Increased risk of haematological malignancy in adults over age 60 with thrombocytopenia compared with matched controls: Time for an upfront bone marrow evaluation?

International societies have conflicting recommendations on whether bone marrow aspirate/biopsy (BMB) is needed during workup for isolated thrombocytopenia. Our objective was to determine if thrombocytopenia in patients aged ≥60 years is associated with an increased incidence of haematological malignancy. We performed a retrospective population-based cohort study in patients aged ≥60 years between January 1, 2009 to December 31, 2019. Exposed patients had specialist consultation for thrombocytopenia, with platelet count <100 × 109/L, but normal haemoglobin and white blood cell count. Unexposed patients were those who never had specialist consultation for thrombocytopenia and whose platelets were ≥100 × 109/L. The primary outcome was the diagnosis of haematological malignancy using a competing risk of death model. During 4.0 years (IQR 2.2-6.7) of follow-up, 378/4930 exposed (19.1/1000PY, 95% CI 17.1-21.0), and 204/17556 unexposed patients (2.5/1000PY, 95% CI 2.2-2.8) were diagnosed with haematological malignancy (HR 15.5 (95% CI 11.3-21.4, p < 0.0001) in year 1, and 5.3 (95% CI 4.4-6.6, p < 0.0001) in years 2+). This finding persisted in analyses stratified by sex, age, severity, or duration of thrombocytopenia, and treatment with corticosteroids within 2 weeks of consultation. This study found a strong association between isolated thrombocytopenia and haematological malignancy in patients ≥60 years, supporting consideration of diagnostic testing including BMB during outpatient specialist consultation.

Using administrative health data to identify individuals with intellectual and developmental disabilities: a comparison of algorithms.

BACKGROUND: Individuals with intellectual and developmental disabilities (IDD) experience high rates of physical and mental health problems; yet their health care is often inadequate. Information about their characteristics and health services needs is critical for planning efficient and equitable services. A logical source of such information is administrative health data; however, it can be difficult to identify cases with IDD in these data. The purpose of this study is to evaluate three algorithms for case finding of IDD in health administrative data. METHODS: The three algorithms were created following existing approaches in the literature which ranged between maximising sensitivity versus balancing sensitivity and specificity. The broad algorithm required only one IDD service contact across all available data and time periods, the intermediate algorithm added the restriction of a minimum of two physician visits while the narrow algorithm added a further restriction that the time period be limited to 2006 onward. The resulting three cohorts were compared according to socio-demographic and clinical characteristics. Comparisons on different subgroups for a hypothetical population of 50,000 individuals with IDD were also carried out: this information may be relevant for planning specialised treatment or support programmes. RESULTS: The prevalence rates of IDD per 100 were 0.80, 0.52 and 0.18 for the broad, intermediate and narrow algorithms, respectively. Except for 'percentage with psychiatric co-morbidity', the three cohorts had similar characteristics (standardised differences < 0.1). More stringent thresholds increased the percentage of psychiatric co-morbidity and decreased the percentages of women and urban residents in the identified cohorts (standardised differences = 0.12 to 0.46). More concretely, using the narrow algorithm to indirectly estimate the number of individuals with IDD, a practice not uncommon in planning and policy development, classified nearly 7000 more individuals with psychiatric co-morbidities than using the intermediate algorithm. CONCLUSIONS: The prevalence rate produced by the intermediate algorithm most closely approximated the reported literature rate suggesting the value of imposing a two-physician visit minimum but not restricting the time period covered. While the statistical differences among the algorithms were generally minor, differences in the numbers of individuals in specific population subgroups may be important particularly if they have specific service needs. Health administrative data can be useful for broad-based service planning for individuals with IDD and for population level comparisons around their access and quality of care.

Complex chronic conditions among children born to women with schizophrenia.

PURPOSE: Maternal schizophrenia is linked to complications in offspring near the time of birth. Whether there is also a higher future risk of the child having a complex chronic condition (CCC) - a pediatric condition affecting any bodily system expected to last at least 12 months that is severe enough to require specialty care and/or a period of hospitalization - is not known. METHODS: In this population-based health administrative data cohort study (Ontario, Canada, 1995-2018), the risk for CCC was compared in 5066 children of women with schizophrenia (the exposed) vs. 2,939,320 unexposed children. Adjusted hazard ratios (aHR) were generated for occurrence of any CCC, by CCC category, and stratified by child sex, and child prematurity. RESULTS: CCC was more frequent in the exposed (7.7 per 1000 person-years [268 children]) than unexposed (4.2 per 100 person-years [124,452 children]) - an aHR of 1.25 (95% CI 1.10-1.41). aHRs were notably higher in 5 of 9 CCC categories: neuromuscular (1.73, 1.28-2.33), cardiovascular (1.94, 1.64-2.29), respiratory (1.83, 1.32-2.54), hematology/immunodeficiency (2.24, 1.24-4.05) and other congenital or genetic defect (1.59, 1.16-2.17). The aHR for CCC was more pronounced among boys (1.32, 1.13-1.55) than girls (1.16, 0.96-1.40), and of similar magnitude in term (1.22, 1.05-1.42) and preterm infants (1.18, 0.95-1.46). CONCLUSIONS: The risk for a CCC appears to be higher in children born to women with schizophrenia. This finding introduces opportunities for targeted preconception counselling, optimization of maternal risk factors, and intervention to support a vulnerable parent population who will experience unique challenges caring for a child with CCCs.

Patterns of care in the initial management of women with ovarian cancer in Ontario.

BACKGROUND: To facilitate the planning of future resources for cancer services in Ontario, Cancer Care Ontario commissioned an evaluation of operative services delivered for ovarian cancers. The affected population was characterized in terms of age, location of residence, and SES. Operative care delivery was described in terms of inpatient verses outpatient access, LHIN of treatment, surgical specialist providing treatment, and specific operative procedures. The investigations and consults around the time of diagnosis are described. METHODS: Women with an incident diagnosis of an ovarian malignancy were identified from 1 April 2003 to 31 March 2004 using the Ontario Cancer Registry. Record linkages were created to other provincial health databases such as the Ontario Health Insurance Plan. RESULTS: We report on 963 women with ovarian cancer. The incidence of disease was related to increasing age. Access to surgery correlated with the highest income quintile, urban residence and LHIN. Twenty-seven percent of women did not have surgery for their ovarian cancer. Women of younger age were more like to receive surgery for ovarian cancer. Use of a laparotomy for biopsy was most common in community hospital (40%). Lymphadenectomy rates were low overall; rates for gynecologic oncologists were 13.2%. All women were assessed by CXR. CT scan of abdomen and pelvis occurred in 77% of women. MRIs were done infrequently. Medical oncology were involved in 26.6% of the patients. CONCLUSIONS: These pilot data would be enhanced with further information such as comorbidity, treatment intent (palliative/curative), histology, grade and stage. However, there are clear referral patterns to academic centres which means a need for manpower and hospital resources to deal with this population.

Patterns of surgical care for uterine cancers in Ontario.

OBJECTIVES: To facilitate the planning of future resources for cancer services in Ontario, Cancer Care Ontario commissioned an evaluation of operative services delivered for uterine cancer. METHODS: Women with an incident diagnosis of a uterine malignancy were identified from 1 April 2003 to 31 March 2004 using the Ontario Cancer Registry. Record linkages were created to other provincial health databases such as the Ontario Health Insurance Plan. RESULTS: Uterine cancer affected 1,436 women. Disease specific rates of cancer were higher in rural areas and those from the highest income quintiles. Surgery occurred in 94.7% of women. Use of surgery did not appear to vary by SEC, urban/rural residence or LHIN. Gynecologists conducted 76.1% of the operations. Lymphadenectomy took place in 18.7% of women. Lymphadenectomy rates were highest in gynecologic oncologists (43.3%). All women were assessed by CXR. Radiation therapy consults were preformed in half of the women with uterine cancer but treatment was only delivered in half of those seen. Medical oncologists saw about 6.3% of women with uterine cancers. CONCLUSIONS: There appear to be variations in incidence rates of uterine cancer with disease being more frequent in those of the highest SES. In two-thirds of the population, surgery is delivered in the region where the patient lives. Subspecialty care from gynecologic oncologists was provided to one-third of women. Rates of lymphadenectomy as part of a surgical attempt to assess disease spread appear low. These pilot data would be enhanced with further information such as comorbidity, treatment intent (palliative/curative), histology, grade and stage.

Patterns of care for the initial management of cervical cancer in Ontario.

OBJECTIVE: To facilitate the planning of resources for cancer services in Ontario, Cancer Care Ontario commissioned an evaluation of operative services delivered for cervical cancer. METHODS: Women with an incident diagnosis of cervical cancer were identified from 1 April, 2003 to 31 March, 2004 using the Ontario Cancer Registry. Record linkages were created to other provincial health databases such as the Ontario Health Insurance Plan. RESULTS: There were 513 incident cases. Disease-specific rates of cancer were higher in rural areas and those from lower income quintiles. Forty-three percent of women had no surgery. Use of surgery did not appear to vary by SEC, urban/rural residence or LHIN. Women of younger age were more like to receive surgery for cervical cancer. Gynecologists conducted 63% of the operations. Gynecologics were most likely to complete a lymphadenectomy (70.3%). All women were assessed by CXR. Only 22% of women had a CT scan of the abdomen and pelvis. Radiation consults were performed in half of the women with cervix cancer but treatment was only delivered to half of those seen. Medical oncologists saw about 10% of women with cervical cancers. CONCLUSIONS: There appear to be variations in incidence rates of cervical cancer, with cancers being more frequent in rural areas. In two-thirds of the population, surgery is performed in the region where the patient lives. Subspecialty care from gynecologic oncologists was provided to one-third of women. These preliminary data would be enhanced with further information such as comorbidity, treatment intent (palliative/curative), histology, grade and stage.

Patterns of care in the initial management of women with vulvar cancers in Ontario.

BACKGROUND: To facilitate the planning of future resources for cancer services in Ontario, Cancer Care Ontario commissioned an evaluation of operative services delivered for vulvar cancer. METHODS: Women with an incident diagnosis of vulvar malignancy were identified from 1, April 2003 to 31 March, 2004 using the Ontario Cancer Registry. Record linkages were created to other provincial health databases such as the Ontario Health Insurance Plan. RESULTS: Vulvar cancers affected 148 women. Disease specific rates of cancer were higher in rural areas and in women in the lower income quintiles. No surgery occurred in 17.6% of women. Use of surgery did not appear to vary by urban/rural residence or LHIN. Ontario's 17 gynecologic oncologists performed 75% of the surgeries. Groin lymphadenectomy rate was 52.8%. Surgery was performed in the LHIN of residence for 41% of women. All women were assessed by CXR. CT scan of the abdomen and pelvis occurred in 77%. MRIs were done infrequently. Radiation consults were preformed in half of the women with vulvar cancer but treatment was only delivered in half of those seen. Medical oncologists saw about 10% of women with gynecologic cancers. CONCLUSIONS: There appear to be variations in incidence rates of vulvar cancer with disease being more frequent in rural areas. Subspecialty care from gynecologic oncologists was provided to 75% of women. Rates of lymphadenectomy as part of a surgical attempt occurred in 52.8% of women. These data would be enhanced with further information such as comorbidity, treatment intent (palliative/curative), histology, grade and stage.

Second-line age-adjusted International Prognostic Index in patients with advanced non-Hodgkin lymphoma after T-cell depleted allogeneic hematopoietic SCT.

T-cell depleted allogeneic hematopoietic SCT (TCD-HSCT) have shown durable disease-free survival with a low risk of GVHD in patients with AML. We investigated this approach in 61 patients with primary refractory or relapsed non-Hodgkin lymphoma (NHL), who underwent TCD-HSCT from January 1992 through September 2004. Patients received myeloablative cytoreduction consisting of hyperfractionated total body irradiation, followed by either thiotepa and cyclophosphamide (45 patients) or thiotepa and fludarabine (16 patients). We determined the second-line age-adjusted International Prognostic Index score (sAAIPI) before transplant transplant. Median follow-up of surviving patients is 6 years. The 10-year OS and EFS were 50% and 43%, respectively. The relapse rate at 10 years was 21% in patients with chemosensitive disease and 52% in those with resistant disease at time of HSCT. Nine of the 18 patients who relapsed entered a subsequent CR. OS (P=0.01) correlated with the sAAIPI. The incidence of grades II-IV acute GVHD was 18%. We conclude that allogeneic TCD-HSCT can induce high rates of OS and EFS in advanced NHL with a low incidence of GVHD. Furthermore, the sAAIPI can predict outcomes and may be used to select the most appropriate patients for this type of transplant.