Introduction: Oncology patients are generally transfused to maintain a hemoglobin (Hb) above 7 g/dL (Holst et. al. BMJ 2015). Some centers use higher Hb thresholds before radiation therapy (RT) because pre-clinical data suggest that oncology patients with low hemoglobin levels may respond sub-optimally to radiation therapy due to hypoxia-induced radio-resistance (Pitson et. al. Int J Radiat Oncol Biol Phys 2001; Tatum et. al. Int J Radiat Biol 2006). It is hypothesized that higher hemoglobin levels improve tissue oxygenation, which facilitates formation of reactive oxygen species that optimize cancer cell death. No standard red blood cell transfusion thresholds have been established using interventional study data for patients with malignancies treated with radiation. This systematic review aimed to investigate the role of red blood cell (RBC) transfusion in radiation oncology patients and whether maintaining a higher Hb leads to improved overall survival, efficacy of RT on disease control and transfusion-related morbidity. Methods: We performed a literature search of PubMed, EMBASE and the Cochrane Library for randomized controlled trials, cohort studies and large case series comparing RBC transfusion thresholds in radiation oncology patients. We hand-searched references of identified articles. Eligibility criteria were studies that assessed patients receiving any RT modality for malignancy of any diagnosis and stage. Exclusion criteria were studies that did not evaluate hemoglobin or transfusion as an intervention or outcome. The primary outcome was overall survival. Secondary outcomes included locoregional tumor control, number of transfusions and adverse events associated with either radiation or transfusion. Screening and data extraction were done in duplicate. A meta-analysis was planned with outcomes presented as odds ratios with 95% confidence intervals. Results: Our search yielded 6172 titles. After exclusions, 39 articles underwent full text review (Figure 1). Only one study met the pre-specified inclusion criteria; therefore, a meta-analysis was not performed. The identified study pooled results from two Danish randomized controlled trials (DAHANCA 5 and 7) that stratified patients with head and neck squamous cell carcinoma with low pre-radiation hemoglobin levels (females <13 g/dL and males <14.5 g/dL) to RBC transfusion (235 patients) versus no transfusion (230 patients) (Hoff et. al. Acta Oncol 2011). The study found no significant differences between groups in locoregional disease control or overall survival after five years of follow up, despite increased hemoglobin levels in the transfused group. Given the search results, we expanded the review to extract data from other relevant trials not meeting inclusion criteria to conduct a narrative review of the available literature. The extracted studies involved a variety of malignancies and were primarily single-center retrospective studies assessing outcomes of local transfusion policies. Some studies featured univariate and multivariate analyses, but had conflicting results on the effects of transfusion on disease control and mortality. A major criticism of these studies was the lack of comparison between different transfusion thresholds in anemic patients. Conclusions: This systematic review illustrates the lack of data on the effect of RBC transfusion strategies in oncology patients undergoing radiation. Well-designed prospective studies are urgently needed in this area due to variability in practice. Disclosures No relevant conflicts of interest to declare.
In recent years there has been a proliferation in the practice of vaping to consume nicotine-and cannabis-based products. While evidence on the benefits and risks of electronic cigarettes (e-cigarettes) is evolving, this brief primer highlights important new information about vaping for clinicians, researchers and the public. In 2018, the Canadian government passed legislation to regulate tobacco and vaping products. We discuss evidence comparing e-cigarettes versus nicotine replacement therapy for smoking cessation and highlight limitations of this body of research. While e-cigarettes are felt to contain fewer toxins than cigarettes, the long-term effects of vaping remain unknown. Emerging data demonstrates associations between vaping and acute and chronic lung disease. We discuss the emergence of an outbreak of severe lung injury associated with e-cigarette use in the United States and similar cases in Canada. Finally, we review evidence demonstrating the growing prevalence of vaping and smoking amongst Canadian youth. RESUMECes dernières années, on a assisté à une prolifération de la pratique de la vaporisation pour consommer des produits à base de nicotine et de cannabis. Alors que les preuves sur les avantages et les risques des cigarettes électroniques (e-cigarettes) évoluent, ce bref aperçu met en lumière de nouvelles informations importantes sur le vaping pour les cliniciens, les chercheurs et le public. En 2018, le gouvernement canadien a adopté une loi pour réglementer les produits du tabac et les produits à base de vapeur. Nous examinons les données comparant les e-cigarettes et les thérapies de remplacement de la nicotine pour le sevrage tabagique et soulignons les limites de ce corpus de recherche. Bien que l’on estime que les e-cigarettes contiennent moins de toxines que les cigarettes, les effets à long terme des vapeurs restent inconnus. Les données émergentes démontrent des associations entre l’inhalation de vapeurs et les maladies pulmonaires aiguës et chroniques. Nous discutons de l’émergence d’une épidémie de lésions pulmonaires graves associées à l’utilisation des e-cigarettes aux États-Unis et de cas similaires au Canada. Enfin, nous passons en revue les preuves démontrant la prévalence croissante des vapeurs et du tabagisme chez les jeunes Canadiens.
Graft versus host disease is a rare but deadly complication of solid organ transplant. Clinical features of graft-versus-host-disease are non-specific, which may lead to delayed diagnosis as more common conditions including infections or drug reactions are considered. We describe a 54-year-old male patient who underwent liver transplantation for alcohol use disorder-related cirrhosis and developed acute graft-versus-host disease. Initial clinical presentation included dermatitis, bone marrow failure and enteritis. Results of skin biopsy and cytogenetic studies were consistent with liver transplant-associated acute graft-versus-host disease. The importance of this case is to highlight to transplant physicians and surgeons the challenges of diagnosing graft-versus-host-disease. In our case, pre-existing partnerships among the liver and hematopoietic stem cell transplant teams, transfusion medicine specialists, critical care specialists and facilitated timely communication relevant to confirming graft-versus-host disease. We propose an algorithm to assist in the workup of suspected graft-versus-host disease. Because this condition is characterized by high mortality, a high index of suspicion is imperative for prompt diagnosis and optimal management of the donor-recipient immune interaction when patients present with classic clinical features.
In this case study, we provide angiographic and computed tomography images demonstrating a large cal-cified left ventricular (LV) aneurysm and associated calcified thrombus—unique, and now rare, sequelae of ST-elevation myocardial infarction (MI) that are rarely seen in the era of percutaneous coronary intervention (PCI). We discuss here the epidemiology, natural history, workup, and recommended management for LV aneurysms and thrombi with reference to clinical guidelines. Our patient’s calcified LV aneurysm and thrombus were discovered at the time of cardiac catheterization undertaken for a 2-month history of stable angina. He suffered an anterior MI 17 years ago and took aspirin only. He remained asymptomatic until presentation. Angiography also demonstrated severe triple-vessel coronary artery disease including left anterior descending artery occlusion. Our patient underwent stenting of the left circumflex and first diagonal and staged PCI to the right coronary artery, which led to functionally complete revascularization. RésuméDans cette étude de cas, nous présentons des images angiographiques et des coupes tomographiques d’un gros anévrisme calcifié du ventricule gauche (VG) et d’un thrombus calcifié qui y est associé – des séquelles uniques, mais maintenant rares, de l’infarctus du myocarde (IM) avec susdécalage du segment ST qui sont rarement constatées à l’ère de l’intervention coronarienne percutanée (ICP). Nous nous penchons sur l’épidémiologie, l’histoire naturelle, le processus d’évaluation et la prise en charge recommandée des anévrismes et des thrombus du VG en nous appuyant sur les lignes directrices cliniques. L’anévrisme et le thrombus calcifiés du VG de notre patient ont été découverts lors d’un cathétérisme cardiaque effectué pour une angine de poitrine stable depuis deux mois. Il a déjà subi un IM il y a 17 ans et ne prend que des aspirines. Il est demeuré asymptomatique jusqu’à la consultation. L’angiographie montre également la présence d’une coronaropathie tritronculaire grave, dont une occlusion de l’artère descendante antérieure gauche. Notre patient a subi une implantation d’endoprothèses dans l’artère auriculoventriculaire et la première branche diagonale et une ICP différée de l’artère coronaire droite, ce qui a mené à une revascularisation complète fonctionnelle.
Pendant des décennies, les populations autochtones au Canada ont connu des taux élevés de suicide comparativement à la population générale. Ce commentaire suggère que le suicide chez les personnes autochtones ne peut être expliqué uniquement par les effets causaux des déterminants de la santé « en aval » ; les déterminants de la santé « en amont », tels le passé colonial du Canada et la continuité culturelle, sont tout aussi, sinon plus importants pour comprendre la tragédie se déroulant dans plusieurs communautés autochtones à travers le Canada. Les médecins et étudiants en médecine peuvent contribuer à l'amélioration de la santé autochtone en plaidant pour de la recherche et un accès aux soins de santé qui sont culturellement sécuritaires, et pour des formations médicales axées sur la santé autochtone.C o m m e n t a r y
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