Ketan Kulkarni

Increased requirement for central venous catheter replacement in paediatric oncology patients with deep venous thrombosis: A multicentre study

Increased requirement for central venous catheter replacement in paediatric oncology patients with deep venous thrombosis: A multicentre study -

Hospital detention practices: statement of a global taskforce

Hospital detention practices can be defined as refusal to release living patients after medical discharge is clinically indicated, or refusal to release bodies of deceased patients, when families are unable to pay hospital bills. Each additional day for which patients are detained adds to their bills, increasingly hindering families’ ability to obtain patients’ release. Patients are sometimes detained in hospitals, or bodies detained in mortuaries, for months. Occasionally, patients are completely left behind in hospitals when families are unable to pay. Unclaimed patients’ bodies might be disposed of in mass graves. The problem’s magnitude is unknown, but is probably more widespread than is documented. Hospital detention has been reported by human rights organisations, clinicians, journalists, and laypeople in Africa, Asia, Latin America, and eastern Europe. The problem aff ects children and adults with acute disorders (eg, people involved in road accidents and women with birth complications) and chronic diseases (eg, cancer or HIV/AIDS). Reports do not have consistent terminology to enable comparisons of studies worldwide or to eff ectively unite forces. We have formed the International Society of Paediatric Oncology and Paediatric Oncology in Developing Countries (SIOP PODC) Global Taskforce on Hospital Detention Practices, with the following objectives: to augment critical awareness; to introduce consistent terminology; to help to map global scope reliably; to elucidate adverse consequences; to address root causes; and to identify and support implementation of eff ective solutions to end hospital detention practices. The Taskforce endorses the following core statements related to each objective. Patients’ detention violates international human rights, including the right to not be imprisoned as a debtor and to have access to medical care. Recommended terminology includes “hospital detention practices” and “detained patients”. The term “detention” minimises confusion with positive health-care retention in medical literature. The term “practices” more accurately describes reality than does “policies”. Although hospital detention is often not the offi cial policy publicly defended by governments, it might be a wide spread unofficial practice. To map the global scope, the Taskforce calls on professionals and advocates to report hospital detention in scientifi c journals, media, and public venues. Recognition of adverse consequences is crucial. Fear of detention might prevent or delay conventional medical help-seeking, and encourages abandonment of potentially curative treatment after patients’ release. Progressive or relapsed disease and unnecessary death often result. Detention aggravates hospital overcrowding, increases infection risk, and denies schooling to children. Hospital detention is often the result of mismanagement, corruption, dysfunctional health-care system structures, inadequate health insurance coverage, and unfair waiver procedures, warranting attention. Advocacy by stakeholders is urgently needed (panel). Our Taskforce endorses this position statement in the conviction that detention of patients is unethical and inhumane, and must end.

In the realms of future: new frontiers of 'techno-oncology' as a platform for global improvement in the outcomes of childhood cancer.

The survival outcome of childhood cancers in developing nations has failed to keep pace with that of developed nations. Technological advances offer a unique and radical opportunity to develop programs and strategies to improve outcomes of childhood cancer globally. The novel field of ‘techno-oncology’ has a broad scope and the potential to phenomenally impact, revamp and model the care of pediatric cancer patients in the developing world. Many frontiers and opportunities in the area remain to be explored as well as many challenges to be surmounted.

Enrolling children with acute lymphoblastic leukaemia on a clinical trial improves event-free survival: a population-based study

Background:The objectives of this study were to describe the impact of trial enrollment at diagnosis on event-free and overall survival in paediatric acute lymphoblastic leukaemic (ALL) using a population-based approach.Methods:We conducted a retrospective cohort study that included children newly diagnosed with ALL between 1 and 14 years of age. The data source was the Cancer in Young People in Canada (CYP-C) national paediatric cancer population-based database. We conducted univariate and multiple Cox proportional hazards models.Results:There were 2569 children with ALL; 1408 (54.8%) were enrolled on a clinical trial at initial diagnosis. Event-free survival at 5 years was 89.8%±0.9 vs 84.1%±1.2. (P<0.0001) for those enrolled and not enrolled on a clinical trial, respectively. Overall survival at 5 years was higher for those enrolled (94.1%±0.7) vs not enrolled (90.5%±1.0; P=0.001). In a model that adjusted for demographic, leukaemic and socioeconomic factors, enrollment on trials was significantly associated with better event-free survival (hazard ratio (HR) 0.67, 95% confidence interval (CI) 0.47–0.95; P=0.023), but not overall survival (HR 0.69, 95% CI 0.44–1.08; P=0.102).Conclusions:Event-free survival was significantly better in children with ALL enrolled on a clinical trial. Future research should identify barriers to clinical trial enrollment for children with ALL.

Incidence and characteristics of venous thrombotic events in pediatric cancer patients: A 20-year experience in the Maritimes, Canada

ABSTRACT Objective: Venous thrombotic events (VTE) are a well-recognized complication in pediatric cancer patients. Population-based data on the incidence and characteristics of VTE in all pediatric cancer patients are limited. This information is crucial to identify patients at high risk and design targeted interventions accordingly. The present study was designed to determine the incidence and characteristics of VTE in the pediatric oncology population. Participants: We conducted a retrospective, population-based, cohort study of patients treated in the Maritimes, Canada between 1995 and 2015. Results: There were 1210 pediatric hematology/oncology patients from the Maritimes, Canada, treated at the IWK Health Centre between 1995 and 2015. Fifty-eight (4.8%) experienced at least 1 VTE and the majority of patients experienced it within 6 months of cancer diagnosis. The median age of patients who experienced VTE was 10.7 years (SD = 6.0). The most common presenting symptom of thrombosis was central venous line dysfunction, and the most common location for thrombosis was within the upper venous system. We observed that 65.6% of the patients with VTE required >1 central venous catheters (CVC). The presence of a VTE increased the odds of requiring >1 CVC to 3.6 (95% confidence interval: 1.76–7.3). Conclusion: Thus, in this large, population-based study, we present the incidence and characteristics of VTE in the pediatric oncology population and demonstrate the clinical impact of VTE in terms of loss of CVC. Larger, prospective studies are required to confirm these findings and to develop a risk model for managing and preventing VTE in this patient population.

Thromboembolism Incidence and Risk Factors in Children with Cancer: A Population-Based Cohort Study

There is conflicting information about the epidemiology of thromboembolism (TE) in paediatric oncology. Objectives were to describe the incidence and risk factors of TE in children with cancer. We included all children with cancer less than 15 years of age diagnosed from 2001 to 2016, treated at one of the 12 Canadian paediatric centres outside of Ontario and entered into the Cancer in Young People-Canada database. Potential risk factors for TE were evaluated using Cox proportional hazards regression stratified by haematological malignancies versus solid tumours. Factors associated with vascular access- and non-vascular access-related TE were compared using chi-square or Fishers exact tests. Of the 7,471 children included, 283 experienced TE requiring medical intervention; cumulative incidence of TE at 5 years was 3.8 ± 0.2% and 0.36% ± 0.07% for life-threatening or fatal TE. For haematological malignancies, the following factors were associated with TE in multivariable regression: age < 1 year, 5 to 9.99 years and 10 to 14.99 years (relative to age 1-4.99 years), haematopoietic stem cell transplant (hazard ratio [HR] = 1.49, 95% confidence interval [CI], 1.00-2.32), anthracyclines (HR = 2.21, 95% CI, 1.12-4.37) and asparaginase (HR = 1.68, 95% CI, 1.15-2.44). For solid tumours, obesity (HR = 1.92, 95% CI, 1.01-3.68), surgery (HR = 2.70, 95% CI, 1.44-5.08), radiation (HR = 47.51, 95% CI, 24.01-94.01), anthracyclines (HR = 2.74, 95% CI, 1.29-5.82) and platinum agents (HR = 2.26, 95% CI, 1.19-4.28) were associated with TE. Life-threatening and fatal TEs were more common among non-vascular access TEs (14.5% vs. 3.3% p = 0.001). In a population-based cohort, 4% of children with cancer developed a clinically significant TE. Accurate risk stratification tools are needed specific to malignancy type.

Early career professionals: A challenging road

The term “early career professional” (ECP) indicates a generation of professionals that demonstrates the potential to succeed established professionals and leaders. The field of thrombosis and hemostasis has a large ECP community. They often face typical challenges in their endeavor to establish an independent academic career. A healthy work‐life balance and mentoring are key for ECPs to create the ideal circumstances to advance their careers. However, multitasking training, research and clinical duties is a burden, and burnout is a looming issue. The advent of the smartphone presents an additional challenge by blurring the border between work and non‐work time. This Forum describes some of the typical challenges faced by ECPs, highlights existing literature and suggests practical solutions relevant to ECPs in the field of thrombosis and hemostasis, and the possible role of the ISTH Early Career Committee.

Enrollment on clinical trials does not improve survival for children with acute myeloid leukemia: A population-based study

It is questionable whether enrollment on clinical trials offers any survival advantage at the population level over standard‐of‐care treatment. The objectives of this study were to describe the impact of trial enrollment on event‐free survival and overall survival in pediatric acute myeloid leukemia (AML) using the Cancer in Young People in Canada (CYP‐C) database.

Correction to: The association of venous thromboembolism with survival in pediatric cancer patients: a population-based cohort study

The Figure 1 used in the originally published version of this article was incorrect.

Tracking children with acute lymphoblastic leukemia who abandoned therapy: Experience, challenges, parental perspectives, and impact of treatment subsidies and intensified counseling

ABSTRACT Refusal for treatment and therapy abandonment are important reasons for unfavorable outcome of childhood acute lymphoblastic leukemia (ALL) in resource-poor countries. The present study, conducted on children with ALL whose treatment was abandoned, attempted to track all these children to ascertain the causes and outcome of therapy abandonment/refusal. In order to improve outcome of ALL, measures to prevent abandonment were introduced in the form of treatment subsidies and intensified multistage counseling. Of the 77 (of 418) children abandoning therapy, 17 (22%) refused upfront, whereas the rest abandoned during various phases of chemotherapy. Only 39 (50.6%) of these 77 families could be subsequently contacted. Financial problems, too many dependents at home, and wrong perceptions about cancer led to abandonment in majority. Children abandoning treatment before completion of induction had a significantly shorter survival than who abandoned post induction (P < .0001). Intensified preabandonment counseling and subsidized treatment led to significant reduction in abandonment rates (P < .0001).