Refusal Of Treatment Research Articles

Exploring the perspectives of early-stage postoperative glioblastoma patients and their caregivers on end-of-life care planning: An exploratory qualitative interview study.

Compare the convergent and divergent viewpoints of early-stage postoperative patients with glioblastoma and their caregivers on end-of-life care planning in Taiwan. Decision-making capacity in patients with glioblastoma may be compromised as disease progresses, making early future care planning essential to ensure that the provided care aligns with patients' goals. However, within many Asian cultures, the tendency to avoid discussions about death can lead patients to feel hesitant about addressing end-of-life care options. This reluctance may impact the quality of care provided and increase the surrogate decision-making burden on caregivers. An exploratory qualitative study with semi-structured qualitative interviews was conducted on early-stage postoperative glioblastoma-caregiver dyads at a medical center in Northern Taiwan informed by social constructivism. Thematic analysis with analytical rigor enhanced by dual coders and exploration of convergent and divergent views. We interviewed 7 patient-caregiver dyads (n=14). More than half of patients were male (median age: 62 y/o). Primary Caregivers were primarily their spouses (median age: 47 y/o). Convergent viewpoints include death-prolonging treatment refusal, end-of-life fulfillment, timing of end-of-life care discussions, end-of-life concerns, and advance end-of-life care arrangement. Divergent viewpoints include life value (quality vs. quantity), lack transparent and shared discussions (explicit vs. implicit), and decision-making paradigm (individualistic vs. collective). Early end-of-life care discussions for patients with glioblastoma are crucial to address differing values and cultural emphasis on family harmony. Transparent communication reduces caregiver stress and supports informed decisions on advance care planning, symptom management, and financial or social support.

P0056 Efficacy of Infliximab in Biologic-Experienced Patients with Inflammatory Bowel Disease: A Retrospective Study

Abstract Background Infliximab is typically the first biologic choice for patients with inflammatory bowel disease (IBD), and its role is well-established in biologic-naive patients. However, based on patient characteristics, an alternative biologic may sometimes be selected as the initial treatment, with numerous options currently available. In cases of intolerance or loss of response to these alternatives, the role of Infliximab in biologic-experienced patients remains unclear1,2. This study aims to evaluate the efficacy of Infliximab in a cohort of biologic-experienced patients. Methods We conducted a retrospective study at a tertiary centre, including all biologic-experienced patients with IBD who were subsequently treated with Infliximab. Clinical records were thoroughly reviewed to collect data on demographics, prior and current medication, and clinical, endoscopic, analytical and histological disease activity. Statistical analysis was performed using SPSS Statistics version 26®. Results Seventeen patients were included, of whom 6 females, with a mean age of 45.8 ± 17.6 years. Twelve patients with ulcerative colitis (UC) and five with Crohn’s disease (CD) were identified. Of the 17 patients, 10 had previously been treated with an anti-TNFα agent (either Adalimumab or Golimumab), 4 with Vedolizumab, 1 with Guselkumab and 2 with an anti-TNFα (both Adalimumab) followed by other drugs with distinct mechanism of action (Vedolizumab alone in 1, Ustekinumab and Tofacitinib in the other). All these drugs were suspended due to primary failure (PF), except for two (both Adalimumab) due to secondary failure (SF). Currently, 8 patients are continuing treatment with Infliximab, of which 5 are UC patients, all in clinical remission and 1 in deep remission; and 3 CD patients, all in clinical remission with a current Harvey-Bradshaw score of 1. Of those who discontinued Infliximab (9 patients), 4 were due to PF, 3 due to SF, 1 due to death (not related with disease or drug administration) and the other due to treatment refusal. Conclusion Infliximab appears to be effective in certain biologic-experienced IBD patients and given its lower cost this treatment option may be viable. Nonetheless, larger series are needed for a more comprehensive understanding, to allow an inferential statistical analysis and define the best candidates to Infliximab.

Towards a European End-of-Life Regulation: A Necessary Analysis.

Background/Objectives: Biomedical progress has extended the lifespan of patients with incurable diseases, sparking debates about their desire to live under certain conditions. This study examines the ethical and legal challenges surrounding end-of-life issues in Europe, including informed consent, the refusal of treatment, the right to health, self-determination, advance directives, assisted suicide, and euthanasia. European countries exhibit different interpretations and regulations of these practices, leading to patient "migrations" seeking favorable legal environments. Methods: This study analyzes end-of-life legislation across European countries in a comparative and qualitative way, highlighting differences, commonalities, and the potential for uniform regulation. The data were collected from the literature published between 2000 and 2024, focusing on the EU member states, Switzerland, and the United Kingdom. Results: The examination of the norms governing end-of-life practices in various European countries revealed significant differences in legislative frameworks, reflecting diverse cultural, ethical, and legal perspectives. These variations have led to patient migrations in search of suitable legal environments to end their lives with dignity. Conclusions: This study highlights the need for a harmonized approach to end-of-life legislation in Europe to ensure equitable access to end-of-life care and to uphold human dignity. Continuous legal updates and comparative studies are essential to balance medical advancements with ethical considerations. The findings emphasize the importance of autonomy and self-determination, which are fundamental human rights that should be respected in the context of end-of-life decisions.

Association of Social Vulnerability Index With Declining Recommended Surgical Treatment in Head and Neck Cancer Patients.

To investigate the impact of county-level social vulnerability on patients' decision to refuse recommended surgical treatment. Retrospective cohort analysis conducted on HNSCC cases documented in the latest available SEER databases from 2000 to 2020; various demographic, including county of residence, and disease-related variables were collected. CDC's Social Vulnerability Index (SVI) was assigned based on patients' county of residence, and patients were subsequently categorized into four SVI quartiles. Pearson chi-square tests and binomial logistic regression was conducted to determine the impact of variables on patients' refusal of surgical treatment. Among 83,184 patients, 2.6% (2,165) refused surgical intervention recommended by their physician as part of treatment. Social vulnerability (higher SVI), male sex, older age, more advanced disease stage, belonging to non-Hispanic Black or Native Hawaiian/Asian Pacific Islander Race and Origin, and single marital status were associated with higher likelihood of refusing surgery. SVI is a significant factor in the refusal of recommended surgical treatment in HNSCC patients. Advanced disease stages and social vulnerability appear to interplay, influencing treatment decisions. Culturally competent care and support for socially vulnerable patients may mitigate disparities in treatment acceptance, potentially improving survival outcomes. 3 Laryngoscope, 2025.

Long COVID patients' reconstruction of medical gaslighting discourse in online epistemic communities.

To analyse long COVID patients' reconstruction of medical gaslighting (MG) discourse in online epistemic communities in order to identify the MG types experienced and unfold root causes. The mixed-methods of corpus‑based critical discourse analysis was applied to an ad hoc corpus of 18 threads (n = 1176 posts) from two sub-communities on the social media site Reddit. Comparative concordance analyses were performed on the two sub-corpora to semantically code concordance lines as MG types. Critical discourse analysis was conducted to uncover power/ideological drivers of MG discourse. Keyness log‑likelihood statistical measures displayed higher values for the pronouns I, me, you, it, they and the noun doctor(s). KWIC (Key Word in Context) output for these items exhibited seven main MG types: scapegoating, downplay, treatment refusal, psychosomatic disorder, disbelief, denial and dismissal. Concordance lines revealed three major sites of contention - epistemic knowledge, epistemic authority, long COVID indeterminacy - where MG tactics operate through epistemic injustice, ignorance, discrimination and lack of epistemic humility. MG discourse is triggered by deep-seated ideologies rather than by mere doctor-patient interaction as a face-saving strategy which faults patients as epistemic agents. Patients' social media mobilisation helps unmask MG tactics, raising providers' awareness of the need for perspective-taking to build collaborative doctor-patient relationships.

Evaluation of energy recovery, pollutant removal, and microbial dynamics in aged refuse bioreactor for landfill leachate treatment

The study evaluates the effectiveness of aged refuse bioreactors (ARBs) in treating young landfill leachate and recovering energy through biogas production. Over 90 days, duplicate reactors (ARB1 and ARB2) were operated through three 30-day recirculation cycles under anaerobic conditions, utilizing aged refuse from a closed landfill in Bangalore, India. The study was extended by an additional 900 days without further leachate addition to assess long-term gas generation potential. Cumulative gas production amounted to 1384 L in ARB1 and 1182 L in ARB2, with maximum methane production per gram of chemical oxygen demand (COD) recorded at 0.474 L and 0.387 L, respectively. Variability in biogas production was correlated with differences in volumetric moisture content, which also influenced pollutant removal and led to significant improvements in the leachate pollution index, decreasing from 24.4 to 12.84 in ARB1 and to 16.46 in ARB2. COD levels were decreased by 70–90%, and TDS by 46–63%. Heavy metal concentrations, including copper, chromium, cadmium, lead, zinc, and nickel, were reduced by 95–99% to acceptable levels, though increases in ammonia and total phosphorus were noted. Key mechanisms in the ARB included anaerobic degradation, adsorption, oxidation-reduction reactions, and precipitation. In the fourth cycle, without leachate recirculation, gas production reached 320 L in ARB1 and 358.8 L in ARB2, indicating effective conversion of carbon retained from aged refuse and leachate treatment into biogas. Microbial analysis identified dominant communities of Methanosarcina and Methanomicrobia. Overall, this study demonstrates that ARBs are effective in treating young landfill leachate and recovering energy, offering insights into sustainable waste management.

Quality of life outcomes in terminal cancer patients attending regional cancer centers in South Korea: protocol for a prospective cohort study

IntroductionPatients with cancer experience physical, mental, and social pain that affects themselves and their families. The increasing cancer incidence and advances in treatment have increased the number of cancer survivors in Korea, and there is an influx of patients in Seoul and other metropolitan areas, leading to shortages of continuous care and comprehensive life support facilities. Patients must travel long distances for treatment, which poses logistical and quality-of-life challenges.MethodsThis prospective cohort study targets patients with incurable cancer (n = 720) and their families (n = 288) from ten regional cancer centers and two affiliated hospitals in Korea. The sub-cohorts are based on treatment refusal, spinal metastasis with symptoms, catheter-related symptoms, and skeletal-related events. Medical records and patient-reported outcomes will be collected every three months and for up to three years, with surveys for guardians conducted for one-year post-patient demise.DiscussionThe dynamic nature of cancer significantly affects patients and their caregivers. It is necessary to identify the factors that affect their quality of life to integrate them into society.ConclusionThe findings of this study will inform the establishment of a regional cancer center consortium. This will address the unmet needs of local cancer patients and their families, enhance their overall quality of life, and contribute to the well-being of the local community.Trial registrationKCT0009177 (registered at https//cris.nih.go.kr/ on 2024/02/16).

Refusal of Surgical Treatment for Advanced Oral Squamous Cell Carcinoma in a Long-Term Naswar Consumer: A Case Report

Introduction: Oral squamous cell carcinoma (OSCC) is a significant global health concern, primarily associated with tobacco use, including naswar—a smokeless tobacco mixture widely used in South Asia. Naswar is composed of ground tobacco leaves, slaked lime, and occasionally flavoring agents. When mixed with saliva, it releases carcinogenic nitrosamines, nicotine, and other harmful toxins. Despite the well-documented risks, including oral cancer, naswar continues to be used by many. Its harmful effects extend beyond oral health, contributing to heart disease, gastrointestinal issues, and reproductive health problems. It is also associated with mouth lesions, gum disease, and an elevated risk of oral cancers. This study emphasizes the urgent need for targeted global strategies to address naswar-related oral cancers. Case Presentation: This article details the case of a 62-year-old woman with a 40-year history of naswar consumption, who was diagnosed with advanced oral squamous cell carcinoma (SCC) affecting the right side of her face. She was referred to the Maxillofacial Surgery Department of Zahedan University of Medical Sciences. Despite recommendations for surgical intervention, the patient declined treatment following comprehensive consultations with medical professionals. This case highlights the complexities of managing advanced oral SCC in chronic naswar users and underscores the role of patient autonomy in treatment decisions. Conclusions: This case illustrates the challenges in treating advanced oral SCC in long-term naswar users and emphasizes the critical importance of respecting patient autonomy in treatment decision-making.

Ethics round table: choice and autonomy in obstetrics

Decisions about how and where they deliver their baby are extremely important to pregnant women. There are very strong ethical norms that women’s autonomy should be respected, and that plans...

Clinical decision making and moral distress among intensive care units nurses in Iran

BackgroundIntensive care units are often presented as environments where ethical issues are common and decisions can determine the life or death of patients, and these units have unique challenges due to critical health care. In these units, the relationship between the medical team and the patient’s relatives, their refusal of treatment, informed consent causes the nurses to have conflict in their decision making, therefore, this study aims to determine the level of clinical decision-making and moral distress and the relationship between them in intensive care units nurses.MethodsThis cross-sectional study was conducted with a descriptive-analytical approach in 2023 in Gorgan city. The number of 198 nurses in the intensive care units of Gonbad Kavos hospitals in the north of Iran were investigated and evaluated using the Corley Moral Distress questionnaire (2002), and Laurie’s Clinical Decision questionnaire (2001) in 2023. Independent T-test and anova analysis of variance were used for bivariate analysis. The significance level in this study was considered 0.05.ResultsThe results of the study showed that the mean and standard deviation of clinical decision making was 60.98 ± 10.25 (analytical-systematic level) and moral distress was 92.2 ± 23.61 (moderate level). There was a statistically significant relationship between clinical decision-making and nurses’ moral distress (P < 0.001 and r = 0.370). The moral distress score had a statistically significant relationship with marriage, employment status, education level, age, work experience and duration of employment in the special department. Also, the clinical decision score had a statistically significant relationship with employment status, education level, age and work experience.ConclusionAccording to these results, it seems that more attention should be paid to the moral distress of nurses in intensive care units, and it is necessary to improve their decision-making towards intuitive interpretation, which is done by designing and compiling training programs and workshops for nurses can be done, so that we can provide optimal nursing services to the patients of this department.

Determination of Attitudes and Knowledge Levels of Pediatricians about Pediatric Medicolegal Problems in Turkey

Objective: In recent years, allegations of medical errors in Turkey have been increasing. These allegations are generally concentrated on the issue of consent. Since most children are medically and legally incapable of making their own decisions on consent issues and the decision is made by the legal representative instead, various legal and ethical dilemmas arise. Pediatrics ranks first in lawsuits filed for medical errors. In our study, we aimed to evaluate the awareness of forensic legal issues among pediatricians. Materials and Methods: Our study is prospective and cross-sectional. Participants were asked 25 questions based on 14 possible case examples. They were asked to give a score between 1 and 5 points for each question about their feeling of adequacy regarding the information, consent, documents, and procedures that should be done according to these cases. Mann‒Whitney U and Kruskal‒Wallis tests were used statistically; p&lt;0.05 was considered significant. Results: Two hundred nine pediatricians answered the questions. Sixty-six percent of the participants were working in tertiary care hospitals. Pediatricians were undecided about feeling adequate regarding the necessary information, consent, documents, and procedures to be performed for children (3.19/5) and felt inadequate when facing the refusal of treatment (2.77/5). There was no statistically significant difference between feeling competent in terms of title and professional seniority. Only 2% of the pediatricians stated that children under 12 years of age have the power of discernment, and only 7% stated that children over 15 years of age do not have the power of discernment. Conclusion: The general conclusion we reached in our study is that pediatricians do not feel adequate even concerning basic legal issues such as information, consent, and refusal of treatment. Therefore, they need to gain knowledge of these issues. For this reason, educational activities such as adding legal education to the medical school curriculum, legal training for pediatricians, and regular seminars effectively eliminate the lack of knowledge on this issue and prevent lawsuits.

Long-term follow-up of anti-TNF treatment in adult and pediatric DADA2 patients: Insights from real-world data.

Our objective was to investigate real-world outcomes and treatment strategies in individuals affected by DADA2 using over 10-year period real-life experience. This descriptive analysis encompassed all adult/pediatric patients with DADA2 from our Vasculitis Research Center prospective database. Patients on anti-TNF therapy have been specifically examined, analyzing the treatment's duration, indications, and outcomes. Treatment responses were based on physicians' assessments and categorized as full response (symptom-free with normal acute phase reactants) or partial/no response. Totally 32 patients (Adult/Childhood age: 19/13) were analyzed. Anti-TNF agents were prescribed to 27 of the 32 patients. Over a median follow-up of 58 months on anti-TNF therapy, 10 patients (35.7%) exhibited a complete response, predominantly in cases with nervous system or skin involvement. Partial responses were observed in the other 10 patients (35.7%). Currently, 20/ 27 patients remain on anti-TNF treatment. Among the seven who are not on anti-TNF now: five died (four of them with a late diagnosis, one could not continue due to cardiomyopathy), one refused treatment and one had a cure after bone marrow transplantation. We have become aware that four patients increased their dose interval and one returned to the normal interval after an increase in CRP. The first patient was diagnosed in 2013 and over the last 10 years, 6/32 (18.8%) of the patients died. Anti-TNF treatment is beneficial for vasculitic and inflammatory lesions. The clinical course of patients is diverse, especially if the diagnosis is delayed, with a mortality rate of up to 20% over a 10-year period.

Legal Involvement in Pediatric Cancer Treatment Refusal: A Qualitative Study.

To characterize the spectrum of legal options considered in cases of treatment refusal, nonadherence, and abandonment (TRNA); clinicians' thought processes regarding legal intervention; and perceived consequences of legal involvement. We conducted in-depth, semistructured interviews with 30 pediatric oncologists between May and September of 2019 regarding experiences with TRNA. The interview guide covered types of conflicts encountered; factors and strategies considered in response; effects of TRNA cases, personally and professionally; the role of ethical frameworks and legal requirements; and resources needed to manage TRNA cases. Interviews were transcribed and coded iteratively using thematic analysis. Participants represented a range of institutional sizes, geographic locations, and years in practice. Twenty-five of 30 interviewees discussed legal consideration with regard to TRNA. Most participants first engaged the legal system through child protective service agencies. They considered patient age, treatment efficacy, quality of life (burden of treatment), and prognosis; family resources and social context; and preservation of therapeutic relationships and possible consequences of reporting. Experiences and outcomes of legal involvement varied. Clinicians struggle with the tension between obligations to report medical neglect and fears that reporting may result in more harm than benefit to the child in question. We urgently need more dialog between health care professionals and child protective services and legal professionals. Stakeholders from both groups would benefit from a greater understanding of the other's thought processes; clarity regarding the relevant facts; and mutual progress toward creative, evidence-based solutions to working out these complex challenges.

Routine outcomes to investigate differences between ethnic minorities and White British people presenting to emergency services for injury: the stakeholder consultation.

Research has found differences in processes and outcomes of care between people in ethnic minorities and White British populations in some clinical conditions, although findings have been mixed. The Building an understanding of Ethnic minority people's Service Use Relating to Emergency care for injuries study is investigating differences in presentation, experience and health outcomes between people from ethnic minorities and White British people who seek emergency health care for injury. Our aim was to consult with stakeholders to define measurable outcomes available in routine ambulance and emergency department data; to assess the appropriateness of existing outcome measures for ethnic minorities and White British people; and to identify any gaps. Clinicians, public contributors, researchers, people from the third sector, public health, healthcare inclusion were invited to join an online workshop to discuss routine outcomes. Twenty participants attended the stakeholder consultation, with only one being a public contributor, a limitation. Eleven were from a minority ethnic background and seven were female. The integrated list of outcomes included 25 items, combining routine outcomes from the Building an understanding of Ethnic minority people's Service Use Relating to Emergency care for injuries protocol and literature (n = 17) with additional outcomes (n = 8). Notably, the initial list lacked provisions for safeguarding referrals and cases of treatment refusal, which were new additions. Safety concerns arose due to the lack of safeguarding referrals, treatment refusal and self-discharge. Factors such as pre-existing health conditions, injury location and experiences of discrimination were identified as possible influences on care quality and waiting times for ethnic minority patients. Although the number of stakeholders taking part in our consultation was low, their participation identified outcomes not found in routine data, supporting the adoption of a mixed-methods approach to answer our research questions. A future consultation could look to include more public members and wider range of clinicians including those who work in safeguarding and rehabilitation services. This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme as award number NIHR132744.

"Terminal Anorexia", Treatment Refusal and Decision-Making Capacity.

Whether anorexic patients should be able to refuse treatment when this refusal potentially has a fatal outcome is a vexed topic. A recent proposal for a new category of "terminal anorexia" suggests criteria when a move to palliative care or even physician-assisted suicide might be justified. The author argues that this proposed diagnosis presents a false sense of certainty of the illness trajectory by conceptualizing anorexia in analogy with physical disorders and stressing the effects of starvation. Furthermore, this conceptualization is in conflict with the claim that individuals who meet the diagnostic criteria for terminal anorexia have decision-making capacity. It should therefore be rejected.

Ethical concerns in caring for persons with anorexia nervosa: content analysis of a series of documentations from ethics consultations

BackgroundCaring for patients with anorexia nervosa (AN) is associated with high levels of moral distress among healthcare professionals. The main moral conflict has been posited to be between applying coercion to prevent serious complications such as premature death and accepting treatment refusals. However, empirical evidence on this topic is scarce.MethodsWe identified all 19 documentations of ethics consultations (ECs) in the context of AN from one clinical ethics support service in Switzerland. These documentations were coded with a sequential deductive-inductive approach and the code system was interpreted in a case-based manner. Here, we present findings on patient characteristics and ethical concerns.FindingsThe ECs typically concerned an intensely pretreated, extremely underweight AN patient endangering herself by refusing the proposed treatment. In addition to the justifiability of coercion, frequent ethical concerns were whether further coerced treatment aimed at weight gain would be ineffective or even harmful, evidencing uncertainty about beneficence and non-maleficence and a conflict between these principles. Discussed options included harm reduction (e.g. psychotherapy without weight gain requirements) and palliation (e.g. initiating end-of-life care), the appropriateness of which were ethical concerns in themselves. Overall, nine different types of conflicts between or uncertainties regarding ethical principles were identified with a median of eight per case.ConclusionsEthical concerns in caring for persons with AN are diverse and complex. To deal with uncertainty about and conflict between respect for autonomy, beneficence and non-maleficence, healthcare professionals consider non-curative approaches. However, currently, uncertainty around general justifiability, eligibility criteria, and concrete protocols hinders their adoption.

The cardiovascular scamdemic: The epidemic spread of cardiovascular treatment scams and misinformation.

Recently, some cardiovascular surgeons have been increasingly using social media for marketing, often employing misleading terminology. This trend, which we termed the "cardiovascular scamdemic," involves the widespread dissemination of deceptive advertisements for cardiovascular treatments, resembling an epidemic. Exposure to such misinformation not only endangers patients, who naturally rely on information from professional sources, but also erodes public trust in medical ethics and scientific integrity. Additionally, it contributes to treatment refusal and adverse health outcomes. The lack of comprehensive global regulations addressing these issues highlights the urgent need for more effective enforcement measures.

Advance Healthcare Directives: the Irish Implementation Reality from an Interdisciplinary Group Concept Mapping Study

Abstract Background Advance Healthcare Directives became legal in Ireland on 26th April 2023. While Advance Healthcare Directives are primarily rooted in patients’ legally binding refusal of treatments or interventions, they also encourage patients to set out their care preferences for the future (Government of Ireland 2015). Despite care of the older adult broadly transitioning from acute hospital to community, and a greater than ever focus on keeping older adults living at home for longer, low awareness of, and professional uncertainty around, Advance Healthcare Directives and how to integrate them into the care of the older adult has been widely expressed by Irish hospital physicians (Crowley and Doran 2022). Methods In this implementation study, Group Concept Mapping, using the relatively novel ‘GroupWisdom™’ software, is used to collect and analyse data from multiple healthcare professions to identify contextual issues that affect the implementation of Advance Healthcare Directives. 44 frontline healthcare professionals including Hospital Consultants (n=6), General Practitioners (n=5), Paramedics (n=7), Advance Nurse Practitioners (n=4), Clinical Nurse Specialists (n=4), Public Health Nurses (n=5), Critical Care Nurses (n=3), Nurse Managers (n=2), Healthcare Managers (n=2), Occupational Therapists (n=2) and Social Workers (n=4) participate in this mixed method study. Policymakers and other stakeholders are also involved throughout. Results The main implementation issues for Advance Healthcare Directives in order of importance as outlined by Healthcare Professionals are: 1) Public Education; 2) Homecare Services; 3) Timing and Location; 4) Family Members; 5) Lack of Education for the Healthcare Professional; 6) Complications for the Healthcare Professional; 7) Individual and Cultural Beliefs. Conclusion This study contributes a valuable understanding of where the implementation issues reside for healthcare professionals and policymakers, and how these can be addressed to ensure successful implementation. This implementation study focuses on practical considerations, offering multiple workable solutions to help to resolve these implementation issues on the ground.

An intentional overdose of ultra-long-acting insulin analogue complicated by treatment refusal in a patient with mixed personality disorder and type 2 diabetes mellitus

An intentional overdose of ultra-long-acting insulin analogue complicated by treatment refusal in a patient with mixed personality disorder and type 2 diabetes mellitus

A prospective registry study of the epidemiology and management of childhood cancer in the Gambia-The first year experience.

Globally, over 180,000 children develop cancers yearly, with about 80% residing in low- or middle-income countries where cancer-associated mortality is also high. In The Gambia, cumulative incidence rate of 27.6 childhood cancers/million population was reported between 2002 and 2011. The current study appraised newly-established pediatric oncological services in The Gambia. In this prospective registry study, children with cancer who presented at the pediatric units, Edward Francis Small Teaching Hospital, Banjul, between November 2022 and October 2023 were assessed. Data on sociodemographic variables, mode of admission and presentation, tumor type, diagnostic methods, and challenges such as laboratory support, treatment, use of blood/blood products; and eventual outcome were analyzed. The median (interquartile range, IQR) age at presentation of the 44 children was 36.0 (22.3-117.0) months. Wilms tumor was the most common tumor 12 (27.3%); followed by leukemia 11 (25.0%); germ cell tumor 8 (18.2%); lymphoma 6 (13.6%); retinoblastoma 4 (9.1%); rhabdomyosarcoma 2 (4.5%) and one central nervous system tumor (2.3%). The median(IQR) duration of symptoms before presentation was 48 (21-90) days, presentation to diagnosis 7.5 (3-20.8) days, and first symptom to diagnosis 62.5 (32-126.8) days. Treatment refusal and abandonment rates were 20.5% and 13.6%, respectively. Families of 93.8% of children could not procure cytotoxic drugs due to nonavailability, high cost, or both. Adequate laboratory monitoring was only available in 6.8%, and none had platelet concentrate transfusion or radiotherapy. The nine (20.5%) who completed treatment are currently being followed up, 10(22.7%) are still receiving chemotherapy, while 2(4.5%) were referred. Eight (18.2%) died, predominantly from metastasis (75%) and severe drug toxicities (25%). Late presentation and diagnosis, poverty, unavailability of drugs, suboptimal or lack of laboratory testing, blood product, adjuvant medications, and psychosocial supports contributed to high treatment refusal, abandonment, and mortality. These daunting challenges can be ameliorated with regular community sensitization, frequent cancer auditing, and strong political will.