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Agulnik A. Management of septic shock in children with cancer-Common challenges and research priorities. J Pediatr (Rio J) 2023; 99:101-104. [PMID: 36706794 PMCID: PMC10031354 DOI: 10.1016/j.jped.2023.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Affiliation(s)
- Asya Agulnik
- St. Jude Children's Research Hospital, Memphis, TN.
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2
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Kirolos N, Tang K, Abbott LS. Does age play a role in fever and neutropenia events and complications: A comparison of adolescents versus younger children with cancer at a tertiary care pediatric hospital, a pilot project. Cancer Rep (Hoboken) 2022; 6:e1767. [PMID: 36494902 PMCID: PMC10075292 DOI: 10.1002/cnr2.1767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 10/19/2022] [Accepted: 11/28/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Adolescents and young adults with cancer (AYA) are a complex group of patients. The development of fever and neutropenia (FN) is a potentially lethal complication of chemotherapy. Risk stratification of patients with FN has become increasingly valuable allowing for early intervention and to guide treatment type and duration appropriately. There are risk stratification guidelines that exist, but most are validated in young children with cancer (YCWC). AYA are frequently shown to have more numerous and severe side effects from chemotherapy. AIMS This study aimed to identify whether age contributes to the incidence and severity of FN. METHODS AND RESULTS Patients diagnosed with a malignancy in a 5-year period at our institution were included from ages 0-18 years. We reviewed details of their FN events, including duration of hospital admission, source (bacterial/fungal), PICU admission and duration, positive blood cultures and mortality. Adolescents with cancer (AWC) had a trend of being 1.56 times more likely to have FN events (CI 95% 0.936-2.622, p = 0.087). Assessment of the duration of PICU stay showed that AWC were 4.9 times more likely to have longer admissions (CI 95% 0.998-24.067, p = 0.050). There was no significant difference between the two groups in the rate of PICU admission, positive cultures, identification of a bacterial or fungal source, hospital admission duration or mortality from FN. CONCLUSION This study demonstrated a trend towards AWC being more likely to develop FN events. When such events occur in this group, the severity of them may be heightened as evidenced by longer duration of PICU admission.
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Affiliation(s)
- Nardin Kirolos
- Division of Hematology/Oncology Children's Hospital of Eastern Ontario Ottawa Ontario Canada
| | - Ken Tang
- CHEO Research Institute Children's Hospital of Eastern Ontario Ottawa Ontario Canada
| | - Lesleigh S. Abbott
- Division of Hematology/Oncology Children's Hospital of Eastern Ontario Ottawa Ontario Canada
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3
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Caniza MA, Homsi MR, Vázquez M, Gutierrez IF, Kopsidas I, Mukkada S, Friedrich P, Metzger M. The PRINCIPAL Network: A Model to Optimize Infection Care and Prevention in Pediatric Oncology in the Latin American Region. JCO Glob Oncol 2022; 8:e2200187. [PMID: 36446035 PMCID: PMC10166443 DOI: 10.1200/go.22.00187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
PURPOSE Children with cancer are at high risk for poor outcomes, and health care providers are often unfamiliar with best practices in infection care and prevention (IC&P) in this small and fragile population. Graduates of training courses in IC&P in immunocompromised hosts identified a need for a community that would enable members to share health care experiences, provide resources for continuing medical education, and foster collaborative research and quality improvement opportunities. We developed a Latin American network, Prevencionistas e Infectólogos para Cáncer Pediátrico en América Latina, to grow and sustain the expertise of the clinical workforce in IC&P. Here, we describe the network, how we built it, and its early outcomes. METHODS We began by codesigning the mission, vision, objectives, and values. We then established the structure for leadership and network management to provide a functional uniformity and sustainability. Virtual meetings with network members and strategic in-person gatherings optimized the use of the time and resources of the network. RESULTS The network has seen good participation by members and candidates for membership, who have provided feedback on case-based learning. Members have attended training sessions on quality improvement, research in human subjects, and IC&P in pediatric oncology at national and regional meetings and workshops. Network members have presented their work at regional and global meetings, and publications are beginning to emerge from this community. A direct effect of the Prevencionistas e Infectólogos para Cáncer Pediátrico en América Latina network has been the creation of a similar network for the Asia Pacific region, and a third network is being planned. CONCLUSION We have demonstrated the power of a discipline-specific network structure to facilitate sharing of evidence-based information that enhances the quality-of-care delivery in pediatric oncology.
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Affiliation(s)
- Miguela A Caniza
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN.,Department of Infectious Diseases, St Jude Children's Research Hospital, Memphis, TN.,Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN
| | - Maysam R Homsi
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN
| | - Milka Vázquez
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN
| | | | - Ioannis Kopsidas
- 2nd Department of Pediatrics and Center for Clinical Epidemiology and Outcomes Research, National and Kapodistrian University of Athens, Athens, Greece
| | - Sheena Mukkada
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN.,Department of Infectious Diseases, St Jude Children's Research Hospital, Memphis, TN
| | - Paola Friedrich
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN.,Department of Oncology, St Jude Children's Research Hospital, Memphis, TN
| | - Monika Metzger
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN.,Department of Oncology, St Jude Children's Research Hospital, Memphis, TN
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4
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Boeriu E, Borda A, Vulcanescu DD, Sarbu V, Arghirescu ST, Ciorica O, Bratosin F, Marincu I, Horhat FG. Diagnosis and Management of Febrile Neutropenia in Pediatric Oncology Patients—A Systematic Review. Diagnostics (Basel) 2022; 12:diagnostics12081800. [PMID: 35892511 PMCID: PMC9394251 DOI: 10.3390/diagnostics12081800] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 07/17/2022] [Accepted: 07/22/2022] [Indexed: 11/16/2022] Open
Abstract
Infectious diseases are associated with a high morbidity and mortality rate among pediatric cancer patients undergoing treatment or receiving a transplant. Neutropenia represents a potentially fatal complication of cancer treatment and is associated with a high risk of developing bacterial infections. Although febrile neutropenia (FN) can affect both adults and children, the latter has a higher chance of infections with an unknown origin. Prompt empiric broad-spectrum antibiotic administration is collectively considered the best therapeutic approach. This review aims to analyze the latest works from the literature regarding the therapeutic strategies, schemes, and approaches and the efficacy of these in pediatric febrile neutropenia. Following PRISMA guidelines, an advanced search on PubMed, Scopus, and Cochrane Library, using the keywords “febrile neutropenia”, “pediatric”, “cancer”, and “oncology”, was performed. A total of 197 articles were found to be eligible. After screening the abstracts and excluding unfit studies, 16 articles were analyzed. There were eight retrospective studies, five prospective studies, and two clinical trials. Altogether, these studies have described around 5000 episodes of FN. The median age of the participants was 7.6 years, and the underlying condition for most of them was acute leukemia. The infectious agent could only be determined in around one-fifth of cases, from which 90% were of bacterial origin. As such, empirical broad-spectrum antibiotics are used, with the most used treatment scheme comprising third- and fourth-generation cephalosporins and antipseudomonal penicillins. In order to improve the treatment strategies of FN episodes and to successfully de-escalate treatments toward narrower-spectrum antibiotics, hospitals and clinics should increase their efforts in identifying the underlying cause of FN episodes through blood culture urine culture and viral tests, wherever infrastructure enables it.
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Affiliation(s)
- Estera Boeriu
- Department of Pediatrics, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square 2, 300041 Timisoara, Romania;
- Department of Oncology and Haematology, “Louis Turcanu” Emergency Clinical Hospital for Children, Iosif Nemoianu Street 2, 300011 Timisoara, Romania;
| | - Alexandra Borda
- Department of Oncology and Haematology, “Louis Turcanu” Emergency Clinical Hospital for Children, Iosif Nemoianu Street 2, 300011 Timisoara, Romania;
| | - Dan Dumitru Vulcanescu
- Multidisciplinary Research Center on Antimicrobial Resistance (MULTI-REZ), Microbiology Department, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (D.D.V.); (V.S.); (F.G.H.)
| | - Vlad Sarbu
- Multidisciplinary Research Center on Antimicrobial Resistance (MULTI-REZ), Microbiology Department, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (D.D.V.); (V.S.); (F.G.H.)
| | - Smaranda Teodora Arghirescu
- Department of Pediatrics, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square 2, 300041 Timisoara, Romania;
- Correspondence: (S.T.A.); (O.C.)
| | - Ovidiu Ciorica
- Business Administration and Economics Faculty, West University of Timisoara, Johann Heinrich Pestalozzi Street 16, 300115 Timisoara, Romania
- Correspondence: (S.T.A.); (O.C.)
| | - Felix Bratosin
- Methodological and Infectious Diseases Research Center, Department of Infectious Diseases, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (F.B.); (I.M.)
| | - Iosif Marincu
- Methodological and Infectious Diseases Research Center, Department of Infectious Diseases, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (F.B.); (I.M.)
| | - Florin George Horhat
- Multidisciplinary Research Center on Antimicrobial Resistance (MULTI-REZ), Microbiology Department, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (D.D.V.); (V.S.); (F.G.H.)
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5
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Israels T, Afungchwi GM, Klootwijk L, Njuguna F, Hesseling P, Kouya F, Paintsil V, Landman L, Chitsike I, Chagaluka G, Sung L, Molyneux E. Fever and neutropenia outcomes and areas for intervention: A report from SUCCOUR - Supportive Care for Children with Cancer in Africa. Pediatr Blood Cancer 2021; 68:e29224. [PMID: 34245212 DOI: 10.1002/pbc.29224] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 05/18/2021] [Accepted: 06/22/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND Death during paediatric cancer treatment is common in sub-Saharan Africa. Using the infrastructure of Supportive Care for Children with Cancer in Africa (SUCCOUR), our objective was to describe fever and neutropenia (FN) characteristics and outcomes in order to identify potential areas for future intervention. METHODS A multicentre prospective, observational cohort study was conducted in sub-Saharan Africa. Data were collected from September 2019 to March 2020. Children below 16 years with newly diagnosed cancer treated with curative intent were included. Data were abstracted in real time using standardised case report forms by trained personnel. Characteristics and outcomes of FN during the first 3 months of treatment were documented. RESULTS A total of 252 patients were included (median age 6.0, range 0.2-15.0 years, 54% male). The most common cancer was Burkitt lymphoma (63/252, 25%). Among 104 FN episodes, 21 (21%) were associated with prolonged neutropenia (>1 week) and 32 (31%) were associated with profound neutropenia (absolute neutrophil count <0.1 × 109 /L). In 10/104 (10%) episodes, empiric antibiotics were started within 1 hour following fever onset and in 16/104 (15%) episodes, a blood culture was obtained before starting antibiotics. Malaria parasitaemia was detected in four of 104 (4%). A total of 11/104 (11%) patients died in the FN episodes. CONCLUSIONS Although in most, FN was not associated with prolonged or profound neutropenia, 11% resulted in death. Areas to target include blood cultures prior to antibiotics and earlier initiation of empiric antibiotics. Future efforts should modify FN practices to reduce treatment-related mortality.
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Affiliation(s)
- Trijn Israels
- Princess Máxima Centre for Pediatric Oncology, Utrecht, The Netherlands
| | | | - Larissa Klootwijk
- Princess Máxima Centre for Pediatric Oncology, Utrecht, The Netherlands
| | - Festus Njuguna
- Department of Child Health and Paediatrics, Moi University, Eldoret, Kenya
| | - Peter Hesseling
- Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch, South Africa
| | - Francine Kouya
- Cameroon Baptist Convention Hospitals, Mutengene, Cameroon
| | - Vivian Paintsil
- Department of Child Health, Kumasi School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Lisa Landman
- Princess Máxima Centre for Pediatric Oncology, Utrecht, The Netherlands
| | - Inam Chitsike
- Department of Paediatrics and Child Health, University of Zimbabwe, Harare, Zimbabwe
| | - George Chagaluka
- Queen Elizabeth Central Hospital (QECH), College of Medicine, Blantyre, Malawi
| | - Lillian Sung
- Division of Haematology/Oncology and Program in Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Elizabeth Molyneux
- Queen Elizabeth Central Hospital (QECH), College of Medicine, Blantyre, Malawi
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Melgar MA, Homsi MR, Happ B, Su Y, Tang L, Gonzalez ML, Caniza MA. Survey of practices for the clinical management of febrile neutropenia in children in hematology-oncology units in Latin America. Support Care Cancer 2021; 29:7903-7911. [PMID: 34189607 PMCID: PMC8550596 DOI: 10.1007/s00520-021-06381-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 06/21/2021] [Indexed: 11/18/2022]
Abstract
The management of febrile neutropenia (FN) in pediatrics is evolving. Our objective was to describe current practices for the care of patients with FN in pediatric oncology centers in Latin America and identify areas for practice improvement. We used an online survey to enroll eligible healthcare providers who treat children with cancer in Latin America. The survey addressed respondents’ characteristics, the environment of care, and FN care practices, including risk assessment, criteria for hospitalization, initial management of FN, evaluation, antibiotic administration, and discharge. From 220 surveys sent, we received 109 responses and selected 108 from 19 countries for analysis. Most (94%) respondents were working in specialized oncology centers, oncology units within a pediatric or general care hospital. The cohort included oncologists (42%) and infectious diseases physicians (30%). Most (67%) respondents had available guidelines; they used a risk-stratification scoring system (73%) for severe infection; and their guidelines had locally adapted risk stratification (34%) or published risk stratification (51%). The respondents used diverse FN definitions and concepts, including fever definitions, temperature-obtaining methods, neutropenia values for assigning risk, empiric antimicrobials administration, and length of hospitalization. Overall, we detected common practices aligning with standard published recommendations, as well as care variability. These findings can guide further evaluations of care resources and practices to prioritize interventions, and professional networks can be used for FN discussions and consensus in Latin America.
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Affiliation(s)
- Mario A Melgar
- Department of Pediatrics, Unidad Nacional de Oncología Pediátrica, Guatemala City, Guatemala
| | - Maysam R Homsi
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, 38105, USA
| | - Brooke Happ
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, 38105, USA
| | - Yin Su
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN, 38105, USA
| | - Li Tang
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN, 38105, USA
| | - Miriam L Gonzalez
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, 38105, USA
| | - Miguela A Caniza
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, 38105, USA. .,Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, TN, 38105, USA. .,Health Science Center, University of Tennessee, Memphis, TN, USA.
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Suwanpakdee D, Prasertsin W, Traivaree C, Rujkijyanont P. Serum Lactate: A Predictor of Septic Shock in Childhood Cancers with Febrile Neutropenia. Glob Pediatr Health 2021; 8:2333794X211022711. [PMID: 34104707 PMCID: PMC8170332 DOI: 10.1177/2333794x211022711] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 05/14/2021] [Indexed: 12/22/2022] Open
Abstract
Early recognition and management are the key elements to prevent febrile
neutropenia associated mortality. The prospective observational study aimed to
investigate prognostic accuracy of serum lactate to predict septic shock within
48 hours among hemodynamically stable children with febrile neutropenia. In all,
99 pediatric oncology patients who developed febrile neutropenia were enrolled
in the study. Clinical information during 48 hours and serum lactate at the time
of enrollment were analyzed. Among 99 participating patients, 10 developed
septic shock and 4 of those expired. No significant difference was found of
patients’ baseline characteristics and basic laboratory parameters between
patients with and without septic shock. Serum lactate was significantly elevated
among patients developing septic shock (P-value < .001) and
those who expired (P-value .002). Receiver operating
characteristic (ROC) curve was created to identify the best cutoff value for
initial serum lactate associated with the development of septic shock within
48 hours. Baseline serum lactate more than 2.5 mmol/L showed the largest area
under the ROC curve to predict the septic shock development within 48 hours (ROC
area, 0.90; 95% confidence interval [CI], 0.81-0.98), with sensitivity,
specificity, negative predictive value, and accuracy of 80.0%, 92.1%, 97.6%, and
90.9%, respectively. Serum lactate level determined early at the time of febrile
neutropenia was an effective surrogate marker for developing septic shock within
48 hours among hemodynamically stable, pediatric oncology patients. The level
more than 2.5 mmol/L was the best threshold to start preemptive aggressive
hemodynamic monitoring and prompt treatment to ensure adequate tissue
perfusion.
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Caniza MA, Homsi M, Gonzalez M, Moreira DC, Tang L, Adderson E, Rodriguez-Galindo C. Development, Implementation, and Outcomes of a Global Infectious Disease Training Course. JOURNAL OF MEDICAL EDUCATION AND CURRICULAR DEVELOPMENT 2021; 8:23821205211015290. [PMID: 34104784 PMCID: PMC8165826 DOI: 10.1177/23821205211015290] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 04/16/2021] [Indexed: 06/12/2023]
Abstract
BACKGROUND Skilled healthcare professionals are critical for providing quality healthcare for children with cancer globally. Training curricula addressing the knowledge needs in infection care and prevention (ICP) in cancer are scarce. PROGRAM DESCRIPTION We implemented a 10-week blended course in ICP. The distance learning had four 2-week modules: Infectious Complications, Quality in Infection Care, Quality in Infection Prevention, and Sustainability, Research, and Dissemination. Each module had pre- and post-tests and weekly webinars. The 2-week in-person learning had lectures, group exercises, clinical observations, hospital and laboratory tours, and ended in an annual conference. An individual project developed during the distance learning was presented in the in-person workshop. Course attendance criteria were English language proficiency and participants' role in ICP at their institutions. PROGRAM EVALUATION AND RESULTS Twenty-two students from 17 hospitals in 10 countries completed the course, developed a project, and answered surveys covering knowledge assessments and satisfaction, and 6-month course and 1-year project follow-ups. Pretest and post-test scores revealed knowledge improvement (P < .001). Participants rated the distance learning as outstanding (63%) or good (28%); and the in-person as outstanding (87%). In the follow-up survey, graduates felt more comfortable at managing infections and participated more in quality improvement and academics at their institutions. Seventeen participants (77%) took steps to implement their study projects, and 9 were successful. Collaboration and networking of trainees were notable outcomes. DISCUSSION The ICP course is a resource to improve knowledge, engage graduates in network collaborations, and a reliable model to develop other thematic healthcare global training programs.
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Affiliation(s)
- Miguela A Caniza
- Department of Global Pediatric Medicine and the Department of Infectious Diseases, St. Jude Children’s Research Hospital, Memphis, TN, USA
- University of Tennessee, Memphis, TN, USA
| | - Maysam Homsi
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Miriam Gonzalez
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Daniel C Moreira
- Department of Global Pediatric Medicine and the Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Li Tang
- Department of Biostatistics, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Elisabeth Adderson
- Department of Infectious Diseases, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Carlos Rodriguez-Galindo
- Department of Global Pediatric Medicine and the Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN, USA
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Mukkada S, Hakim H. Fever in neutropenia: time to re-evaluate an old paradigm? THE LANCET CHILD & ADOLESCENT HEALTH 2020; 4:480-481. [PMID: 32497519 DOI: 10.1016/s2352-4642(20)30138-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 04/28/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Sheena Mukkada
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN 38105, USA; Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, TN 38105, USA.
| | - Hana Hakim
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, TN 38105, USA
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