Eastern Canadian Gastrointestinal Cancer Consensus Conference 2019.

The annual Eastern Canadian Gastrointestinal Cancer Consensus Conference 2019 was held in Morell, Prince Edward Island, 19-21 September 2019. Experts in medical oncology, radiation oncology, and surgical oncology who are involved in the management of patients with gastrointestinal malignancies participated in presentations and discussion sessions for the purpose of developing the recommendations presented here. This consensus statement addresses multiple topics in the management of anal, colorectal, biliary tract, and gastric cancers, including: radiotherapy and systemic therapy for localized and advanced anal cancer; watch and wait strategy for the management of rectal cancer; role of testing for dihydropyrimidine dehydrogenase (DPD) deficiency prior to commencement of fluoropyrimidine therapy; radiotherapy and systemic therapy in the adjuvant and unresectable settings for biliary tract cancer; and radiotherapy and systemic therapy in the perioperative setting for early-stage gastric cancer.

Adherence to clinical practice guidelines in the management of children, youth, and young adults with type 1 diabetes--a prospective population cohort study.

OBJECTIVE: To describe adherence to clinical practice guidelines for the treatment of childhood type 1 diabetes and identify associated patient and system level factors. STUDY DESIGN: This prospective cohort study used population-based administrative data to describe individuals aged 1-24 years who had been diagnosed with type 1 diabetes at <20 years of age (1472 unique individuals and 5883 person-years over a 7-year period) living in British Columbia, Canada. The outcome measure was proportion 'at goal,' which was defined as having optimal adherence (3 diabetes-related physician visits/year, 3 hemoglobin A1c (HbA1c) tests/year, 1 glucagon prescription dispensed/year, and appropriate screening for diabetes-related comorbidity [ie, hypothyroidism] and complications [ie, retinopathy and nephropathy]), or good adherence to guidelines (2 diabetes-related physician visits/year, 2 HbA1c tests/year, and appropriate screening for diabetes-related comorbidity and complications). Statistical methods included descriptive statistics and logistic regression modeling. RESULTS: Fifty-four percent person-years had poor adherence to guidelines (<2 diabetes-related physician visits and HbA1c tests/year) and 7.4% had optimal adherence. The proportion of person-years at goal was higher in females vs males (41.0% vs 37.6%; P = .007). Individuals 4-years post-diagnosis of diabetes were 78% less likely to be at goal compared with the year of diagnosis (P < .0001). CONCLUSIONS: The treatment of pediatric type 1 diabetes likely does not meet national and international standards. Future studies should explore facilitators and barriers to adherence to guidelines among health care providers, patients, and families, and whether adherence to guidelines is associated with glycemic control.

A randomized, controlled trial comparing acetaminophen plus ibuprofen versus acetaminophen plus codeine plus caffeine (Tylenol 3) after outpatient breast surgery.

BACKGROUND: The combination of acetaminophen, codeine, and caffeine (Tylenol 3, T3) is a standard postoperative analgesia after breast surgery despite the adverse effects and variable efficacy of narcotics. This study compared the efficacy of a nonnarcotic approach (acetaminophen and ibuprofen; AcIBU) to T3 after outpatient breast surgery. METHODS: This double-blind randomized equivalence trial involved patients undergoing outpatient breast surgery. Patients were randomized (stratified by procedure type) to receive AcIBU or T3 four times daily for 7 days, or until free of pain. Pain intensity, measured four times daily by the visual analog scale, was the primary outcome; secondary outcomes were pain relief with analgesic, days until freedom from pain, adverse effects, discontinuation of drug as a result of adverse effects, and patient satisfaction. RESULTS: There were 71 patients randomized to AcIBU and 70 patients to T3. Repeated measures analysis showed no significant difference in average pain intensity over 7 days (AcIBU 19.9 mm vs. T3 20.6 mm; P = 0.78). Similarly, there was no significant difference in pain relief with analgesic (P = 0.46). Although no difference in the incidence of adverse effects was observed (P = 0.94), discontinuation of the study drug as a result of adverse effects was more common with T3 (19 % vs. 6 %; P = 0.018). No significant differences were identified in days until freedom from pain or patient satisfaction; 92 % of AcIBU and 89 % of T3 patients were satisfied with their pain control (P = 0.55). CONCLUSIONS: AcIBU is a safe, effective method of pain control after outpatient breast surgery. Compared to T3, it provides at least equivalent analgesia and has a more tolerable adverse effect profile.

Sarcomatoid carcinoma of the bladder after simultaneous kidney-pancreas transplant: a case report and review of the literature.

Carcinosarcoma and sarcomatoid carcinoma of the bladder after organ transplantation is higher in comparison to the general population but overall occurrence is still very uncommon. Due to the decreased immunitary response effects of antirejection drugs, these cancers have aggressive course and respond poorly to treatment. Bladder drained pancreatic transplants are associated with a number of urologic challenges that can delay the diagnosis and the treatment of malignancies of the genito-urinary system. The authors present a case of a rare sarcomatoid carcinoma of the bladder following bladder drained simultaneous kidney and pancreas transplant and discuss its pathogenesis and clinical management.

Validation of classification algorithms for childhood diabetes identified from administrative data.

OBJECTIVE: Type 1 diabetes is the most common form of diabetes among children; however, the proportion of cases of childhood type 2 diabetes is increasing. In Canada, the National Diabetes Surveillance System (NDSS) uses administrative health data to describe trends in the epidemiology of diabetes, but does not specify diabetes type. The objective of this study was to validate algorithms to classify diabetes type in children <20 yr identified using the NDSS methodology. PATIENTS AND METHODS: We applied the NDSS case definition to children living in British Columbia between 1 April 1996 and 31 March 2007. Through an iterative process, four potential classification algorithms were developed based on demographic characteristics and drug-utilization patterns. Each algorithm was then validated against a gold standard clinical database. RESULTS: Algorithms based primarily on an age rule (i.e., age <10 at diagnosis categorized type 1 diabetes) were most sensitive in the identification of type 1 diabetes; algorithms with restrictions on drug utilization (i.e., no prescriptions for insulin ± glucose monitoring strips categorized type 2 diabetes) were most sensitive for identifying type 2 diabetes. One algorithm was identified as having the optimal balance of sensitivity (Sn) and specificity (Sp) for the identification of both type 1 (Sn: 98.6%; Sp: 78.2%; PPV: 97.8%) and type 2 diabetes (Sn: 83.2%; Sp: 97.5%; PPV: 73.7%). CONCLUSIONS: Demographic characteristics in combination with drug-utilization patterns can be used to differentiate diabetes type among cases of pediatric diabetes identified within administrative health databases. Validation of similar algorithms in other regions is warranted.

Saturated muscle activation contributes to compensatory reaching strategies after stroke.

The control and execution of movement could potentially be altered by the presence of stroke-induced weakness if muscles are incapable of generating sufficient power. The purpose of this study was to identify compensatory strategies during a forward (sagittal) reaching task for 20 persons with chronic stroke and 10 healthy age-matched controls. We hypothesized that the paretic anterior deltoid would be maximally activated (i.e., saturated) during a reaching task and that task completion would require activation of additional muscles, resulting in compensatory movements out of the sagittal plane. For reaching movements by control subjects, joint motion remained largely in the sagittal plane and hand trajectories were smooth and direct. Movement characteristics of the nonparetic arm of stroke subjects were similar to control subjects except for small increases in the abduction angle and the percentage that anterior deltoid was activated. In contrast, reaching movements of the paretic arm of stroke subjects were characterized by increased activation of all muscles, especially the lateral deltoid, in addition to the anterior deltoid, with resulting shoulder abduction power and segmented and indirect hand motion. For the paretic arm of stroke subjects, muscle and kinetic compensations increased with impairment severity and weaker muscles were used at a higher percentage of their available muscle activity. These results suggest that the inability to generate sufficient force with the typical agonists involved during a forward reaching task may necessitate compensatory muscle recruitment strategies to complete the task.

Consequences of increased neuromotor noise for reaching movements in persons with stroke.

Understanding stroke-induced changes to the motor control of the more affected arm of people with stroke may lead to more effective rehabilitation interventions that improve function. Reaching movements of the more affected arm in persons with stroke are slow, segmented, and indirect. Such changes may be related to a reduced capacity to transmit motor commands in the presence of neuromotor noise. In tasks requiring both speed and accuracy, transmission capacity can be characterized by the linear relationship between movement time and task difficulty (Fitts' law). This study quantified Fitts' slope and intercept coefficients in stroke during reaching tasks and their relationship to kinematic measures of path accuracy (directness), trajectory corrections (segmentation), and planning strategy (skewness). We compared Fitts' slope and intercept and kinematics among the more and the less affected arm of 20 persons with stroke and the nondominant arm of ten healthy persons. Slope and intercept were significantly increased in the more affected arm of the group with stroke and related to clinical measurements of motor impairment and tone. For both the more and the less affected arm of the group with stroke, increased slopes and intercepts were correlated to more indirect, segmented, and positively skewed movement. Our findings suggest that stroke results in greater neuromotor noise, which has consequences for both motor execution and planning. Individuals with stroke demonstrate substantially more deviation from straight-line paths than do controls, despite using more conservative strategies (i.e., leftward shift of velocity profile) and extensive feedback control (i.e., segmentation).

Phenol reduces hypertonia and enhances strength: a longitudinal case study.

Phenyl alcohol blocks are used to relieve spasticity. Such nerve conduction blocks result from phenol-induced axonotmesis and could potentially affect muscle properties related to the ability to generate, maximize, and reduce force. This study assessed the 12-week longitudinal effect of phenol on position (stiffness) and velocity (damping) components of hypertonia, in addition to strength (peak torque and times to generate and reduce torque) in an individual with chronic elbow flexor spasticity following stroke. Phenol motor point injections of flexor muscles paradoxically increased the magnitude of flexion torque and decreased the times required to generate and reduce flexion and extension joint torques, in addition to reducing elbow extension stiffness and damping. Large reductions in the velocity-related component of hypertonia (damping changes > 90%) occurred immediately following injection, which is a finding that supports the velocity-dependent definition of spasticity. Although the changes in damping were large and transient, changes in stiffness and strength variables were small, slower to occur, and maintained. This suggests secondary changes following nerve block, possibly facilitated by regular elbow use subsequent to spasticity reduction.

Linear spring-damper model of the hypertonic elbow: reliability and validity.

Hypertonia of the elbow joint complex is common in individuals with stroke and is related to the magnitude of the torque response (described by position dependent parameters) during constant velocity extensions. The objective of this study was to model position and velocity dependent characteristics of hypertonia. For both the more and less affected arms in 17 persons with chronic stroke, we measured the torque response to constant velocity stretches (30-180 degrees/s). The responses were combined in position-velocity space and parameters of stiffness, damping, and offset angle were determined from a linear spring-damper model of the torque profile. The model was assessed at three levels: (1) ability to describe the combined torque profile variance, (2) reliability of parameters, and (3) validity of parameters (i.e. clinical correlation). Model parameters fit the torque profiles of both arm groups well and exhibited day-to-day reliability. Stiffness (r=0.820), damping (r=0.816), and 'viscoelasticity' (r=0.909), a composite parameter index developed posthoc, were highly correlated to a manual assessment of hypertonia (Modified Ashworth Scale). Mechanically determined parameters of hypertonia graded along a continuum may have better discriminatory power than manual assessments and thus, may be better at tracking recovery and evaluating interventions.

Time and magnitude of torque generation is impaired in both arms following stroke.

Muscle strength, usually measured as the peak torque during maximal contraction, is impaired in persons with stroke. Time-dependent properties of muscle contraction may also be altered but have not been quantified. We quantified both magnitude (peak torque) and time-dependent parameters (times to develop and reduce torque) in eight different isometric joint actions. Parameters were compared among the more and less affected arms of 20 persons with chronic stroke and the nondominant arms of 10 similarly aged healthy persons. Torque-generation parameters were independent from one another (i.e., low correlations) and highly reliable between trials and days. All parameters were impaired in the more affected arm, whereas peak torque and time to develop torque were impaired in the less affected arm. Following stroke, torque-generation impairments include both magnitude and time-dependent properties and exist not only in the more affected but also in the less affected arm. Clinicians attempting to improve upper-extremity function should employ therapeutic exercises that challenge patients to improve both their strength and speed of muscle contraction.