Depersonalization and derealization as sequelae of a temporal lobe lesion: a case report.

BACKGROUND: Depersonalization and derealization can occur not just from psychiatric causes but also from various organic etiologies, such as seizures and intracerebral structural abnormalities. However, there have been no previous reported cases to the authors' knowledge detailing isolated depersonalization and derealization in the absence of clinical seizure activity or other psychiatric pathology, as sequelae of structural intracerebral lesions. CASE PRESENTATION: In this case report, we detail the unique presentation of a 68-year-old woman under the care of palliative medicine who experienced depersonalization and derealization secondary to a metastatic lesion in her temporal lobe, in the parahippocampal gyrus to medial occipitotemporal gyrus region. These symptoms were present in the absence of any clinical seizure activity or other psychiatric symptomatology and largely resolved with the use of steroidal therapy, before returning secondary to disease progression. CONCLUSIONS: We discuss the relationship among isolated depersonalization and derealization with pathology of the left posterior temporal lobe in the context of this interesting case. This case expands our knowledge of the neurobiology of these phenomena, given the specific localization of the intracerebral pathology and temporal specificity of symptoms relative to tumor growth and treatment course.

Sex-Based Analysis of Quality Indicators of End-of-Life Care in Gastrointestinal Malignancies.

Indices of aggressive or supportive end-of-life (EOL) care are used to evaluate health services quality. Disparities according to sex were previously described, with studies showing that male sex is associated with aggressive EOL care. This is a secondary analysis of 69,983 patients who died of a GI malignancy in Ontario between 2006 and 2018. Quality indices from the last 14-30 days of life and aggregate measures for aggressive and supportive EOL care were derived from administrative data. Hospitalizations, emergency department use, intensive care unit admissions, and receipt of chemotherapy were considered indices of aggressive care, while physician house call and palliative home care were considered indices of supportive care. Overall, a smaller proportion of females experienced aggressive care at EOL (14.3% vs. 19.0%, standardized difference = 0.13, where ≥0.1 is a meaningful difference). Over time, rates of aggressive care were stable, while rates of supportive care increased for both sexes. Logistic regression showed that younger females (ages 18-39) had increased odds of experiencing aggressive EOL care (OR 1.71, 95% CI 1.30-2.25), but there was no such association for males. Quality of EOL care varies according to sex, with a smaller proportion of females experiencing aggressive EOL care.

MAiD for geriatric syndromes: Special considerations.

Medical Assistance in Dying (MAiD) brings unique considerations in the context of geriatric syndromes such as frailty and cognitive or functional impairment. These conditions are associated with complex vulnerability across health and social domains and often do not have predicable trajectories or responses to healthcare interventions. In this article, we focus on four categories of gaps in care that are particularly relevant for MAiD in geriatric syndromes, namely, inadequacies in access to medical care, appropriate advance care planning, social supports, and funding for supportive care. We conclude by arguing that appropriately situating MAiD in the context of care for older adults requires careful consideration of these gaps in care to enable real, robust, and respectful healthcare choices for people living with geriatric syndromes and approaching end-of-life.

Quality of End-of-Life Care in Gastrointestinal Cancers: A 13-Year Population-Based Retrospective Analysis in Ontario, Canada.

Population-based quality indicators of either aggressive or supportive care at end of life (EOL), especially when specific to a cancer type, help to inform quality improvement efforts. This is a population-based, retrospective cohort study of gastrointestinal (GI) cancer decedents in Ontario from 1 January 2006-31 December 2018, using administrative data. Quality indices included hospitalizations, emergency department (ED) use, intensive care unit admissions, receipt of chemotherapy, physician house call, and palliative home care in the last 14-30 days of life. Previously defined aggregate measures of both aggressive and supportive care at end of life were also used. In our population of 69,983 patients who died of a GI malignancy during the study period, the odds of experiencing aggressive care at EOL remained stable, while the odds of experiencing supportive care at EOL increased. Most of our population received palliative care in the last year of life (n = 65,076, 93.0%) and a palliative care home care service in the last 30 days of life (n = 45,327, 70.0%). A significant number of patients also experienced death in an acute care hospital bed (n = 28,721, 41.0%) or had a new hospitalisation in the last 30 days of life (n = 33,283, 51.4%). The majority of patients received palliative care in the last year of life, and a majority received a palliative care home service within the last 30 days of life. The odds of receiving supportive care at EOL have increased over time. Differences in care exist according to income, age, and rurality.

Surviving Long Enough to Die? An Analysis of Incomplete Assessments for Medical Assistance in Dying.

Background: Medical assistance in dying (MAiD) was legalized in Canada on June 17, 2016, yet many who request MAiD do not complete the assessment process and instead experience a natural death. This analysis of patients who made a formal request for MAiD aims to clarify timelines and factors associated with completion of the MAiD assessment process, and factors associated with completion or noncompletion of MAiD once eligible. Materials and Methods: This retrospective cohort study included all patients in Nova Scotia who requested MAiD between January 1, 2018 and December 31, 2018, were deceased at the time of analysis, did not withdraw their request, and were not formally deemed ineligible for the procedure (n = 218). Descriptive statistics, Kaplan-Meier curves, and logistic regression were used in data analysis. Results: Of 218 patients, 48 did not complete the MAiD assessment process. Of the 170 patients who completed the assessment process and were deemed eligible for MAiD, 79.4% (n = 135) completed the procedure. Those with an incomplete assessment had a median survival from request to death of 8.0 days (interquartile range [IQR] = 11.5), whereas for those deemed eligible, median survival from request to determination of MAiD eligibility was also 8.0 days (IQR = 16.0). Interpretation: Proximity to natural death and poor performance status at the time of MAiD request may drive incomplete MAiD assessments. The majority of patients deemed eligible for MAiD complete the procedure, and as such, patients who did not complete the MAiD assessment process may not have experienced their preferred mode of death.

A Retrospective Review of Medically Assisted Deaths in Nova Scotia: What Do We Know and Where Should We Go?

Background: Since legalization of medical assistance in dying (MAiD) in Canada on June 17, 2016, there has been limited information regarding how outcomes of those requesting MAiD relates to comorbidity, social circumstances, geographic location, and access to care. This study aims to identify characteristics associated with the completion of MAiD, once requested, with specialist palliative care (SPC) as the primary exposure of interest. Methods: This retrospective cohort study consists of all patients in Nova Scotia who requested MAiD between June 17, 2016 and December 31, 2018 and were deceased at the time of analysis (n = 383). Descriptive statistics and logistic regression were performed. Results: A smaller proportion of patients who completed MAiD were seen in consultation by SPC (69.4% vs. 81.1%, p = 0.01). SPC was associated with decreased odds of completing MAiD (odds ratio [OR] 0.59, 95% confidence interval [CI] 0.36-0.96, p = 0.04), as was cohabitation (OR 0.64, 95% CI 0.41-0.99, p = 0.05) and Charlson comorbidity index >6 (OR 0.64, 95% CI 0.41-0.99, p = 0.05). Interpretation: SPC consultation was associated with significantly reduced likelihood of MAiD completion. Contributing factors may include differences in access to SPC services, those completing MAiD being more likely to decline a consultation with SPC, or the impact of SPC upon patient preferences and access to MAiD. While the interface between SPC and MAiD is in its early stages, our findings are supportive of a more integrated approach to coordination of SPC and MAiD services.

Frailty Hinders Recovery From Influenza and Acute Respiratory Illness in Older Adults.

BACKGROUND: We examined frailty as a predictor of recovery in older adults hospitalized with influenza and acute respiratory illness. METHODS: A total of 5011 patients aged ≥65 years were admitted to Canadian Serious Outcomes Surveillance Network hospitals during the 2011/2012, 2012/2013, and 2013/2014 influenza seasons. Frailty was measured using a previously validated frailty index (FI). Poor recovery was defined as death by 30 days postdischarge or an increase of more than 0.06 (≥2 persistent new health deficits) on the FI. Multivariable logistic regression controlled for age, sex, season, influenza diagnosis, and influenza vaccination status. RESULTS: Mean age was 79.4 (standard deviation = 8.4) years; 53.1% were women. At baseline, 15.0% (n = 750) were nonfrail, 39.3% (n = 1971) were prefrail, 39.8% (n = 1995) were frail, and 5.9% (n = 295) were most frail. Poor recovery was experienced by 21.4%, 52.0% of whom had died. Frailty was associated with lower odds of recovery in all 3 seasons: 2011/2012 (odds ratio [OR] = 0.70; 95% confidence interval [CI], 0.59-0.84), 2012/2013 (OR = 0.72; 95% CI, 0.66-0.79), and 2013/2014 (OR = 0.75; 95% CI, 0.69-0.82); results varied by season, influenza status, vaccination status, and age. CONCLUSIONS: Increasing frailty is associated with lower odds of recovery, and persistent worsening frailty is an important adverse outcome of acute illness.

Takotsubo Cardiomyopathy During Anti-HER2 Therapy for Metastatic Breast Cancer.

Human epidermal growth factor receptor 2 (HER2)-targeted antibodies, including pertuzumab and trastuzumab, improve overall survival and progression-free survival among women with HER2-positive metastatic breast cancer, but grade ≥3 cardiotoxicity occurs in approximately 8% of cases. Here we report a case of Takotsubo cardiomyopathy associated with the use of dual anti-HER2 therapy in a 63-year-old woman who presented to the emergency department with an 8- to 10-hour history of progressive dyspnea after completing her third cycle of pertuzumab plus trastuzumab in addition to nab-paclitaxel chemotherapy. To our knowledge, this patient represents the first reported case of Takotsubo cardiomyopathy associated with pertuzumab plus trastuzumab combination therapy in the literature.

Scientific Overview on CSCI-CITAC Annual General Meeting and 2016 Young Investigators' Forum.

The 2016 Annual General Meeting of the Canadian Society of Clinician Investigators (CSCI) and Clinician Investigator Trainee Association of Canada/Association des Cliniciens-Chercheurs en Formation du Canada (CITAC/ACCFC) was a national conference held in Toronto November 21-23, 2016, in conjunction with The University of Toronto Clinician Investigator Program Research Day. The theme for this year's meeting was "Mapping Your Career as a Clinician-Scientist"; emphasizing essential skills for developing a fruitful career as clinician-scientist. The meeting featured an opening presentation by Dr. Alan Underhill, Dr. Nicola Jones and Alexandra Kuzyk. The keynote speakers were Dr. Nada Jabado (McGill University), who discussed the association between cancer and histones, Dr. Norman Rosenblum (University of Toronto), who addressed the career path and the "calling" of the Clinician Scientist, Dr. Martin Schmeing (McGill University), who was the 2016 Joe Doupe Award recipient, and Dr. Linda Rabeneck (Cancer Care Ontario and University of Toronto), who received the Friends of CIHR lectureship. The workshops, focusing on career development for clinician scientists, were hosted by Drs. Alan Underhill, Nicola Jones, Lynn Raymond, Michael Schlossmacher and Norman Rosenblum, as well as University of Toronto communication specialists, Caitlin Johannesson and Suzanne Gold. In addition, the Young Investigators' Forum included presentations from clinician investigator trainees from across the country. The research topics were diverse and comprehensive: from basic sciences to clinical practice; from epidemiology to medical engineering. All scientific abstracts are summarized in this review. Over 70 abstracts were showcased at this year's meeting during two poster sessions, with six outstanding abstracts selected for oral presentations during the President's Forum.

Effect of aerobic exercise on cognition, academic achievement, and psychosocial function in children: a systematic review of randomized control trials.

INTRODUCTION: Although the effects of aerobic physical activity (APA) on children's physical health is well characterized, the effect of aerobic physical activity on cognition, academic achievement, and psychosocial function has not yet been established. This systematic review provides an overview of research elucidating the relationship between aerobic physical activity and children's cognition, academic achievement, and psychosocial function. METHODS: A systematic review of English articles was performed in April 2013 using MEDLINE, Cochrane, PsycINFO, SPORTDiscus, and EMBASE. Additional studies were identified through back-searching bibliographies. Only randomized control trials with an intervention of aerobic physical activity in children younger than 19 years that measured psychological, behavioral, cognitive, or academic outcomes were included. RESULTS: We found 8 relevant randomized control trials that met our inclusion criteria and extracted relevant data and evaluated the methodologic quality of the studies. Of the 8 studies identified, 2 studies were crossover randomized control trials studying the effects of acute aerobic physical activity on cognitive performance. Six studies were parallel-group randomized control studies, of which only 2 had a follow-up period of longer than 6 months. All studies showed that APA had a generally positive impact on children's cognition and psychosocial function. However, this relationship was found to be minimal in many studies and in some measures, no significant improvement was seen at all. There was no documentation of APA having any negative impact on children's cognition and psychosocial health, even in cases where school curriculum time was reassigned from classroom teaching to aerobic physical activity. CONCLUSION: APA is positively associated with cognition, academic achievement, behavior, and psychosocial functioning outcomes. More rigorous trials with adequate sample sizes assessing the impact of APA on children's cognitive abilities, psychosocial functioning, behavior, and academic achievement are needed, with standardized interventions, valid and reliable tools of measurement, and long-term follow-up for sustained cognitive and psychosocial outcomes.