Modern treatment strategies have led to improvements in cancer survival, however, these gains might be offset by the potential negative effect of cancer therapy on cardiovascular health. Cardiotoxicity is now recognized as a leading cause of long-term morbidity and mortality among cancer survivors. This guideline, authored by a pan-Canadian expert group of health care providers and commissioned by the Canadian Cardiovascular Society, is intended to guide the care of cancer patients with established cardiovascular disease or those at risk of experiencing toxicities related to cancer treatment. It includes recommendations and important management considerations with a focus on 4 main areas: identification of the high-risk population for cardiotoxicity, detection and prevention of cardiotoxicity, treatment of cardiotoxicity, and a multidisciplinary approach to cardio-oncology. All recommendations align with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. Key recommendations for which the panel provides a strong level of evidence include: (1) that routine evaluation of traditional cardiovascular risk factors and optimal treatment of preexisting cardiovascular disease be performed in all patients before, during, and after receiving cancer therapy; (2) that initiation, maintenance, and/or augmentation of antihypertensive therapy be instituted per the Canadian Hypertension Educational Program guidelines for patients with preexisting hypertension or for those who experience hypertension related to cancer therapy; and (3) that investigation and management follow current Canadian Cardiovascular Society heart failure guidelines for cancer patients who develop clinical heart failure or an asymptomatic decline in left ventricular ejection fraction during or after cancer treatment. This guideline provides guidance to clinicians on contemporary best practices for the cardiovascular care of cancer patients.
E osinophilic myocarditis (EM) is a rare, potentially fatal disease if left untreated. The spectrum of clinical presentation is wide. The present report describes three different clinical presentations of EM. It also demonstrates the response to steroid therapy with complete recovery of ventricular function and the disappearance of inflammatory cell infiltrate in a repeat endomyocardial biopsy (EMB). The incidence, etiology, histopathology, clinical manifestations, diagnosis, treatment and prognosis of EM are discussed. CASE PRESENTATIONS Case 1A 40-year-old man presented to the emergency department with a history of flu-like illness, fever, malaise and chills, followed by severe nonpleuritic chest pain and shortness of breath. He had a 13-year history of psoriasis treated with topical steroids, phototherapy and intralesional steroids. He was not asthmatic, had no allergies and did not take any regular medications. There was no significant animal or bird exposure history. He was self-employed as a carpet cleaner.On arrival, he was in no acute distress, afebrile, with a heart rate of 90 beats/min and a blood pressure of 85/50 mmHg. A general physical examination was unremarkable except for a psoriatic plaque on the right leg without nail or joint involvement. Cardiovascular examination showed no jugular venous distension, gallops, rubs or murmurs.Blood work revealed only an elevated eosinophil count of 1.1×10 9 /L (normal values less than 0.4×10 9 /L) and troponin I of 46 µg/L (normal values less than 0.1 µg/L); the results of other laboratory tests are shown in Table 1. An electrocardiogram (ECG) revealed T wave inversion in the anterolateral leads, and the chest radiograph was normal. The diagnosis of acute coronary syndrome (ACS) was made and he was referred to a tertiary centre for selective coronary angiogram (SCA), which revealed normal coronary arteries. The echocardiogram showed mildly impaired global left ventricular (LV) systolic function with a visually estimated ejection fraction (EF) of 50%; there were no valvular lesions.The EMB showed changes of EM with inflammatory cell infiltrates that appeared to follow the interstitial and perivascular tissue planes and were also localized within the subendocardial tissues. The infiltrates were composed of mononuclear inflammatory cells, as well as eosinophils. In many locations, eosinophils were very prominent. Occasional myocytes showed degeneration or necrosis, but this was not a prominent feature. There was no vasculitis and no microorganisms were seen. Special stains for iron and amyloid were negative.The patient was started on oral prednisone at 1 mg/kg/day, beta-blockers and angiotensin-converting enzyme (ACE) inhibitors. At one-month follow-up, he had no recurrence of his initial symptoms, and the eosinophil count became normal at 0. Although the etiology of eosinophilic myocarditis (EM) is not always apparent, several causes are identified, including hypersensitivity to a drug or substance, with the heart as the target organ. However, symptoms and sign...
This retrospective study analysed data for 703 children who died from 2000 to 2006 to examine where children with a broad range of progressive, life-limiting illnesses actually die when families are able to access hospital, paediatric hospice facility and care at home. There was an overall even distribution for location of death in which 35.1% of children died at home, 32.1% died in a paediatric hospice facility, 31.9% in hospital and 0.9% at another location. Previous research suggests a preference for home as the location of death, but these studies have primarily focused on adults, children with cancer or settings without paediatric hospice facilities available as an option. Our results suggest that the choice of families for end-of-life care is equally divided amongst all three options. Given the increasing numbers of children's hospices worldwide, these findings are important for clinicians, care managers and researchers who plan, provide and evaluate the care of children with life-limiting illness.
The results of this study can inform and prioritize a framework for an ongoing programme of research in Canada. The inclusion of clinicians and academics ensures that the research agenda incorporates perspectives from the front-line work of individuals providing care to this population as well as individuals from the academic community with important knowledge and skills related to research approaches and methods.
I Background: Pediatric palliative care is increasingly recognized to be a specialized type of care requiring specific skills and knowledge, yet, as found in several countries, there is little available research evidence on which to base care. Objectives: The goal of the project was to achieve consensus among palliative care practitioners and researchers regarding the identification of pertinent lines of research. Method: A Delphi technique was used with an interdisciplinary panel (n=14-16) of researchers and frontline clinicians in pediatric palliative care in Canada. Results: Four priority research questions were identified: What matters most for patients and parents receiving pediatric palliative services? What are the bereavement needs of families in pediatric palliative care? What are the best practice standards in pain and symptom management? What are effective strategies to alleviate suffering at the end of life? Conclusions: These identified priorities will provide guidance and direction for research efforts in Canada, and may prove useful in providing optimal care to patients and families in pediatric palliative care. Resume I Contexte: De plus en plus les soins palliatifs pediatrlques sont reconnus comme etant une approche de soins specialises necessltant des connaissances et des hablletes particulieres. Cependant, comme nous I'avons constate dans plusieurs pays, iI existe peu de resultats de recherche sur lesquels on peut s'appuyer pour juger du bien-fonds de ces soins. Objectif: Le but de ce projet etait de pouvoir atteindre un concensus chez les professionels de la sante et les chercheurs en soins palliatifs afin de determiner et d'identifier des objectifs de recherche. Methode: Nous avons utilise la methode Delphi et avons ainsi recrute un panel interdisciplinaire (n=14-16) compose de chercheurs et de c1iniciens de premiere ligne engages en soins palliatifs au Canada. Resultats: Les quatres questions ldentifiees comme etant prioritaires pour la recherche en ce dornalne sont les suivantes : Quelles sont les choses les plus importantes pour les patients et leurs parents qui ont recours aux soins palliatifs? Quels sont les services de soutien dont les families endeulliees ont besoin? Quelles sont les meilleurs pratiques cliniques pour controler la douleur et les symptomes? Quelles sont les meilleures strategies pour alleqer la souffrance en fin de vie? Les priorites ainsi identlflees pourront servir de Iignes de conduite pour diriger la recherche en ce domaine au Canada et pourront surement aider adispenser des soins palliatifs optimaux aux patients et leur famille.
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