESUMO
Autografts and allografts are commonly used in microtia reconstruction. We aimed to systematically review and compare these reconstructive materials in pediatric congenital microtia reconstruction. A systematic review of the literature was performed. MEDLINE, Embase, PubMed, Web of Science, and CINAHL databases were searched for original studies on congenital microtia reconstruction in pediatric patients since database inception to 2021. Microtia grade was stratified as high or low. Meta-analysis of pooled proportions and continuous variables was performed using inverse variance weighting with a random effects model to compare between the autograft and allograft groups. Sixty-eight studies with a total of 5,546 patients used autografts (n = 5,382) or alloplastic implants (n = 164). Four other studies used prosthesis, cadaveric homografts, or tissue engineering. The allograft group was on average younger than the autograft group (8.4 vs. 11.1 years). There were no syndromic patients in the allograft group, compared to 43% in the autograft group. Patients treated with allografts had higher microtia grade than those treated with autograft (98 vs. 72%). Autografts were more commonly utilized by plastic surgeons and allografts by otolaryngologists (95 vs. 38%). No autografts and 41% of allografts were done concurrently with atresiaplasty or bone conduction implant. Satisfaction rates were similarly high (>90%) with similar complication rates (<10%). Microtia reconstruction using autografts and allografts had similar satisfaction and complication rates. Allografts were preferred for younger patients and concurrent hearing restoration. Further large-scale studies are required to evaluate the long-term efficacy of these reconstructive techniques.
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OBJECTIVE: Percutaneous tracheostomy is routinely performed in adult patients but is seldomly used in the pediatric population due to concerns regarding safety and limited available evidence. This study aims to consolidate the current literature on percutaneous tracheostomy in the pediatric population. METHODS: A systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was conducted. MEDLINE, EMBASE, CINAHL, and Web of Science were searched for studies on pediatric percutaneous tracheostomy (age ≤18). The Joanna Briggs Institute and ROBINS-I tools were used for quality appraisal. RESULTS: Twenty-one articles were included resulting in 143 patients. Patient age ranged from 2 days to 17 years, with the largest subpopulation of patients (n = 57, 40 %) being adolescents (age between 12 and 17 years old). Main indications for percutaneous tracheostomy included prolonged ventilation (n = 6), respiratory insufficiency (n = 5), and upper airway obstruction (n = 5). One-third (n = 47) of percutaneous tracheostomies were completed at the bedside in an intensive care unit. Select studies reported on surgical time and time from intubation to tracheostomy with a mean of 13.8 (SD = 7.8) minutes (n = 27) and 8.9 (SD = 2.8) days (n = 35), respectively. Major postoperative complications included tracheoesophageal fistula (n = 4, 2.8 %) and pneumothorax (n = 3, 2.1 %). There were four conversions to open tracheostomy. CONCLUSION: Percutaneous tracheostomy had a similar risk of complications to open surgical tracheostomy in children and adolescents and can be performed at the bedside in a select group of patients if necessary. However, we feel that consideration must be given to the varying anatomical considerations in children and adolescents compared with adults, and therefore suggest that this procedure be reserved for adolescent patients with a thin body habitus and clearly demarcated and palpable anatomical landmarks who require a tracheostomy. When performed, we strongly support using endoscopic guidance and a surgeon who has the ability to convert to an open tracheostomy if required.
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Traqueostomia , Humanos , Traqueostomia/métodos , Traqueostomia/efeitos adversos , Criança , Adolescente , Pré-Escolar , Lactente , Complicações Pós-Operatórias/epidemiologia , Recém-Nascido , Feminino , MasculinoRESUMO
As a key component of overall health and quality of life, oral health is recognized by public health organizations globally as a basic human right. Dentists are oral health experts involved in the primary prevention of oral injury and the detection and management of oral diseases. As regulated healthcare professionals, dentists identify and treat dental caries, gum disease, oral cancers, and edentulism, among other conditions. Oral diseases that go undetected and/or untreated burden patients with increased severity of disease and worse health outcomes. The Canadian Dental Association (CDA) recommends routinely scheduled reexamination and preventive care as an essential component of maintaining optimal oral health. Investments by the federal government into dental services for high-risk groups have failed to resolve pervasive oral health disparities among Canadians related to dental care affordability, accessibility, and availability. Vulnerable groups across Canada, including children, seniors in long-term care, Indigenous peoples, new immigrants with refugee status, people with special needs, and the low-income population, have been identified as having challenges accessing regular dental care. Herein, an equity-focused commentary on the current climate of oral healthcare in Canada is presented. We outline how addressing disparities in Canadian dental care will require the engagement of physicians on multiple levels of care, negotiation with both dentists and policymakers, as well as sustained oral health data collection to inform provincial and national decision-making/strategies.
RéSUMé: Élément clé de la santé globale et de la qualité de vie, la santé buccodentaire est reconnue par les organismes de santé publique du monde entier comme un droit humain fondamental. Les dentistes sont des spécialistes de la santé buccodentaire qui s'occupent de la prévention primaire des lésions buccodentaires et de la détection et de la prise en charge des maladies buccodentaires. Ce sont des professionnels de santé réglementés qui détectent et qui traitent les caries dentaires, les maladies des gencives, les cancers buccaux et l'édentement, entre autres affections. Les maladies buccodentaires non détectées ou non traitées s'aggravent et conduisent à de plus mauvais résultats cliniques pour les patients. L'Association dentaire canadienne (ADC) recommande des examens dentaires périodiques et des soins préventifs, car elle les juge essentiels au maintien d'une santé buccodentaire optimale. Les investissements du gouvernement fédéral dans les soins dentaires des groupes fortement exposés n'ont pas permis de résoudre les disparités d'état de santé buccodentaire omniprésentes liées à l'abordabilité, à l'accessibilité et à la disponibilité des soins dentaires. On sait que les groupes vulnérables au Canada, dont les enfants, les aînés résidant dans des établissements de soins de longue durée, les peuples autochtones, les nouveaux immigrants ayant le statut de réfugiés, les personnes ayant des besoins particuliers et la population à faible revenu, ont des problèmes d'accès aux soins dentaires réguliers. Nous commentons ici dans une optique d'équité le climat actuel des soins de santé buccodentaires au Canada. Nous expliquons que pour aborder les disparités dans les soins dentaires canadiens, il faudra mobiliser les médecins de multiples niveaux de soins, négocier à la fois avec les dentistes et les responsables des politiques et assurer une collecte soutenue de données sur la santé buccodentaire pour éclairer les décisions et stratégies provinciales et nationales.
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Cárie Dentária , Disparidades em Assistência à Saúde , Criança , Humanos , Canadá , Acessibilidade aos Serviços de Saúde , Qualidade de Vida , Cárie Dentária/epidemiologia , Cárie Dentária/prevenção & controle , Saúde BucalRESUMO
BACKGROUND: The COVID-19 pandemic has exacerbated pre-existing challenges with respect to access to elective surgery across Canada, and a single-entry model (SEM) approach has been proposed as an equitable and efficient method to help manage the backlog. With Ontario's recent investment in centralized surgical wait-list management, we sought to understand the views of health system leaders on the role of SEMs in managing the elective surgery backlog. METHODS: We used the qualitative method of interpretive description to explore participant perspectives and identify practical strategies for policy-makers, administrators and clinical leaders. We conducted semistructured interviews with health system leaders from across Ontario on Zoom between March and June 2021. We used snowball and purposive sampling. Inclusion criteria included Ontario health care leaders, fluent in English or French, in positions relevant to managing the elective surgery backlog. Exclusion criteria were individuals who work outside Ontario, or do not hold relevant roles. RESULTS: Our interviews with 10 health system leaders - including hospital chief executive officers, surgeons, administrators and policy experts - resulted in 5 emergent domains: perceptions of the backlog, operationalizing and financing SEMs, barriers, facilitators, and equity and patient factors. All participants emphasized the need for clinical leaders to champion SEMs and the utility of SEMs in managing wait-lists for high-volume, low-acuity, low-complexity and low-variation surgeries. INTERPRETATION: Although SEMs are no panacea, the participants in our study stated that they believe SEMs can improve quality and reduce variability in wait times when SEMs are designed to address local needs and are implemented with buy-in from champions. Health care leaders should consider SEMs for improving surgical backlog management in their local jurisdictions.
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COVID-19 , COVID-19/epidemiologia , Procedimentos Cirúrgicos Eletivos , Humanos , Ontário/epidemiologia , Pandemias , Listas de EsperaRESUMO
INTRODUCTION: Traumatic brain injury (TBI) is estimated to affect 10 million people annually, making it a leading cause of morbidity and mortality worldwide. One cost-effective intervention that has been shown to minimize some of the negative sequelae after TBI is peer support. However, the evidence supporting the benefits of peer support for individuals with TBI is sparse and of low quality. Integrated knowledge translation (iKT) may be one approach to optimizing the evaluation of peer support programs among individuals with TBI. Therefore, the objectives are: (1) To understand key informants' perspectives of the barriers and facilitators of participating in peer support research and programs among individuals with TBI; (2) to understand key informants' perspectives on the perceived impacts of peer support programs on individuals with TBI; and, (3) to demonstrate how an iKT approach can inform the development and implementation of a pilot feasibility randomized controlled trial (RCT). METHODS: A qualitative descriptive approach using one-on-one semi-structured interviews was used. Purposive sampling of 22 key informants included 8 peer support mentors, 4 individuals with TBI who received peer support, 3 caregivers of individuals with TBI, 4 peer support program staff, and 3 academics in peer support and/or TBI. RESULTS: There were five main themes related to the barriers and facilitators to participating in peer support research and programs: knowledge, awareness, and communication; logistics of participating; readiness and motivation to participate; need for clear expectations; and matching. There were three main themes related to the perceived impact of peer support: acceptance, community, social experiences; vicarious experience/learning through others: shared experiences, role-modelling, encouragement; and "I feel better." Discussions with our Research Partner led to several significant adaptations to our trial protocol, including removing the twice/week intervention arm, shortening of the length of trial, and changing the measure for the community integration outcome. DISCUSSION/CONCLUSION: This is the first study to use an iKT approach to inform a trial protocol and the first to assess the barriers and facilitators to participating in peer support research.
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Lesões Encefálicas Traumáticas/patologia , Cuidadores/psicologia , Mentores/psicologia , Conscientização , Lesões Encefálicas Traumáticas/reabilitação , Estudos de Viabilidade , Humanos , Entrevistas como Assunto , Conhecimento , Motivação , Grupo Associado , Avaliação de Programas e Projetos de Saúde , Pesquisa Qualitativa , Ensaios Clínicos Controlados Aleatórios como AssuntoRESUMO
BACKGROUND: The long-term consequences of traumatic brain injury can create major barriers to community integration. Peer support represents a sustainable model of support across this transition. The objective of the current study was to determine the feasibility of conducting a randomized controlled trial on the Ontario Brain Injury Association Peer Support Program and the preliminary effectiveness of the program on community integration, mood, health-related quality of life, and self-efficacy; Methods: A pilot feasibility randomized controlled trial with an embedded qualitative component was conducted. Mentees with moderate-to-severe traumatic brain injury (n = 13) were randomized to a weekly intervention or waitlist control group. Interviews were conducted with a subset of mentees and peer mentors (n = 10). Integration of the quantitative and qualitative data was completed using a joint display approach; Results: No statistically significant results were found for community integration, mood, or self-efficacy; however, changes in these outcomes were accompanied by moderate-to-large effect sizes. Within health-related quality of life, the mean pain score of the intervention group was significantly lower than that of the control group at the two-month timepoint but not at completion. Interviews revealed proximal improvements in knowledge, skills, and goals, and identified two domains related to trial acceptability: (1) environmental context and resources, and (2) reinforcement; Conclusions: Given the conceivable importance of proximal improvements in domains such as knowledge, skills, and/or goals for the attainment of more distal outcomes, modifications to the existing Peer Support Program may be warranted. The introduction of program recommendations which promote discussion around particular domains may help facilitate long-term improvements in health outcomes.
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Stigma toward people living with HIV/AIDS (PLWHA) has impeded the response to the disease across the world. Widespread stigma leads to poor adherence of preventative measures while also causing PLWHA to avoid testing and care, delaying important treatment. Stigma is clearly a hugely complex construct. However, it can be broken down into components which include internalized stigma (how people with the trait feel about themselves) and enacted stigma (how a community reacts to an individual with the trait). Levels of HIV/AIDS-related stigma are particularly high in sub-Saharan Africa, which contributed to a surge in cases in Kenya during the late twentieth century. Since the early twenty-first century, the United Nations and governments around the world have worked to eliminate stigma from society and resulting public health education campaigns have improved the perception of PLWHA over time, but HIV/AIDS remains a significant problem, particularly in Kenya. We take a data-driven approach to create a time-dependent stigma function that captures both the level of internalized and enacted stigma in the population. We embed this within a compartmental model for HIV dynamics. Since 2000, the population in Kenya has been growing almost exponentially and so we rescale our model system to create a coupled system for HIV prevalence and fraction of individuals that are infected that seek treatment. This allows us to estimate model parameters from published data. We use the model to explore a range of scenarios in which either internalized or enacted stigma levels vary from those predicted by the data. This analysis allows us to understand the potential impact of different public health interventions on key HIV metrics such as prevalence and disease-related death and to see how close Kenya will get to achieving UN goals for these HIV and stigma metrics by 2030.
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Infecções por HIV , Modelos Biológicos , Estigma Social , Infecções por HIV/epidemiologia , Infecções por HIV/terapia , Humanos , Quênia/epidemiologia , Saúde Pública/estatística & dados numéricosRESUMO
CONTEXT: Transition from the pediatric to the adult health care system is a complex process that should include medical, psychosocial, educational, recreational, and vocational considerations. OBJECTIVE: In this systematic review, we aim to synthesize the evidence on transitional care interventions (TCIs) to improve the quality of life (QoL) for adolescents and young adults with childhood-onset disabilities, including neurodevelopmental disorders. DATA SOURCES: Four electronic databases (Medline, Embase, PsycINFO, and Cumulative Index to Nursing and Allied Health Literature) were searched. STUDY SELECTION: In the included studies, researchers examined TCIs for adolescents and young adults (12-24 years of age) with childhood-onset disabilities. Studies were experimental, quasi-experimental, and observational studies published in the last 26 years. DATA EXTRACTION: Two reviewers independently completed study screening, data extraction, and risk-of-bias assessment. RESULTS: Fifty-two studies were included. Five studies reported on QoL, but statistically significant improvements were noted in only 1 of these studies. Significant improvements were also found in secondary outcomes including disability-related knowledge and transitional readiness. TCIs targeted patients, families and/or caregivers, and health care providers and exhibited great heterogeneity in their characteristics and components. LIMITATIONS: Inconsistent reporting on interventions between studies hindered synthesis of the relationships between specific intervention characteristics and outcomes. CONCLUSIONS: Although there is limited evidence on the impact of TCIs on the QoL for youth with childhood-onset disabilities, there is indication that they can be effective in improving patient and provider outcomes. The initiation of transition-focused care at an early age may contribute to improved long-term health outcomes in this population.
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Crianças com Deficiência , Serviços de Saúde para Pessoas com Deficiência , Qualidade de Vida , Transição para Assistência do Adulto , Adolescente , Viés , Criança , Humanos , Adulto JovemRESUMO
BACKGROUND: We conducted the first trial of neoadjuvant PD-1 blockade in resectable non-small cell lung cancer (NSCLC), finding nivolumab monotherapy to be safe and feasible with an encouraging rate of pathologic response. Building on these results, and promising data for nivolumab plus ipilimumab (anti-CTLA-4) in advanced NSCLC, we expanded our study to include an arm investigating neoadjuvant nivolumab plus ipilimumab. METHODS: Patients with resectable stage IB (≥4 cm)-IIIA (American Joint Committee on Cancer Tumor Node Metastases seventh edition), histologically confirmed, treatment-naïve NSCLC received nivolumab 3 mg/kg intravenously plus ipilimumab 1 mg/kg intravenously 6 weeks prior to planned resection. Nivolumab 3 mg/kg was given again approximately 4 and 2 weeks preoperatively. Primary endpoints were safety and feasibility with a planned enrollment of 15 patients. Pathologic response was a key secondary endpoint. RESULTS: While the treatment regimen was feasible per protocol, due to toxicity, the study arm was terminated early by investigator consensus after 9 of 15 patients were enrolled. All patients received every scheduled dose of therapy and were fit for planned surgery; however, 6 of 9 (67%) experienced treatment-related adverse events (TRAEs) and 3 (33%) experienced grade ≥3 TRAEs. Three of 9 patients (33%) had biopsy-confirmed tumor progression precluding definitive surgery. Of the 6 patients who underwent resection, 3 are alive and disease-free, 2 experienced recurrence and are actively receiving systemic treatment, and one died postoperatively due to acute respiratory distress syndrome. Two patients who underwent resection had tumor pathologic complete responses (pCRs) and continue to remain disease-free over 24 months since surgery. Pathologic response correlated with pre-treatment tumor PD-L1 expression, but not tumor mutation burden. Tumor KRAS/STK11 co-mutations were identified in 5 of 9 patients (59%), of whom two with disease progression precluding surgery had tumor KRAS/STK11/KEAP1 co-mutations. CONCLUSIONS: Though treatment was feasible, due to toxicity the study arm was terminated early by investigator consensus. In light of this, and while the long-term disease-free status of patients who achieved pCR is encouraging, further investigation of neoadjuvant nivolumab plus ipilimumab in patients with resectable NSCLC requires the identification of predictive biomarkers that enrich for response.
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Carcinoma Pulmonar de Células não Pequenas/tratamento farmacológico , Ipilimumab/uso terapêutico , Neoplasias Pulmonares/tratamento farmacológico , Terapia Neoadjuvante/métodos , Nivolumabe/uso terapêutico , Idoso , Feminino , Humanos , Ipilimumab/farmacologia , Masculino , Pessoa de Meia-Idade , Nivolumabe/farmacologiaRESUMO
BACKGROUND: Neurological disorders may negatively impact community integration and/or quality of life. Peer support has emerged as a potential strategy to enhance patients' efficacy in managing their own health. This review examines the key characteristics and impact of peer support interventions for adults with acquired brain injury, cerebral palsy, and spina bifida on community integration and quality of life. METHODS: Eligible studies reported on peer support interventions for adults (16 years of age or older) with acquired brain injury, cerebral palsy, or spina bifida. Only randomized controlled trials published in English in the last 10 years were included. MEDLINE, EMBASE, PsycINFO, and CINAHL were used to conduct the literature search. Two reviewers independently screened studies, abstracted data, and evaluated the risk of bias (for individual study elements and overall) using the Cochrane Risk of Bias Tool. RESULTS: The systematic review included 6 trials reporting on acquired brain injury only. Of these studies, 4 reported on stroke and 2 reported on traumatic brain injury. Two studies found significant improvements in quality of life following peer support. No studies reported significant results on community integration. Considerable heterogeneity existed in the key characteristics of interventions. CONCLUSIONS: There are a limited number of studies on the impact of peer support interventions for adults with acquired brain injury, cerebral palsy, or spina bifida on community integration and quality of life. Standardization of key intervention characteristics may aid the global adoption of peer support as a formalized, evidence-based practice.