Medical Assistance in Dying in Patients With Cancer.

PURPOSE: Medical assistance in dying (MAiD) was legalized in Canada in 2016. To date, patients with cancer account for 69% of MAiD deaths, yet little information is available about these patients. We reviewed disease and treatment characteristics of patients with cancer who underwent MAiD to better understand this population and identify gaps in our current system of care. MATERIALS AND METHODS: Patients with cancer who underwent MAiD through the Champlain Regional MAiD Network from June 2016 to November 2020 were reviewed. Baseline demographic, diagnostic, and treatment details were collected by retrospective review. RESULTS: During the study period, 255 patients with cancer underwent MAiD. At the time of MAiD, 201 patients (79%) had metastatic disease. Most prevalent solid organ tumors were gastrointestinal (30%), lung (18%) and genitourinary (14%). MAiD was primarily provided in the home (48%) or an acute inpatient facility (40%). One hundred eighty-nine (74%) patients were evaluated by medical oncology, 23 by gynecology oncology (9%), 11 by hematology oncology (4%), and 177 (69%) by radiation oncology. One hundred fifty-eight (62%) patients were not seen by oncology specialists in the 30 days prior to MAiD. One hundred fifty-nine patients (62%) had at least one line of systemic therapy, 138 patients (54%) received radiotherapy, and 61 patients (24%) did not receive cancer-directed treatment. Palliative care assessed at least 213 patients (84%). Common reasons for pursuing MaiD included disease-related symptoms (33%), fear of future suffering or disability (19%), and the ability to control the time and manner of death (17%). In 36% of cases, the reason was not documented. CONCLUSION: Although formal oncology consultation is not required before MAiD, with an ever-increasing number of novel cancer therapies, oncologists, cancer centers, and MAiD providers should consider collaborating to ensure a streamlined assessment process for patients.

Pericardial Decompression Syndrome: A Case Series and Literature Review.

Cardiac tamponade is a medical emergency requiring prompt recognition and intervention to avoid potentially fatal consequences. We present a case series of ventricular dysfunction and cardiogenic shock following pericardiocentesis in 3 patients with pericardial effusions at The Ottawa Hospital between 2014 and 2020. This report highlights the need for monitoring post-pericardiocentesis and raises awareness of this phenomenon, particularly in patients with malignancy. We propose a novel pressure-monitoring protocol to guide drainage and prevent development of pericardial decompression syndrome. The novel teaching points include limiting drainage to prevent development of pericardial decompression syndrome and a protocol for intra-pericardial pressure monitoring.

La tamponnade cardiaque est une urgence médicale qui, à défaut d'une reconnaissance et d'une intervention rapides, peut avoir des conséquences potentiellement fatales. Nous présentons une série de cas sur des dysfonctions ventriculaires et des chocs cardiogéniques survenus après une péricardiocentèse chez trois patients présentant des épanchements péricardiques traités à l'Hôpital d'Ottawa entre 2014 et 2020. Notre article souligne la nécessité de surveiller les patients au cours de la période suivant la péricardiocentèse et met en lumière le phénomène de la tamponnade cardiaque, en particulier chez les patients atteints de cancer. Nous proposons un nouveau protocole de surveillance des pressions conçu pour guider le drainage et prévenir le syndrome de décompression péricardique. Les nouveautés à enseigner comprennent la limitation du drainage afin de prévenir le syndrome de décompression péricardique et un protocole de surveillance des pressions intrapéricardiques.

Brief Report: Medical Assistance in Dying in Patients With Lung Cancer.

INTRODUCTION: Medical assistance in dying (MAiD) was legalized in Canada in 2016. Cancer accounts for 60% to 65% of MAiD cases. Lung cancer, the most common cause of cancer death, is expected to makeup a large number of MAiD cases. Lung cancer treatment has advanced in recent years; however, involvement of oncology specialists and use of systemic therapy in patients who receive MAiD are unknown. METHODS: All patients with lung cancer referred to the Champlain Regional MAiD Program from June 17, 2016, to November 30, 2020, were reviewed. Baseline demographics, diagnostic, referral, and treatment details were collected by retrospective review. Coprimary end points were the proportion of patients who met a medical oncologist or who received systemic therapy. RESULTS: During the study period, 255 patients with cancer underwent MAiD. Of these, 45 (17.6%) had lung cancer, comprising our final study population. Baseline characteristics: median age 72 years, 64% female, 85% former or current smoking history, 82% non-small cell, 4% small cell, and 13% clinical diagnosis without biopsy. Most patients (78%) were seen by a medical oncologist, though only 16 (36%) received systemic therapy for advanced disease. In subpopulations of interest, 45% of patients with programmed death-ligand 1 greater than or equal to 50% received immunotherapy and 75% with an oncogenic driver mutation received targeted therapy. There were 26 patients (58%) who had a documented discussion with their oncologist regarding the transition to best supportive care. CONCLUSIONS: Most patients with lung cancer are assessed by an oncology specialist before MAiD, though less than half received systemic therapy. Among patients with more treatable forms of lung cancer, many patients still undergo MAiD without accessing, or in some cases being assessed for, these treatment options.

Intravenous administration of Penicillin results in therapeutic intravitreal levels in chronic postoperative endophthalmitis.

IMPORTANCE: The role of systemic antibiotics in the treatment of bacterial endophthalmitis remains controversial. While penicillin is a highly effective antibiotic against bacteria that frequently cause endophthalmitis, the ability of systemically administered Penicillin G to penetrate into the vitreous at adequate therapeutic concentrations has not been studied. Its role in the treatment of endophthalmitis, particularly for bacteria for which it is the antibiotic of choice, therefore remains unknown. OBJECTIVE: We sought to determine whether intravenous administration of Penicillin G leads to adequate therapeutic concentrations in the vitreous for the treatment of bacterial endophthalmitis. DESIGN AND SETTING: This study was conducted in an ambulatory setting, at the Ottawa Hospital Eye Institute, a university-affiliated tertiary care center, where a 77-year old gentleman with chronic post-cataract surgery Actinomyces neuii endophathalmitis was treated with intravenous Penicillin G (4 × 106 units every 4 h) and intravitreal ampicillin (5000µg/0.1 m1). MAIN OUTCOMES AND MEASURES: Intravitreal concentration of Penicillin G and ampicillin were obtained at the time of intraocular lens removal, measured by high-performance liquid chromatography. RESULTS: The intravitreal concentration of penicillin and ampicillin was 3.5µg/ml and 0.3µg/ml, respectively. Both the concentration of penicillin and ampicillin were within the level of detection of their respective assays (penicillin 0.06-5µg/ml, ampicillin 0.12-2.5µg/ml). CONCLUSION AND RELEVANCE: This study shows that intravenous Penicillin G administered every four-hours allows for adequate intravitreal concentrations of penicillin. Future studies are required to determine if the results of this study translate into improved clinical outcomes.

Delivering Hospital-Based Pediatric Palliative Care: The Symptoms, Interventions, and Outcomes for Children With Cancer in Bangladesh.

PURPOSE: The majority of pediatric cancer deaths occur in low- and middle-income countries (LMICs). Pediatric palliative care (PPC) focuses on relieving physical, psychosocial, and spiritual suffering throughout the continuum of cancer care and is considered integral to cancer care for children in all settings. There is limited evidence from LMICs about the characteristics, symptoms, and outcomes of children with cancer who receive PPC, which is needed to define the global need and guide the development of these services. METHODS: This retrospective review of clinical records of children who received PPC was conducted during a pilot project (January 2014-August 2015) that implemented a PPC team at a tertiary hospital in Dhaka, Bangladesh. Clinical data on diagnosis, symptoms, treatment status, deaths, and key palliative care interventions were collected and analyzed using descriptive statistics. RESULTS: There were 200 children who received PPC during the pilot project. The most common diagnoses were acute lymphoblastic leukemia (62%) and acute myeloid leukemia (11%). Psychosocial support for children (n = 305; 53%) and management of physical symptoms (n = 181; 31%) were the most common types of interventions provided. The most frequently recorded symptoms were pain (n = 60; 30%), skin wounds (n = 16; 8%), and weakness (n = 9; 5%). The most common medications prescribed were morphine (n = 32) and paracetamol (n = 21). CONCLUSION: A hospital-based PPC service addresses pain and symptom concerns as well as psychosocial needs for children with cancer and their families in a setting where resources are limited. Health care facilities should incorporate palliative care into the care of children with cancer to address the needs of children and their families.

Toxoplasmosis, cryptosporidiosis, and isosporiasis in HIV-negative immunocompromised patients: A single-centre study, Ottawa, Ontario, Canada.

Background: Historically, patients with HIV have been at the highest risk of infection with opportunistic protozoans such as Toxoplasma, Cryptosporidium, and Isospora. Among patients with HIV who are compliant with antiretroviral therapy, the likelihood of acquiring an opportunistic infection is low. The risk of infection is harder to mitigate in the growing number of HIV-negative immunodeficient patients, such as people with hematological malignancies or those who are post-transplantation. Methods: We conducted a retrospective case series of patients with documented Toxoplasma infections between 2008 and 2017 and with Cryptosporidium and Isospora infections between 2014 and 2017 at the Ottawa Hospital. Results: During the study period, there were 10 confirmed cases of toxoplasmosis, 20 cases of cryptosporidiosis, and 2 cases of isosporiasis. Cryptosporidiosis (95%) and toxoplasmosis (60%) occurred more frequently among HIV-negative patients, whereas isosporiasis cases were limited to HIV-positive patients. Among patients with cryptosporidiosis, the most common underlying cause of immunosuppression in HIV-negative individuals was solid organ transplantation (15.79%), followed by diabetes (10.53%), end-stage renal disease (5.26%), and hematologic malignancy (5.26%). Seventy percent of patients had no known cause of immunosuppression. The most common underlying condition associated with toxoplasmosis was hematological malignancy (50%), followed by solid organ transplantation (33.33%), and solid tumours (16.66%). Conclusions: This study's results suggest that Cryptosporidium infections are more common among immunocompetent patients in Ottawa, whereas Toxoplasma infections are more common among HIV-negative patients with acquired immunodeficiencies. As the demographics of immunocompromised individuals continue to evolve, screening for protozoal infections in high-risk populations may become clinically important.

Historique: Par le passé, les patients atteints du VIH présentaient le plus fort risque d'infection par des protozoaires opportunistes comme le Toxoplasma, le Cryptosporidium et l'Isospora. Chez les patients atteints du VIH qui adhèrent à la thérapie antivirale, la probabilité de contracter une infection opportuniste est faible. Le risque d'infection est toutefois plus difficile à contrôler auprès du nombre croissant de patients immunodéprimés non atteints du VIH, tels que ceux qui souffrent d'un cancer hématologique ou qui ont subi une transplantation. Méthodologie: Les chercheurs ont réalisé une étude auprès d'une série de patients rétrospectifs atteints d'une infection démontrée par le Toxoplasma entre 2008 et 2017 ainsi que d'une infection par le Cryptosporidium et l'Isospora entre 2014 et 2017 à l'Hôpital d'Ottawa. Résultats: Pendant la période de l'étude, dix cas confirmés de toxoplasmose, 20 cas de cryptosporidiose et deux cas d'isosporose ont été recensés. La cryptosporidiose (95 %) et la toxoplasmose (60 %) étaient plus fréquentes chez les patients non atteints du VIH, mais les cas d'isosporose étaient limités aux patients atteints du VIH. Chez les patients atteints de la cryptosporidiose, la transplantation d'un organe plein (15,79 %) était la cause principale d'immunodépression chez les patients non atteints du VIH, suivie du diabète (10,53 %), de l'insuffisance rénale terminale (5,26 %) et du cancer hématologique (5,26 %). Toutefois, 70 % des patients ne présentaient aucune cause connue d'immunodépression. Le cancer hématologique (50 %) était l'affection la plus associée à la toxoplasmose, suivi de la transplantation d'un organe plein (33,33 %) et des tumeurs solides (16,66 %). Conclusions: Selon les résultats de la présente étude, les infections à Cryptosporidium sont plus courantes chez les patients immunocompétents d'Ottawa, mais celles à Toxoplasma le sont davantage chez les patients qui ne sont pas atteints du VIH, mais qui ont une immunodéficience acquise. Devant l'évolution de la démographie des patients immunodéprimés, le dépistage des infections protozoaires peut devenir important sur le plan clinique dans les populations à haut risque.

Complications of tissue expansion in the head and neck.

BACKGROUND: The authors aim to present a comprehensive review detailing the present state of evidence with regard to complications following tissue expansion in the head and neck. METHODS: A systematic literature search was conducted to identify all studies reporting complications of tissue expansion in the head and neck between 2000 and 2019. Subgroup comparisons based on expander locations and planes were conducted. RESULTS: A total of 7058 patients were included. Tissue expansion was associated with an overall complication rate of 8.73% (616/7058). The most common complications were extrusion (207/7009; 3.0%) and hematoma (200/7009; 2.9%). Overall complications were highest in the scalp (65/238; 27.3%) and lowest in the mastoid (347/5688; 6.1%). Complications were more common with expansion in the non-subcutaneous plane (63/590; 10.7%). CONCLUSION: In the absence of large clinical trials, systematic reviews such as these can help inform clinical guidelines and provide practitioners with an evidence-based reference to improve informed consent.

Development and Implementation of a Pediatric Palliative Care Program in a Developing Country.

BACKGROUND: Palliative care is recognized as an important component of care for children with cancer and other life-limiting conditions. In resource limited settings, palliative care is a key component of care for children with cancer and other life-limiting conditions. Globally, 98% of children who need palliative care live in low- or middle-income countries, where there are very few palliative care services available. There is limited evidence describing the practical considerations for the development and implementation of sustainable and cost-effective palliative care services in developing countries. OBJECTIVES: Our aim is to describe the key considerations and initiatives that were successful in planning and implementing a hospital-based pediatric palliative care service specifically designed for a resource-limited setting. SETTING: Bangabandu Sheikh Mujib Medical University (BSMMU) is a tertiary referral hospital in Bangladesh. Local palliative care services are very limited and focused on adult patients. In partnership with World Child Cancer, a project establishing a pediatric palliative care service was developed for children with cancer at BSMMU. RESULTS: We describe four key elements which were crucial for the success of this program: (1) raising awareness and sensitizing hospital administrators and clinical staff about pediatric palliative care; (2) providing education and training on pediatric palliative care for clinical staff; (3) forming a pediatric palliative care team; and (4) collecting data to characterize the need for pediatric palliative care. CONCLUSION: This model of a hospital-based pediatric palliative care service can be replicated in other resource-limited settings and can be expanded to include children with other life-limiting conditions. The development of pilot programs can generate interest among local physicians to become trained in pediatric palliative care and can be used to advocate for the palliative care needs of children.