Low socioeconomic status is associated with worse survival in children with cancer: A systematic review

Background: While low socioeconomic status (SES) has been associated with inferior cancer outcome among adults, its impact in pediatric oncology is unclear. Our objective was therefore to conduct a systematic review to determine the impact of SES upon outcome in children with cancer. Methods: We searched Ovid Medline, EMBASE and CINAHL from inception to December 2012. Studies for which survival-related outcomes were reported by socioeconomic subgroups were eligible for inclusion. Two reviewers independently assessed articles and extracted data. Given anticipated heterogeneity, no quantitative meta-analyses were planned a priori. Results: Of 7,737 publications, 527 in ten languages met criteria for full review; 36 studies met final inclusion criteria. In low- and middle-income countries (LMIC), lower SES was uniformly associated with inferior survival, regardless of the measure chosen. The majority of associations were statistically significant. Of 52 associations between socioeconomic variables and outcome among high-income country (HIC) children, 38 (73.1%) found low SES to be associated with worse survival, 15 of which were statistically significant. Of the remaining 14 (no association or high SES associated with worse survival), only one was statistically significant. Both HIC studies examining the effect of insurance found uninsured status to be statistically associated with inferior survival. Conclusions: Socioeconomic gradients in which low SES is associated with inferior childhood cancer survival are ubiquitous in LMIC and common in HIC. Future studies should elucidate mechanisms underlying these gradients, allowing the design of interventions mediating socioeconomic effects. Targeting the effect of low SES will allow for further improvements in childhood cancer survival. © 2014 Gupta et al

Antenatal Steroid Therapy for Fetal Lung Maturation and the Subsequent Risk of Childhood Asthma: A Longitudinal Analysis

This study was designed to test the hypothesis that fetal exposure to corticosteroids in the antenatal period is an independent risk factor for the development of asthma in early childhood with little or no effect in later childhood. A population-based cohort study of all pregnant women who resided in Nova Scotia, Canada, and gave birth to a singleton fetus between 1989 and 1998 was undertaken. After a priori specified exclusions, 80,448 infants were available for analysis. Using linked health care utilization records, incident asthma cases developed after 36 months of age were identified. Extended Cox proportional hazards models were used to estimate hazard ratios while controlling for confounders. Exposure to corticosteroids during pregnancy was associated with a risk of asthma in childhood between 3–5 years of age: adjusted hazard ratio of 1.19 (95% confidence interval: 1.03, 1.39), with no association noted after 5 years of age: adjusted hazard ratio for 5–7 years was 1.06 (95% confidence interval: 0.86, 1.30) and for 8 or greater years was 0.74 (95% confidence interval: 0.54, 1.03). Antenatal steroid therapy appears to be an independent risk factor for the development of asthma between 3 and 5 years of age

The Ontario Sexual Health Education Update: Perspectives from the Toronto Teen Survey (TTS) Youth

Sexual health education in schools is a controversial topic. In 2015 an updated version of the sex education program was introduced to schools in the Province of Ontario, Canada. The curriculum received strong criticism from some parents and lobby groups. Similar objections led to the Ontario Liberal government withdrawing the previous sex education program update in 2010. Public debates about the appropriateness of the new curriculum are primarily concerned with the extent to which parents were consulted. Absent from these discussions are the opinions of the curriculum’s target group: students. What do young people have to say about their sexual health education, and how can this information be used to provide more effective programs in schools? In this article we draw on the findings of the Toronto Teen Survey (TTS) (N = 1,216) to discuss youth responses to questions about their experience with sexual health education and the relevance of this information for school-based sexual health education (SBSE). Considering that TTS youth identified schools as their primary source of sexual health education, the survey findings have value for SBSE. In discussing the TTS data in the context of the updated Ontario sexual health curriculum, we provide a youth perspective on the revised sexual health education program that was implemented in the fall of 2015

Survival outcomes of a population-based cohort of adolescent and young adult (AYA), acute lymphoblastic leukemia (ALL) patients in Ontario, Canada: The IMPACT Cohort

Introduction Adolescents and young adults (AYA) are an understudied population in cancer research. The Initiative to Maximize Progress in Adolescent and Young Adult Cancer Therapy (IMPACT) cohort includes Ontario individuals aged 15-21 years, diagnosed with a malignancy during 1992-2011. This cohort contains a rich source of patient, disease, and treatment data. Objectives and Approach The IMPACT cohort was created using chart review and linkages to population-based health services databases. The cohort is comprised of AYA with a primary diagnosis of acute leukemia, Hodgkin lymphoma, non-Hodgkin lymphoma, sarcoma, or testicular cancer. For the current study, we focused on acute lymphoblastic leukemia (ALL) patients, and examined survival outcomes of those treated at pediatric vs adult centers, with adult vs pediatric protocols. We assessed 5-year event-free survival (first of relapse, progression, secondary malignant neoplasm, or death) and overall survival. Results The IMPACT cohort contains 2,963 patients, of which 152/271 ALL patients were treated at adult centers. The 5-year event-free survival (EFS ± standard error) among those treated at a pediatric vs. adult center was 72%±4% vs. 56%±4% (p = 0.03), respectively. The 5-year overall survival (OS) was 82%±4% vs. 64%±4% (p Conclusion/Implications ALL patients treated with a pediatric protocol at a pediatric center experienced better, crude survival outcomes compared to those at an adult center. The IMPACT cohort offers the opportunity to study a myriad of questions on different cancer groups, with the ultimate goal of improving outcomes among the AYA population

Protocol: Evaluating the impact of a nation-wide train-the-trainer educational initiative to enhance the quality of palliative care for children with cancer

Background: There are identified gaps in the care provided to children with cancer based on the self-identified lack of education for health care professionals in pediatric palliative care and in the perceptions of bereaved parents who describe suboptimal care. In order to address these gaps, we will implement and evaluate a national roll-out of Education in Palliative and End-of-Life Care for Pediatrics (EPEC (R)-Pediatrics), using a 'Train-the-Trainer' model.Methods/design: In this study we are using a pre-post-test design and an integrated knowledge translation approach to assess the impact of the educational roll-out in four areas: 1) self-assessed knowledge of health professionals; 2) knowledge dissemination outcomes; 3) practice change outcomes; and 4) quality of palliative care. The quality of palliative care will be assessed using data from three sources: a) parent and child surveys about symptoms, quality of life and care provided; b) health record reviews of deceased patients; and c) bereaved parent surveys about end-of-life and bereavement care. After being trained in EPEC (R)-Pediatrics, 'Master Facilitators' will train 'Regional Teams' affiliated with 16 pediatric oncology programs in Canada. Each team will consist of three to five health professionals representing oncology, palliative care, and the community. Each team member will complete online modules and attend one of two face-to-face conferences, where they will receive training and materials to teach the EPEC (R)-Pediatrics curriculum to 'End-Users' in their region. Regional Teams will also choose a Tailored Implementation of Practice Standards (TIPS) Kit to guide implementation of a quality improvement project in their region; support will be provided via quarterly meetings with Co-Leads and via a listserv and webinars with other teams.Discussion: Through this study we aim to raise the level of pediatric palliative care education amongst health care professionals in Canada. Our study will be a significant step forward in evaluation of the impact of EPEC (R)-Pediatrics both on dissemination outcomes and on care quality at a national level. Based on the anticipated success of our project we hope to expand the EPEC (R)-Pediatrics roll-out to health professionals who care for children with non-oncological life-threatening conditions

Association of Country Income Level With the Characteristics and Outcomes of Critically Ill Patients Hospitalized With Acute Kidney Injury and COVID-19

Introduction: Acute kidney injury (AKI) has been identified as one of the most common and significant problems in hospitalized patients with COVID-19. However, studies examining the relationship between COVID-19 and AKI in low- and low-middle income countries (LLMIC) are lacking. Given that AKI is known to carry a higher mortality rate in these countries, it is important to understand differences in this population.Methods: This prospective, observational study examines the AKI incidence and characteristics of 32,210 patients with COVID-19 from 49 countries across all income levels who were admitted to an intensive care unit during their hospital stay.Results: Among patients with COVID-19 admitted to the intensive care unit, AKI incidence was highest in patients in LLMIC, followed by patients in upper-middle income countries (UMIC) and high-income countries (HIC) (53%, 38%, and 30%, respectively), whereas dialysis rates were lowest among patients with AKI from LLMIC and highest among those from HIC (27% vs. 45%). Patients with AKI in LLMIC had the largest proportion of community-acquired AKI (CA-AKI) and highest rate of in-hospital death (79% vs. 54% in HIC and 66% in UMIC). The association between AKI, being from LLMIC and in-hospital death persisted even after adjusting for disease severity.Conclusions: AKI is a particularly devastating complication of COVID-19 among patients from poorer nations where the gaps in accessibility and quality of healthcare delivery have a major impact on patient outcomes

Evaluation of Treatment-Related Mortality Among Paediatric Cancer Deaths: a population based analysis.

BACKGROUND: Objectives were to describe the proportion of deaths due to treatment-related mortality (TRM) and to identify risk factors and probable causes of TRM among paediatric cancer deaths in a population-based cohort. METHODS: We included children with cancer ⩽18 years diagnosed and treated in Ontario who died between January 2003 and December 2012. Deaths were identified using a provincial registry, the Pediatric Oncology Group of Ontario Networked Information System. Probable causes of TRM were described. RESULTS: Among the 964 deaths identified, 821 were included. The median age at diagnosis was 6.6 years (range 0-18.8) and 51.8% had at least one relapse. Of the deaths examined, TRM occurred in 217/821 (26.4%) while 604/821 (73.6%) were due to progressive cancer. Deaths from TRM did not change over time. Using multiple regression, younger age, leukaemia diagnosis and absence of relapse were independently positively associated with TRM. The most common probable causes of TRM were respiratory, infection and haemorrhage. CONCLUSIONS: TRM was responsible for 26.4% of deaths in paediatric cancer. Underlying diagnosis, younger age and absence of relapse were associated with TRM and causes of TRM differed by diagnosis group. Future work should evaluate TRM rate and risk factors among newly diagnosed cancer patients