251
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Iosifidis E, Papachristou S, Roilides E. Advances in the Treatment of Mycoses in Pediatric Patients. J Fungi (Basel) 2018; 4:E115. [PMID: 30314389 PMCID: PMC6308938 DOI: 10.3390/jof4040115] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 10/05/2018] [Accepted: 10/07/2018] [Indexed: 12/16/2022] Open
Abstract
The main indications for antifungal drug administration in pediatrics are reviewed as well as an update of the data of antifungal agents and antifungal policies performed. Specifically, antifungal therapy in three main areas is updated as follows: a) Prophylaxis of premature neonates against invasive candidiasis; b) management of candidemia and meningoencephalitis in neonates; and c) prophylaxis, empiric therapy, and targeted antifungal therapy in children with primary or secondary immunodeficiencies. Fluconazole remains the most frequent antifungal prophylactic agent given to high-risk neonates and children. However, the emergence of fluconazole resistance, particularly in non-albicans Candida species, should be considered during preventive or empiric therapy. In very-low birth-weight neonates, although fluconazole is used as antifungal prophylaxis in neonatal intensive care units (NICU's) with relatively high incidence of invasive candidiasis (IC), its role is under continuous debate. Amphotericin B, primarily in its liposomal formulation, remains the mainstay of therapy for treating neonatal and pediatric yeast and mold infections. Voriconazole is indicated for mold infections except for mucormycosis in children >2 years. Newer triazoles-such as posaconazole and isavuconazole-as well as echinocandins, are either licensed or under study for first-line or salvage therapy, whereas combination therapy is kept for refractory cases.
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Affiliation(s)
- Elias Iosifidis
- Infectious Diseases Unit, 3rd Department of Pediatrics, Faculty of Medicine, Aristotle University School of Health Sciences, Konstantinoupoleos 49, 54642, Thessaloniki, Greece.
| | - Savvas Papachristou
- Infectious Diseases Unit, 3rd Department of Pediatrics, Faculty of Medicine, Aristotle University School of Health Sciences, Konstantinoupoleos 49, 54642, Thessaloniki, Greece.
| | - Emmanuel Roilides
- Infectious Diseases Unit, 3rd Department of Pediatrics, Faculty of Medicine, Aristotle University School of Health Sciences, Konstantinoupoleos 49, 54642, Thessaloniki, Greece.
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252
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Cost-effectiveness and Improved Parent and Provider Satisfaction With Outpatient Management of Pediatric Oncology Patients, With Low-risk Fever and Neutropenia. J Pediatr Hematol Oncol 2018; 40:e415-e420. [PMID: 29334532 DOI: 10.1097/mph.0000000000001084] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
On the basis of significant evidence for safety, the international pediatric fever and neutropenia committee recommends the identification and management of patients with "low-risk fever and neutropenia" (LRFN), outpatient with oral antibiotics, instead of traditional inpatient management. The aim of our study was to compare the cost-per-patient with these 2 strategies, and to evaluate parent and provider satisfaction with the outpatient management of LRFN. Between March 2016 and February 2017, 17 LRFN patients (median absolute neutrophil count, 90/μL) were managed at a single institution, per new guidelines. Fifteen patients were discharged on presentation or at 24 to 48 hours postadmission on oral levofloxacin, and 2 were inadvertently admitted off protocol. The mean cost of management for the postimplementation cohort was compared with a historic preimplementation control group. Satisfaction surveys were completed by parents and health care providers of LRFN patients. The mean total cost of an LRFN episode was $12,500 per patient preimplementation and $6168 postimplementation, a decrease of $6332 (51%) per patient. All parents surveyed found outpatient follow-up easy; most (12/14) parents and all (16/16) providers preferred outpatient management. Outpatient management of LRFN patients was less costly, and was preferred by a majority of parents and all health care providers, compared with traditional inpatient management.
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253
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Calitri C, Ruberto E, Castagnola E. Antibiotic prophylaxis in neutropenic children with acute leukemia: Do the presently available data really support this practice? Eur J Haematol 2018; 101:721-727. [PMID: 30107054 DOI: 10.1111/ejh.13162] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 08/02/2018] [Accepted: 08/03/2018] [Indexed: 12/30/2022]
Abstract
Antibiotics are frequently administered for prophylaxis of fever in neutropenic children with cancer. This strategy is mainly derived from adults' data, and various pediatric studies evidenced the effectiveness of antibiotics (eg, fluoroquinolones) in the prevention of febrile neutropenia. However, only two pediatric randomized, double-blind, placebo-controlled trials have been performed, with a total of 262 leukemic children enrolled, and no other one was ever powered for analyzing effectiveness over other infectious complications. In an era of increasing antibiotic resistance, the widespread use of antibiotic prophylaxis in neutropenic leukemic children needs to be strongly supported.
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Affiliation(s)
| | - Eliana Ruberto
- Department of Translational Medical Science, Section of Pediatrics, Università di Napoli Federico II, Napoli, Italy
| | - Elio Castagnola
- Infectious Diseases Unit, IRCCS Istituto Giannina Gaslini, Genova, Italy
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254
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Klein K, Hasle H, Abrahamsson J, De Moerloose B, Kaspers GJL. Differences in infection prophylaxis measures between paediatric acute myeloid leukaemia study groups within the international Berlin-Frankfürt-Münster (I-BFM) study group. Br J Haematol 2018; 183:87-95. [PMID: 30074239 DOI: 10.1111/bjh.15499] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Accepted: 06/07/2018] [Indexed: 11/29/2022]
Abstract
Prevention of infections is of obvious relevance in paediatric patients with acute myeloid leukaemia (AML). However, recommendations are often non-specific and supported by low-quality evidence, resulting in divergent infection preventive regimens. Using a web-based survey, we investigated the infection prophylaxis guidelines of 22 paediatric AML study groups affiliated to the international Berlin-Frankfürt-Münster study group. In order to evaluate differences in daily practice among hospitals, representatives (n = 27) from the Nordic Society for Paediatric Haematology and Oncology-Dutch-Belgium-Hong Kong - AML study group participated in a slightly modified survey. Seven study groups (32%) advise gram-negative antibiotic prophylaxis, mainly with fluoroquinolones (n = 6). Gram-positive prophylaxis is prescribed by eight groups (36%). Over 60% of the study groups prescribe food and social restrictions, but the specific topics and strictness differ widely. According to the hospital-based survey, sites roughly comply with common study group guidelines. However, the use of any gram-negative antibiotic prophylaxis, the specific prophylactic antifungal agent and the strictness of the food and social restrictions differ substantially between the hospitals. Despite a long history of close collaboration, many differences are still present between the affiliated groups. The results of this survey provide an appropriate baseline measure to study the emergence and impact of future guidelines on infection prophylaxis in paediatric AML.
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Affiliation(s)
- Kim Klein
- Department of Pediatric Oncology/Hematology, VU University Medical Center, Amsterdam, The Netherlands.,Department of Pediatrics, University Medical Center Utrecht/Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | - Henrik Hasle
- Department of Oncology, Aarhus University Hospital Skejby, Aarhus, Denmark.,Nordic Pediatric Hematology and Oncology group, Gothenburg, Sweden
| | - Jonas Abrahamsson
- Nordic Pediatric Hematology and Oncology group, Gothenburg, Sweden.,Department of Pediatric Oncology, Queen Silvia Children's Hospital, Gothenburg, Sweden
| | - Barbara De Moerloose
- Department of Pediatric Hematology-Oncology and Stem Cell Transplantation, Ghent University Hospital, Ghent, Belgium.,Belgian Society of Paediatric Haematology Oncology, Utrecht, The Netherlands
| | - Gertjan J L Kaspers
- Department of Pediatric Oncology/Hematology, VU University Medical Center, Amsterdam, The Netherlands.,Dutch Childhood Oncology Group, Utrecht, The Netherlands.,Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
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255
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Abstract
Children with cancer have high emergency department (ED) utilization, but little is known about their chief complaints. A retrospective chart review of ED chief complaints for children with cancer (actively receiving therapy) at Riley Hospital for Children from January 2014 to December 2015 was performed. Proportions of visits and disposition for top 5 chief complaints were determined. Multivariate logistic regression analyzed factors associated with admission. There were 598 encounters by 231 children with cancer. About half (49%) had >1 complaint. The 5 most common primary chief complaints were: fever (60.2%), pain (6.5%), nausea/vomiting (5.0%), bleeding (3.9%), and abnormal laboratory values (3.3%). Admission rates varied, with the highest rates being for nausea/vomiting (66.7%). Risk factors for admission were: hospitalization in prior 4 weeks (odds ratio [OR], 2.67; confidence interval [CI], 1.77-4.02), chief complaint of fever (OR, 1.90; CI, 1.16-3.09). For each increase in number of chief complaints, odds increased by 1.45 (CI, 1.14-1.83). Black, non-Hispanic (OR, 0.44; CI, 0.22-0.88) as compared with white, non-Hispanic, younger age (OR, 0.53; CI, 0.29-0.99) or complaint of abnormal laboratory values (OR, 0.20; CI, 0.06-0.68) had lower odds of admission. Children with cancer present to the ED with multiple and varied complaints. Future interventions could aim to improve caregiver anticipatory guidance and ED visit preparedness.
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256
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Haeusler GM, Slavin MA, Bryant PA, Babl FE, Mechinaud F, Thursky KA. Management of fever and neutropenia in children with cancer: A survey of Australian and New Zealand practice. J Paediatr Child Health 2018; 54:761-769. [PMID: 29655245 DOI: 10.1111/jpc.13899] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Revised: 11/19/2017] [Accepted: 12/13/2017] [Indexed: 11/30/2022]
Abstract
AIM Variation in the management of fever and neutropenia (FN) in children is well described. The aim of this study was to explore the current management of FN across Australia and New Zealand and highlight areas for improvement. METHODS A practice survey was administered to paediatric health-care providers via four clinical and research networks. Using three clinical case vignettes, we explored risk stratification, empiric antibiotics, initial investigations, intravenous-oral switch, ambulatory management and antibiotic duration in children with cancer and FN. RESULTS A response was received from 104 participants from 16 different hospitals. FN guideline compliance was rated as moderate or poor by 24% of respondents, and seven different fever definitions were described. There was little variation in the selected empiric monotherapy and dual-therapy regimens, and almost all respondents recommended first-dose antibiotics within 1 h. However, 27 different empiric antibiotic combinations were selected for beta-lactam allergy. An incorrect risk status was assigned to the low-risk case by 27% of respondents and to the high-risk case by 41%. Compared to current practice, significantly more respondents would manage the low-risk case in the ambulatory setting provided adequate resources were in place (43 vs. 85%, P < 0.0001). There was variation in the use of empiric glycopeptides as well as use of aminoglycosides beyond 48 h. CONCLUSION Although the antibiotics selected for empiric management of FN are appropriate and consistent, variation and inaccuracies exist in risk stratification, the selection of monotherapy over dual therapy, empiric antibiotics chosen for beta-lactam allergy, use of glycopeptides and duration of aminoglycosides.
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Affiliation(s)
- Gabrielle M Haeusler
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, University of Melbourne, Melbourne, Victoria, Australia.,NHMRC National Centre for Infections in Cancer, University of Melbourne, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia.,Paediatric Integrated Cancer Service, Victoria State Government, Melbourne, Victoria, Australia.,Department of Infection and Immunity, Monash Children's Hospital, Melbourne, Victoria, Australia
| | - Monica A Slavin
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, University of Melbourne, Melbourne, Victoria, Australia.,NHMRC National Centre for Infections in Cancer, University of Melbourne, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia.,Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia.,Victorian Infectious Diseases Service, The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Penelope A Bryant
- Murdoch Children's Research Institute, Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Infectious Diseases Unit, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Franz E Babl
- Murdoch Children's Research Institute, Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Department of Emergency Medicine, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Francoise Mechinaud
- Murdoch Children's Research Institute, Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Children's Cancer Centre, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Karin A Thursky
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, University of Melbourne, Melbourne, Victoria, Australia.,NHMRC National Centre for Infections in Cancer, University of Melbourne, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia.,Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia.,Victorian Infectious Diseases Service, The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia.,NHMRC National Centre for Antimicrobial Stewardship, The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
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257
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Initial Management of Fever and Neutropenia: A Practical Approach. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2018. [DOI: 10.1016/j.cpem.2018.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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258
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Predictive value of PCT and IL-6 for bacterial infection in children with cancer and febrile neutropenia. Support Care Cancer 2018; 26:3819-3826. [PMID: 29777383 PMCID: PMC6182367 DOI: 10.1007/s00520-018-4249-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Accepted: 05/06/2018] [Indexed: 12/17/2022]
Abstract
Purpose Only a third of children with cancer and febrile neutropenia (FN) have a proven bacterial infection; nevertheless, most children are hospitalized and treated with intravenous antibiotics. Several biomarkers have been proposed as predictive markers for bacterial infection in this population. We aimed to evaluate the role of interleukin-6 (IL-6) and procalcitonin (PCT) in diagnosing bacterial infection in children with cancer and FN. Methods The study population was derived from a prospective database (2006–2013, IL-8 study) comprising children with cancer who presented with FN. From stored plasma samples (taken at admission and/or at 12–24 h), we determined the PCT and IL-6 levels. Consequently, we explored their relation with the presence of bacterial infection (positive blood culture, radiologically documented infection or clinical bacterial focus). We predefined cutoff values at 60 ng/L for IL-6 and 0.25 ng/mL for PCT. Results Seventy-seven FN episodes in 55 children with cancer were included. In 18 episodes (23.4%), a bacterial infection was documented. Both at presentation and after 12–24 h, median values of IL-6 and PCT were significantly higher in patients with a bacterial infection compared to patients without a bacterial infection. With both biomarkers above cutoff values, sensitivity was 93% (with either one, this was even 100%). The identified group at low risk for bacterial infection comprised 41% of the population. Conclusion PCT and IL-6 are promising markers in identifying bacterial infection in children with cancer and FN. In a subsequent project, we will incorporate these biomarkers in a risk assessment model that we will test prospectively in a clinical trial.
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259
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Gomez SM, Caniza M, Fynn A, Vescina C, Ruiz CD, Iglesias D, Sosa F, Sung L. Fungal infections in hematopoietic stem cell transplantation in children at a pediatric children's hospital in Argentina. Transpl Infect Dis 2018; 20:e12913. [PMID: 29679436 DOI: 10.1111/tid.12913] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 12/24/2017] [Accepted: 01/07/2018] [Indexed: 12/12/2022]
Abstract
Our primary objective was to describe the incidence of proven or probable invasive fungal infections (IFIs), a devastating complication of hematopoietic stem cell transplant (HSCT), in HCST in a middle-income country. Secondary objectives were to describe factors associated with IFIs and outcomes. In this single center retrospective study, pediatric patients who underwent a first allogeneic or autologous HSCT from 1998 to 2016 were included. Of the 251 HSCT recipients: 143 transplants were allogeneic and 108 were autologous. Overall, 23 (9%) experienced an IFI, mostly due to yeasts (83%). IFIs were more common in allogeneic HSCT (18/143, 13%) than in autologous HSCT (5/108, 5%; P = .045). Of the 23 patients with IFIs, 14 (61%) died, but only 1 directly from IFI (pulmonary aspergillosis). Overall survival at 3 years was 0.42 ± 0.11 in patients with IFIs and 0.60 ± 0.37 in those without IFIs (P = .049). In Argentina, IFIs during HSCT are common. Recipients of allogeneic HSCT are at higher risk, and IFI is associated with reduced overall survival. Future work should focus on interventions to reduce and improve IFI outcomes in children undergoing transplants in low- and middle-income countries.
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Affiliation(s)
- Sergio M Gomez
- Stem Cell Transplantation Unit, Hospital de Niños Sor María Ludovica, La Plata, Argentina
| | - Miguela Caniza
- Global Pediatric Medicine, Infectious Diseases. St. Jude Children's Cancer Research Hospital, Memphis, TN, USA
| | - Alicira Fynn
- Stem Cell Transplantation Unit, Hospital de Niños Sor María Ludovica, La Plata, Argentina
| | - Cecilia Vescina
- Stem Cell Transplantation Unit, Hospital de Niños Sor María Ludovica, La Plata, Argentina
| | - Clau-Dia Ruiz
- Stem Cell Transplantation Unit, Hospital de Niños Sor María Ludovica, La Plata, Argentina
| | - Daniela Iglesias
- Stem Cell Transplantation Unit, Hospital de Niños Sor María Ludovica, La Plata, Argentina
| | - Fernanda Sosa
- Stem Cell Transplantation Unit, Hospital de Niños Sor María Ludovica, La Plata, Argentina
| | - Lillian Sung
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Canada
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260
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Predictors of Antimicrobial Stewardship Program Recommendation Disagreement. Infect Control Hosp Epidemiol 2018; 39:806-813. [DOI: 10.1017/ice.2018.85] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVETo identify predictors of disagreement with antimicrobial stewardship prospective audit and feedback recommendations (PAFR) at a free-standing children’s hospital.DESIGNRetrospective cohort study of audits performed during the antimicrobial stewardship program (ASP) from March 30, 2015, to April 17, 2017.METHODSThe ASP included audits of antimicrobial use and communicated PAFR to the care team, with follow-up on adherence to recommendations. The primary outcome was disagreement with PAFR. Potential predictors for disagreement, including patient-level, antimicrobial, programmatic, and provider-level factors, were assessed using bivariate and multivariate logistic regression models.RESULTSIn total, 4,727 antimicrobial audits were performed during the study period; 1,323 PAFR (28%) and 187 recommendations (15%) were not followed due to disagreement. Providers were more likely to disagree with PAFR when the patient had a gastrointestinal infection (odds ratio [OR], 5.50; 95% confidence interval [CI], 1.99–15.21), febrile neutropenia (OR, 6.14; 95% CI, 2.08–18.12), skin or soft-tissue infections (OR, 6.16; 95% CI, 1.92–19.77), or had been admitted for 31–90 days at the time of the audit (OR, 2.08; 95% CI, 1.36–3.18). The longer the duration since the attending provider had been trained (ie, the more years of experience), the more likely they were to disagree with PAFR recommendations (OR, 1.02; 95% CI, 1.01–1.04).CONCLUSIONSEvaluation of our program confirmed patient-level predictors of PAFR disagreement and identified additional programmatic and provider-level factors, including years of attending experience. Stewardship interventions focused on specific diagnoses and antimicrobials are unlikely to result in programmatic success unless these factors are also addressed.Infect Control Hosp Epidemiol 2018;806–813
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261
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Haeusler GM, Thursky KA, Slavin MA, Mechinaud F, Babl FE, Bryant P, De Abreu Lourenco R, Phillips R. External Validation of Six Pediatric Fever and Neutropenia Clinical Decision Rules. Pediatr Infect Dis J 2018; 37:329-335. [PMID: 28877157 DOI: 10.1097/inf.0000000000001777] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Fever and neutropenia (FN) clinical decision rules (CDRs) are recommended to help distinguish children with cancer at high and low risk of severe infection. The aim of this study was to validate existing pediatric FN CDRs designed to stratify children with cancer at high or low risk of serious infection or medical complication. METHODS Pediatric CDRs suitable for validation were identified from a literature search. Relevant data were extracted from an existing data set of 650 retrospective FN episodes in children with cancer. The sensitivity and specificity of each of the CDR were compared with the derivation studies to assess reproducibility. RESULTS Six CDRs were identified for validation: 2 were designed to predict bacteremia and 4 to predict adverse events. Five CDRs exhibited reproducibility in our cohort. A rule predicting bacteremia had the highest sensitivity (100%; 95% confidence interval (CI): 93%-100%) although poor specificity (17%), with only 15% identified as low risk. For adverse events, the highest sensitivity achieved was 84% (95% CI: 75%-90%), with specificity of 29% and 27% identified as low risk. A rule intended for application after a 24-hour period of inpatient observation yielded a sensitivity of 80% (95% CI: 73-86) and specificity of 46%, with 44% identified as low risk. CONCLUSIONS Five CDRs were reproducible, although not all can be recommended for implementation because of either inadequate sensitivity or failure to identify a clinically meaningful number of low-risk patients. The 24-hour rule arguably exhibits the best balance between sensitivity and specificity in our population.
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262
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Oskarsson T, Söderhäll S, Arvidson J, Forestier E, Frandsen TL, Hellebostad M, Lähteenmäki P, Jónsson ÓG, Myrberg IH, Heyman M. Treatment-related mortality in relapsed childhood acute lymphoblastic leukemia. Pediatr Blood Cancer 2018; 65. [PMID: 29230958 DOI: 10.1002/pbc.26909] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2017] [Revised: 10/28/2017] [Accepted: 11/08/2017] [Indexed: 01/08/2023]
Abstract
BACKGROUND Treatment of relapsed childhood acute lymphoblastic leukemia (ALL) is particularly challenging due to the high treatment intensity needed to induce and sustain a second remission. To improve results, it is important to understand how treatment-related toxicity impacts survival. PROCEDURE In this retrospective population-based study, we described the causes of death and estimated the risk for treatment-related mortality in patients with first relapse of childhood ALL in the Nordic Society of Paediatric Haematology and Oncology ALL-92 and ALL-2000 trials. RESULTS Among the 483 patients who received relapse treatment with curative intent, we identified 52 patients (10.8%) who died of treatment-related causes. Twelve of these died before achieving second remission and 40 died in second remission. Infections were the cause of death in 38 patients (73.1%), predominantly bacterial infections during the chemotherapy phases of the relapse treatment. Viral infections were more common following hematopoietic stem cell transplantation (HSCT) in second remission. Independent risk factors for treatment-related mortality were as follows: high-risk stratification at relapse (hazard ratio [HR] 2.2; 95% confidence interval [CI] 1.3-3.9; P < 0.01), unfavorable cytogenetic aberrations (HR 3.4; 95% CI 1.3-9.2; P = 0.01), and HSCT (HR 4.64; 95% CI 2.17-9.92; P < 0.001). In contrast to previous findings, we did not observe any statistically significant sex or age differences. Interestingly, none of the 17 patients with Down syndrome died of treatment-related causes. CONCLUSIONS Fatal treatment complications contribute significantly to the poor overall survival after relapse. Implementation of novel therapies with reduced toxicity and aggressive supportive care management are important to improve survival in relapsed childhood ALL.
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Affiliation(s)
- Trausti Oskarsson
- Department of Pediatric Oncology, Astrid Lindgren Children's Hospital, Stockholm, Sweden
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden
| | - Stefan Söderhäll
- Department of Pediatric Oncology, Astrid Lindgren Children's Hospital, Stockholm, Sweden
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden
| | - Johan Arvidson
- Department of Pediatric Oncology, Uppsala University Hospital, Uppsala, Sweden
| | - Erik Forestier
- Department of Medical Biosciences, Umeå University, Umeå, Sweden
| | - Thomas Leth Frandsen
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
| | | | - Päivi Lähteenmäki
- Department of Pediatrics, Turku University Hospital and Turku University, Turku, Finland
| | - Ólafur G Jónsson
- Children's Hospital, Landspitali University Hospital, Reykjavik, Iceland
| | - Ida Hed Myrberg
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden
| | - Mats Heyman
- Department of Pediatric Oncology, Astrid Lindgren Children's Hospital, Stockholm, Sweden
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden
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263
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Ojha RP, Asdahl PH, Steyerberg EW, Schroeder H. Predicting bacterial infections among pediatric cancer patients with febrile neutropenia: External validation of the PICNICC model. Pediatr Blood Cancer 2018; 65. [PMID: 29286572 DOI: 10.1002/pbc.26935] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Revised: 11/11/2017] [Accepted: 11/22/2017] [Indexed: 11/10/2022]
Abstract
INTRODUCTION The Predicting Infectious Complications in Neutropenic Children and Young People with Cancer (PICNICC) model was recently developed for antibiotic stewardship among pediatric cancer patients, but limited information is available about its clinical usefulness. We aimed to assess the performance of the PICNICC model for predicting microbiologically documented bacterial infections among pediatric cancer patients with febrile neutropenia. MATERIALS AND METHODS We used data for febrile neutropenia episodes at a pediatric cancer center in Aarhus, Denmark between 2000 and 2016. We assessed the area under the receiver operating characteristic curve (AUC), calibration, and clinical usefulness (i.e., net benefit). We also recalibrated the model using statistical updating methods. RESULTS We observed 306 microbiologically documented bacterial infections among 1,892 episodes of febrile neutropenia. The AUC of the model was 0.73 (95% confidence limits [CL]: 0.71-0.75). The calibration intercept (calibration-in-the-large) was -0.69 (95% CL: -0.86 to -0.51) and the slope was 0.77 (95% CL: 0.65-0.89). Modest net benefit was observed at a decision threshold of 5%. Recalibration improved calibration but did not improve net benefit. CONCLUSIONS The PICNICC model has potential for reducing unnecessary antibiotic exposure for pediatric cancer patients with febrile neutropenia, but continued validation and refinement is necessary to optimize clinical usefulness.
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Affiliation(s)
- Rohit P Ojha
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee.,Center for Outcomes Research, JPS Health Network, Fort Worth, Texas
| | - Peter H Asdahl
- Department of Hematology, Aarhus University Hospital, Aarhus, Denmark
| | - Ewout W Steyerberg
- Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands.,Department of Medical Statistics and Bioinformatics, Leiden University Medical Center, Leiden, The Netherlands
| | - Henrik Schroeder
- Department of Pediatrics, Aarhus University Hospital, Aarhus, Denmark
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264
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Lehrnbecher T, Hassler A, Groll AH, Bochennek K. Diagnostic Approaches for Invasive Aspergillosis-Specific Considerations in the Pediatric Population. Front Microbiol 2018; 9:518. [PMID: 29632518 PMCID: PMC5879093 DOI: 10.3389/fmicb.2018.00518] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 03/07/2018] [Indexed: 11/13/2022] Open
Abstract
Invasive aspergillosis (IA) is a major cause of morbidity and mortality in children with hematological malignancies and those undergoing hematopoietic stem cell transplantation. Similar to immunocompromised adults, clinical signs, and symptoms of IA are unspecific in the pediatric patient population. As early diagnosis and prompt treatment of IA is associated with better outcome, imaging and non-invasive antigen-based such as galactomannan or ß-D-glucan and molecular biomarkers in peripheral blood may facilitate institution and choice of antifungal compounds and guide duration of therapy. In patients in whom imaging studies suggest IA or another mold infection, invasive diagnostics such as bronchoalveolar lavage and/or bioptic procedures should be considered. Here we review the current data of diagnostic approaches for IA in the pediatric setting and highlight the major differences of performance and clinical utility of the tests between children and adults.
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Affiliation(s)
- Thomas Lehrnbecher
- Division of Pediatric Hematology and Oncology, Hospital for Children and Adolescents, Johann Wolfgang Goethe-University, Frankfurt, Germany
| | - Angela Hassler
- Division of Pediatric Hematology and Oncology, Hospital for Children and Adolescents, Johann Wolfgang Goethe-University, Frankfurt, Germany
| | - Andreas H Groll
- Infectious Disease Research Program, Center for Bone Marrow Transplantation, Department of Pediatric Hematology/Oncology, University Children's Hospital, Münster, Germany
| | - Konrad Bochennek
- Division of Pediatric Hematology and Oncology, Hospital for Children and Adolescents, Johann Wolfgang Goethe-University, Frankfurt, Germany
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265
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von Allmen AN, Zermatten MG, Leibundgut K, Agyeman P, Ammann RA. Pediatric patients at risk for fever in chemotherapy-induced neutropenia in Bern, Switzerland, 1993-2012. Sci Data 2018. [PMID: 29534058 PMCID: PMC5849221 DOI: 10.1038/sdata.2018.38] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Fever in neutropenia (FN) is the most frequent potentially life threatening complication of chemotherapy for cancer. Prediction of the risk to develop FN during chemotherapy would allow for targeted prophylaxis. This retrospective, single centre cohort study in pediatric patients diagnosed with cancer before 17 years covered two decades, 1993 to 2012. The 583 (73%) of 800 patients diagnosed with cancer who had received chemotherapy were studied here. Data on 2113 observation periods was collected, defined by stable combinations of 11 predefined characteristics potentially associated with FN. They covered 692 years of cumulative chemotherapy exposure time, during which 712 FN episodes were diagnosed, 154 (22%) of them with bacteremia. The risk to develop FN and FN with bacteremia remained stable over time. These data can mainly be used to study FN risks over time and between centers, and to derive or externally validate FN risk prediction rules.
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Affiliation(s)
- Annina N von Allmen
- Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, CH-3010 Bern, Switzerland
| | - Maxime G Zermatten
- Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, CH-3010 Bern, Switzerland
| | - Kurt Leibundgut
- Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, CH-3010 Bern, Switzerland
| | - Philipp Agyeman
- Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, CH-3010 Bern, Switzerland
| | - Roland A Ammann
- Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, CH-3010 Bern, Switzerland
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266
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Wagner S, Brack EK, Stutz-Grunder E, Agyeman P, Leibundgut K, Teuffel O, Ammann RA. The influence of different fever definitions on diagnostics and treatment after diagnosis of fever in chemotherapy-induced neutropenia in children with cancer. PLoS One 2018; 13:e0193227. [PMID: 29462193 PMCID: PMC5819814 DOI: 10.1371/journal.pone.0193227] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 02/07/2018] [Indexed: 11/18/2022] Open
Abstract
Background There is no evidence-based definition of the temperature limit defining fever (TLDF) in children with neutropenia. Lowering the TLDF is known to increase the number of episodes of fever in neutropenia (FN). This study aimed to investigate the influence of a lower versus standard TLDF on diagnostics and therapy. Methods In a single pediatric cancer center using a high standard TLDF (39°C tympanic-temperature) patients were observed prospectively (NCT01683370). The effect of applying lower TLDFs (range 37.5°C to 38.9°C) versus 39.0°C on these measures was simulated in silicon. Results In reality, 45 FN episodes were diagnosed. Of 3391 temperatures measured, 193 were ≥39.0°C, and 937 ≥38.0°C. For persisting fever ≥24 hours, additional blood cultures were taken in 31 (69%) episodes in reality. This number decreased to 22 (49%) when applying 39.0°C, and increased to 33 for 38.0°C (73%; plus 11 episodes; plus 24%). For persisting fever ≥48 hours, i.v.-antibiotics were escalated in 25 (56%) episodes. This number decreased to 15 (33%) when applying 39.0°C, and increased to 26 for 38.0°C (58%; plus 11 episodes; plus 24%). For persisting fever ≥120 hours, i.v.-antifungals were added in 4 (9%) episodes. This number increased to 6 (13%) by virtually applying 39.0°C, and to 11 for 38.0°C (24%; plus 5 episodes; plus 11%). The median length of stay was 5.7 days (range, 0.8 to 43.4). In 43 episodes with hospital discharge beyond 24 hours, applying 38.0°C led to discharge delay by ≥12 hours in 24 episodes (56%; 95% CI, 40 to 71), with a median delay of 13 hours, and a cumulative delay of 68 days. Conclusion Applying a low versus standard TLDF led to relevant increases of diagnostics, antimicrobial therapy, and length of stay. The differences between management in reality versus simply applying 39.0° as TLDF reflect the important impact of clinical assessment.
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Affiliation(s)
- Stéphanie Wagner
- Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Eva K. Brack
- Department of Infectious Disease and Cancer Research, Children´s Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Eveline Stutz-Grunder
- Department of Pediatric Oncology, Children´s Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Philipp Agyeman
- Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Kurt Leibundgut
- Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Oliver Teuffel
- Division of Oncology, Medical Services of the Statutory Health Insurance Baden-Württemberg, Tübingen, Germany
| | - Roland A. Ammann
- Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- * E-mail:
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267
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Affiliation(s)
- Florence Pasquier
- Département d'Hématologie, Gustave Roussy, Université Paris-Saclay, Villejuif, France
| | - Sabine Khalife-Hachem
- Département d'Hématologie, Gustave Roussy, Université Paris-Saclay, Villejuif, France
| | - Jean-Baptiste Micol
- Département d'Hématologie, Gustave Roussy, Université Paris-Saclay, Villejuif, France
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268
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Granulocyte transfusions in the management of neutropenic fever: A pediatric perspective. Transfus Apher Sci 2018; 57:16-19. [DOI: 10.1016/j.transci.2018.02.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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269
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Klein K, de Haas V, Kaspers GJL. Clinical challenges in de novo pediatric acute myeloid leukemia. Expert Rev Anticancer Ther 2018; 18:277-293. [DOI: 10.1080/14737140.2018.1428091] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Kim Klein
- Department of Pediatric Oncology/Hematology, VU University Medical Center, Amsterdam, The Netherlands
| | - Valérie de Haas
- Dutch Childhood Oncology Group, The Hague, The Netherlands
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Gertjan J. L. Kaspers
- Department of Pediatric Oncology/Hematology, VU University Medical Center, Amsterdam, The Netherlands
- Dutch Childhood Oncology Group, The Hague, The Netherlands
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
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270
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Huppler AR, Fisher BT, Lehrnbecher T, Walsh TJ, Steinbach WJ. Role of Molecular Biomarkers in the Diagnosis of Invasive Fungal Diseases in Children. J Pediatric Infect Dis Soc 2017; 6:S32-S44. [PMID: 28927202 PMCID: PMC5907877 DOI: 10.1093/jpids/pix054] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Invasive fungal diseases are important clinical problems that are often complicated by severe illness and therefore the inability to use invasive measures to definitively diagnose the disease. Tests for a range of fungal biomarkers that do not require an invasive sample-collection procedure have been incorporated into adult clinical practice, but pediatric data and pediatric-specific recommendations for some of these diagnostic tools are lacking. In this review, we summarize the published literature and contemporary strategies for using the biomarkers galactomannan, (1→3)-β-d-glucan, Candida mannan antigen and anti-mannan antibody, and fungal polymerase chain reaction for diagnosing invasive fungal disease in children. Data on biomarker use in neonates and children with cancer, history of hematopoietic stem cell transplant, or primary immunodeficiency are included. Fungal biomarker tests performed on blood, other body fluids, or tissue specimens represent promising adjuncts to the diagnostic armamentarium in populations with a high prevalence of invasive fungal disease, but substantial gaps exist in the correct use and interpretation of these diagnostic tools in pediatric patients.
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Affiliation(s)
- Anna R Huppler
- Department of Pediatrics, Division of Infectious Disease, Medical College of Wisconsin, Children’s Hospital and Health System, Children’s Research Institute, Milwaukee
| | - Brian T Fisher
- Division of Pediatric Infectious Diseases, Children’s Hospital of Philadelphia, Pennsylvania
| | - Thomas Lehrnbecher
- Division of Pediatric Hematology and Oncology, Hospital for Children and Adolescents, Johann Wolfgang Goethe University, Frankfurt, Germany
| | - Thomas J Walsh
- Division of Infectious Diseases, Department of Medicine, Transplantation-Oncology Infectious Diseases Program, and
- Department of Pediatrics, Microbiology and Immunology, Weill Cornell Medicine, Cornell University, New York; and
| | - William J Steinbach
- Division of Pediatric Infectious Diseases and
- Department of Molecular Genetics and Microbiology, Duke University Medical Center, Durham, North Carolina
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271
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Orgel E, Auletta JJ. TACL'ing supportive care needs in pediatric early phase clinical trials for acute leukemia: A report from the therapeutic advances in childhood leukemia & lymphoma (TACL) consortium supportive care committee. Pediatr Hematol Oncol 2017; 34:409-417. [PMID: 29190169 PMCID: PMC7513384 DOI: 10.1080/08880018.2017.1395936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
A Supportive Care Committee was recently developed within the Therapeutic Advances in Childhood Leukemia & Lymphoma (TACL) Consortium. This was substantiated by the significantly high rate of serious adverse events (SAE) (CTCAE Grade ≥3 toxicity) experienced by patients with relapse/refractory acute leukemia enrolled on our phase I trials. Such treatment-related toxicity has resulted in patients being removed from study and thus potentially not receiving clinical benefit from the novel therapy. In addition, increased treatment-related toxicity may compromise new agents from moving forward in their clinical development. To address these challenges, TACL initiated a Supportive Care Committee to help mitigate the treatment-related toxicity risk that exists in heavily pre-treated patients with relapse/refractory leukemia. This manuscript reviews the mission of the TACL Supportive Care Committee presented at the 2016 TACL Investigators' Meeting (Los Angeles, CA) and the future direction in providing enhanced supportive care guidelines for all TACL studies.
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Affiliation(s)
- E Orgel
- Division of Hematology, Oncology & BMT, Children’s Hospital of Los Angeles, Los Angeles, CA,Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - J J Auletta
- Divisions of Hematology/Oncology/BMT and Infectious Diseases, Nationwide Children’s Hospital, Columbus, OH;,Department of Pediatrics, The Ohio State University College of Medicine; Columbus, OH
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