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Schellekens KPJ, Hageman SB, Haverkate EC, van de Wetering MD, Engels FK, Brinksma A, de Vos-Kerkhof E. Evaluation of chemotherapy-induced nausea and vomiting in pediatric patients with high-grade glioma treated with lomustine-a case series. Support Care Cancer 2024; 32:290. [PMID: 38627334 PMCID: PMC11021261 DOI: 10.1007/s00520-024-08474-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 03/29/2024] [Indexed: 04/19/2024]
Abstract
PURPOSE Although lomustine has been used as a chemotherapeutic agent for decades, no recommendation on appropriate chemotherapy-induced nausea and vomiting (CINV) prophylaxis is available. As CINV is considered one of the most bothersome side effects of chemotherapy, adequate prophylaxis is of relevance to improve quality of life during cancer treatment. The aim of this retrospective case series was to report the incidence and severity of CINV in pediatric patients with high-grade glioma treated with lomustine and to formulate recommendations for appropriate CINV prophylaxis. METHODS Pediatric patients treated with lomustine for high-grade glioma according to the ACNS 0423 protocol were identified retrospectively. Two researchers independently reviewed and classified complaints of CINV and administered CINV prophylaxis. Treatment details, tumor localization, and response to therapy were systematically extracted from the patients' files. RESULTS Seventeen children aged 8-18 years received a median of four cycles of lomustine. CINV complaints and administered prophylaxis were evaluable in all patients. Moderate or severe CINV was observed in 13/17 (76%) patients. Administered prophylactic CINV regimens varied from no prophylaxis to triple-agent combinations. CONCLUSION In this case series, we identified lomustine as a highly emetogenic chemotherapeutic agent. According to the current guidelines, CINV prophylaxis with a 5-HT3 receptor antagonist in combination with dexamethasone and (fos)aprepitant is recommended.
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Affiliation(s)
- Kim P J Schellekens
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands.
- Department of Pediatric Oncology, Sophia Children's Hospital, Erasmus Medical Center, Rotterdam, the Netherlands.
| | | | - Els C Haverkate
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | | | | | - Aeltsje Brinksma
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
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2
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Weijers DD, Hirsch S, Bakhuizen JJ, van Engelen N, Kester LA, Kranendonk MEG, Hiemcke-Jiwa LS, de Vos-Kerkhof E, Loeffen JLC, Autry RJ, Pajtler KW, Jäger N, Jongmans MCJ, Kuiper RP. Molecular analysis of cancer genomes in children with Lynch syndrome: Exploring causal associations. Int J Cancer 2024; 154:1455-1463. [PMID: 38175816 DOI: 10.1002/ijc.34832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 11/28/2023] [Accepted: 11/29/2023] [Indexed: 01/06/2024]
Abstract
Lynch syndrome (LS) predisposes to cancer in adulthood and is caused by heterozygous germline variants in a mismatch repair (MMR) gene. Recent studies show an increased prevalence of LS among children with cancer, suggesting a causal relationship. For LS-spectrum (LSS) cancers, including high-grade gliomas and colorectal cancer, causality has been supported by typical MMR-related tumor characteristics, but for non-LSS cancers, causality is unclear. We characterized 20 malignant tumors of 18 children with LS, including 16 non-LSS tumors. We investigated second hits, tumor mutational load, mutational signatures and MMR protein expression. In all LSS tumors and three non-LSS tumors, we detected MMR deficiency caused by second hit somatic alterations. Furthermore, these MMR-deficient tumors carried driver variants that likely originated as a consequence of MMR deficiency. However, in 13 non-LSS tumors (81%), a second hit and MMR deficiency were absent, thus a causal link between LS and cancer development in these children is lacking. These findings demonstrate that causality of LS in children with cancer, which can be determined by molecular tumor characterization, seems to be restricted to specific tumor types. Large molecular and epidemiological studies are needed to further refine the tumor spectrum in children with LS.
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Affiliation(s)
- Dilys D Weijers
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Steffen Hirsch
- Institute of Human Genetics, Heidelberg University Hospital, Heidelberg, Germany
- Hopp Children's Cancer Center Heidelberg (KiTZ), Heidelberg, Germany
- Division of Pediatric Neurooncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Jette J Bakhuizen
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
- Department of Genetics, University Medical Center Utrecht, University of Utrecht, Utrecht, The Netherlands
| | | | - Lennart A Kester
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | | | - Laura S Hiemcke-Jiwa
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
- Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Jan L C Loeffen
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Robert J Autry
- Hopp Children's Cancer Center Heidelberg (KiTZ), Heidelberg, Germany
- Division of Pediatric Neurooncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
- German Cancer Consortium (DKTK), Heidelberg, Germany
| | - Kristian W Pajtler
- Hopp Children's Cancer Center Heidelberg (KiTZ), Heidelberg, Germany
- Division of Pediatric Neurooncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
- Department of Pediatric Hematology and Oncology, Heidelberg University Hospital, Heidelberg, Germany
| | - Natalie Jäger
- Hopp Children's Cancer Center Heidelberg (KiTZ), Heidelberg, Germany
- Division of Pediatric Neurooncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
- German Cancer Consortium (DKTK), Heidelberg, Germany
| | - Marjolijn C J Jongmans
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
- Department of Genetics, University Medical Center Utrecht, University of Utrecht, Utrecht, The Netherlands
| | - Roland P Kuiper
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
- Department of Genetics, University Medical Center Utrecht, University of Utrecht, Utrecht, The Netherlands
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3
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de Vos-Kerkhof E, Buis DR, Lequin MH, Bennebroek CA, Aronica E, Hulleman E, Zwaveling-Soonawala N, van Santen HM, Schouten-van Meeteren AYN. Tocilizumab for the fifth progression of cystic childhood craniopharyngioma-a case report. Front Endocrinol (Lausanne) 2023; 14:1225734. [PMID: 37886643 PMCID: PMC10598752 DOI: 10.3389/fendo.2023.1225734] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 09/12/2023] [Indexed: 10/28/2023] Open
Abstract
We present the case of a 15-year-old girl, with a fifth cystic progression of an adamantinomatous craniopharyngioma after multiple surgeries and previous local radiotherapy. She had severe visual impairment, panhypopituitarism including diabetes insipidus, and several components of hypothalamic damage, including morbid obesity and severe fatigue. To prevent further late effects hampering her quality of survival, she was treated biweekly with intravenous tocilizumab, an anti-interleukin-6 agent, which stabilized the cyst for a prolonged time. Based on the biology of adamantinomatous craniopharyngioma, this immune-modulating treatment seems promising for the treatment of this cystic tumor in order to reduce surgery and delay or omit radiotherapy.
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Affiliation(s)
| | - Dennis R. Buis
- Department of Neurosurgery, University of Amsterdam, Amsterdam University Medical Center (UMC), Amsterdam, Netherlands
| | - Maarten H. Lequin
- Department of Radiology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Carlien A. Bennebroek
- Department of Ophthalmology, Amsterdam University Medical Center (UMC), Amsterdam, Netherlands
| | - Eleonora Aronica
- Department of Neuropathology, University of Amsterdam, Amsterdam University Medical Center (UMC), Amsterdam, Netherlands
| | - Esther Hulleman
- Department of Neuro-oncology, Princess Máxima Center, Utrecht, Netherlands
| | - Nitash Zwaveling-Soonawala
- Department of Pediatric Endocrinology, Amsterdam University Medical Center (UMC), Amsterdam, Netherlands
| | - Hanneke M. van Santen
- Department of Pediatric Endocrinology, Wilhelmina Children’s Hospital, University Medical Center Utrecht, Utrecht, Netherlands
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4
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van Schaik J, Kormelink E, Kabak E, van Dalen EC, Schouten-van Meeteren AYN, de Vos-Kerkhof E, Bakker B, Fiocco M, Hoving EW, Tissing WJE, van Santen HM. Safety of Growth Hormone Replacement Therapy in Childhood-Onset Craniopharyngioma: A Systematic Review and Cohort Study. Neuroendocrinology 2023; 113:987-1007. [PMID: 37231961 DOI: 10.1159/000531226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 05/17/2023] [Indexed: 05/27/2023]
Abstract
INTRODUCTION Survival of childhood-onset craniopharyngioma (cCP) is excellent; however, many survivors suffer from hypothalamic-pituitary dysfunction. Growth hormone replacement therapy (GHRT) is of high importance for linear growth and metabolic outcome. Optimal timing for initiation of GHRT in cCP is on debate because of concerns regarding tumor progression or recurrence. METHODS A systematic review and cohort studys were performed for the effect and timing of GHRT on overall mortality, tumor progression/recurrence, and secondary tumors in cCP. Within the cohort, cCP receiving GHRT ≤1 year after diagnosis were compared to those receiving GHRT >1 year after diagnosis. RESULTS Evidence of 18 included studies, reporting on 6,603 cCP with GHRT, suggests that GHRT does not increase the risk for overall mortality, progression, or recurrent disease. One study evaluated timing of GHRT and progression/recurrence-free survival and found no increased risk with earlier initiation. One study reported a higher than expected prevalence of secondary intracranial tumors compared to a healthy population, possibly confounded by radiotherapy. In our cohort, 75 of 87 cCP (86.2%) received GHRT for median of 4.9 years [0.0-17.1]. No effect of timing of GHRT was found on mortality, progression/recurrence-free survival, or secondary tumors. CONCLUSION Although the quality of the evidence is low, the available evidence suggests no effect of GHRT or its timing on mortality, tumor progression/recurrence, or secondary neoplasms in cCP. These results support early initiation of GHRT in cCP aiming to optimize linear growth and metabolic outcome. Prospective studies are needed to increase the level of evidence upon the optimal timing to start GHRT in cCP patients.
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Affiliation(s)
- Jiska van Schaik
- Division of Pediatric Endocrinology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Eline Kormelink
- Division of Pediatric Endocrinology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Eda Kabak
- Division of Pediatric Endocrinology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | | | | | - Boudewijn Bakker
- Division of Pediatric Endocrinology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Marta Fiocco
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
- Institute of Mathematics, Leiden University, Leiden, The Netherlands
| | - Eelco W Hoving
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Wim J E Tissing
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
- Department of Pediatric Oncology/Hematology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Hanneke M van Santen
- Division of Pediatric Endocrinology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
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5
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Bakhuizen JJ, Hopman SMJ, Bosscha MI, Dommering CJ, van den Heuvel-Eibrink MM, Hol JA, Kester LA, Koudijs MJ, Langenberg KPS, Loeffen JLC, van der Lugt J, Moll AC, van Noesel MM, Smetsers SE, de Vos-Kerkhof E, Merks JHM, Kuiper RP, Jongmans MCJ. Assessment of Cancer Predisposition Syndromes in a National Cohort of Children With a Neoplasm. JAMA Netw Open 2023; 6:e2254157. [PMID: 36735256 PMCID: PMC9898819 DOI: 10.1001/jamanetworkopen.2022.54157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
IMPORTANCE To improve diagnostics of cancer predisposition syndromes (CPSs) in children with cancer, it is essential to evaluate the effect of CPS gene sequencing among all children with cancer and compare it with genetic testing based on clinical selection. However, a reliable comparison is difficult because recent reports on a phenotype-first approach in large, unselected childhood cancer cohorts are lacking. OBJECTIVE To describe a national children's cancer center's experience in diagnosing CPSs before introducing routine next-generation sequencing. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study was conducted at the National Retinoblastoma Treatment Center (Amsterdam, the Netherlands) and the Princess Máxima Center for Pediatric Oncology (Utrecht, Netherlands) and included Dutch pediatric patients with a new diagnosis of neoplasm between June 1, 2018, and December 31, 2019. Follow-up was at least 18 months after neoplasm diagnosis. Data analysis was conducted from July 2021 to February 2022. EXPOSURES As part of routine diagnostics, pediatric oncologists and ophthalmologists checked for characteristics of CPSs and selected children for referral to clinical geneticists and genetic testing. MAIN OUTCOMES AND MEASURES Detected cancer predisposition syndromes. RESULTS A total of 824 patients (median [range] age at diagnosis 7.5 [0-18.9] years; 361 girls [44%]) were assessed, including 335 children with a hematological neoplasm (41%) and 489 (59%) with a solid tumor. In 71 of 824 children (8.6%), a CPS was identified, of which most (96%) were identified by a phenotype-driven approach. Down syndrome and neurofibromatosis type 1 were the most common CPSs diagnosed. In 42 of 71 patients (59%), a CPS was identified after these children developed a neoplasm. The specific type of neoplasm was the most frequent indicator for genetic testing, whereas family history played a minor role. CONCLUSIONS AND RELEVANCE In this cohort study of children with a neoplasm, the prevalence of CPSs identified by a phenotype-driven approach was 8.6%. The diagnostic approach for identifying CPSs is currently shifting toward a genotype-first approach. Future studies are needed to determine the diagnostic value, as well as possible disadvantages of CPS gene sequencing among all children with cancer compared with the phenotype-driven approach.
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Affiliation(s)
- Jette J. Bakhuizen
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
- Department of Genetics, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Saskia M. J. Hopman
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
- Department of Genetics, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Machteld I. Bosscha
- Department of Ophthalmology, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Charlotte J. Dommering
- Department of Clinical Genetics, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Marry M. van den Heuvel-Eibrink
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
- University Medical Center-Wilhelmina Children’s Hospital, Utrecht, the Netherlands
| | - Janna A. Hol
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - Lennart A. Kester
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - Marco J. Koudijs
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | | | - Jan L. C. Loeffen
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | | | - Annette C. Moll
- Department of Ophthalmology, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Max M. van Noesel
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
- Division of Imaging and Oncology, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | | | - Johannes H. M. Merks
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
- Division of Imaging and Oncology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Roland P. Kuiper
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - Marjolijn C. J. Jongmans
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
- Department of Genetics, University Medical Center Utrecht, Utrecht, the Netherlands
- Department of Genetics, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
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6
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Nijstad AL, de Vos-Kerkhof E, Enters-Weijnen CF, van de Wetering MD, Tissing WJE, Tibben MM, Rosing H, Lalmohamed A, Huitema ADR, Zwaan CM. Overestimation of the effect of (fos)aprepitant on intravenous dexamethasone pharmacokinetics requires adaptation of the guidelines for children with chemotherapy-induced nausea and vomiting. Support Care Cancer 2022; 30:9991-9999. [PMID: 36287279 PMCID: PMC9607815 DOI: 10.1007/s00520-022-07423-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 10/15/2022] [Indexed: 11/28/2022]
Abstract
Purpose Chemotherapy-induced nausea and vomiting (CINV) are common side effects in pediatric oncology treatment. Besides 5-HT3-antagonists, both dexamethasone and aprepitant are cornerstone drugs in controlling these side effects. Based on results of adult studies, the dexamethasone dose is reduced by 50% when combined with aprepitant, because of a drug-drug interaction, even though data on the interaction in children is lacking. The current study was developed to investigate the effect of aprepitant on dexamethasone clearance (CL) in children, in order to assess if dexamethasone dose reduction for concomitant use of aprepitant is appropriate in the current antiemetic regimen. Methods In total, 65 children (0.6–17.9 years), receiving intravenous or oral antiemetic therapy (dexamethasone ± aprepitant) as standard of care, were included. 305 dexamethasone plasma concentrations were determined using LC–MS/MS. An integrated dexamethasone and aprepitant pharmacokinetic model was developed using non-linear mixed effects modelling in order to investigate the effect of aprepitant administration on dexamethasone CL. Results In this population, dexamethasone CL in patients with concomitant administration of aprepitant was reduced by approximately 30% of the uninhibited CL (23.3 L/h (95% confidence interval 20.4–26.0)). This result is not consistent with the results of adult studies (50% reduction). This difference was not age dependent, but might be related to the route of administration of dexamethasone. Future studies are needed to assess the difference in oral/intravenous dexamethasone. Conclusion When dexamethasone is given intravenously as a component of triple therapy to prevent CINV in children, we advise to reduce the dexamethasone dose by 30% instead of 50%. Supplementary Information The online version contains supplementary material available at 10.1007/s00520-022-07423-6.
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Affiliation(s)
- A Laura Nijstad
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht, The Netherlands.,Department of Pharmacology, Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Evelien de Vos-Kerkhof
- Princess Máxima Center for Pediatric Oncology, Postbus 113, 3720 AC, Bilthoven, Utrecht, The Netherlands
| | - Catherine F Enters-Weijnen
- Princess Máxima Center for Pediatric Oncology, Postbus 113, 3720 AC, Bilthoven, Utrecht, The Netherlands.,Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marianne D van de Wetering
- Princess Máxima Center for Pediatric Oncology, Postbus 113, 3720 AC, Bilthoven, Utrecht, The Netherlands
| | - Wim J E Tissing
- Princess Máxima Center for Pediatric Oncology, Postbus 113, 3720 AC, Bilthoven, Utrecht, The Netherlands.,Department of Pediatric Oncology and Hematology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Matthijs M Tibben
- Department of Pharmacy & Pharmacology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Hilde Rosing
- Department of Pharmacy & Pharmacology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Arief Lalmohamed
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht, The Netherlands.,Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Alwin D R Huitema
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht, The Netherlands.,Department of Pharmacology, Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands.,Department of Pharmacy & Pharmacology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - C Michel Zwaan
- Princess Máxima Center for Pediatric Oncology, Postbus 113, 3720 AC, Bilthoven, Utrecht, The Netherlands. .,Department of Pediatric Oncology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands.
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7
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Nuijts MA, Stegeman I, van Seeters T, Borst MD, Bennebroek CAM, Buis DR, Naus NC, Porro GL, van Egmond-Ebbeling MB, Voskuil-Kerkhof ESM, Pott JR, Franke NE, de Vos-Kerkhof E, Hoving EW, Schouten-van Meeteren AYN, Imhof SM. Ophthalmological Findings in Youths With a Newly Diagnosed Brain Tumor. JAMA Ophthalmol 2022; 140:982-993. [PMID: 36107418 PMCID: PMC9478881 DOI: 10.1001/jamaophthalmol.2022.3628] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 07/26/2022] [Indexed: 08/15/2023]
Abstract
Importance Visual impairment is an irreversible adverse effect in individuals who experienced a childhood brain tumor. Ophthalmological evaluation at diagnosis enables early detection of vision loss, decision-making about treatment, and when applicable, the timely use of visual interventions. However, awareness of visual impairment in clinical practice is suboptimal, and adherence to ophthalmological evaluation needs to be improved. Objective To assess the prevalence and types of abnormal ophthalmological findings in youths with a newly diagnosed brain tumor. Design, Setting, and Participants In this nationwide, prospective cohort study, youths aged 0 to 18 years with a newly diagnosed brain tumor between May 15, 2019, and August 11, 2021, were consecutively enrolled in 4 hospitals in the Netherlands, including the dedicated tertiary referral center for pediatric oncology care. Exposures A standardized and comprehensive ophthalmological examination, including orthoptic evaluation, visual acuity testing, visual field examination, and ophthalmoscopy, was performed within 4 weeks from brain tumor diagnosis. Main Outcomes and Measures The main outcomes were prevalence and types of visual symptoms and abnormal ophthalmological findings at brain tumor diagnosis. Results Of 170 youths included in the study (96 [56.5%] male; median age, 8.3 years [range, 0.2-17.8 years]), 82 (48.2%) had infratentorial tumors; 53 (31.2%), supratentorial midline tumors; and 35 (20.6%), cerebral hemisphere tumors. A total of 161 patients (94.7%) underwent orthoptic evaluation (67 [41.6%] preoperatively; 94 [58.4%] postoperatively); 152 (89.4%), visual acuity testing (63 [41.4%] preoperatively; 89 [58.6%] postoperatively); 121 (71.2%), visual field examination (49 [40.4%] preoperatively; 72 [59.6%] postoperatively); and 164 (96.5%), ophthalmoscopy (82 [50.0%] preoperatively; 82 [50.0%] postoperatively). Overall, 101 youths (59.4%) presented with visual symptoms at diagnosis. Abnormal findings were found in 134 patients (78.8%) during ophthalmological examination. The most common abnormal findings were papilledema in 86 of 164 patients (52.4%) who underwent ophthalmoscopy, gaze deficits in 54 of 161 (33.5%) who underwent orthoptic evaluation, visual field defects in 32 of 114 (28.1%) with reliable visual field examination, nystagmus in 40 (24.8%) and strabismus in 32 (19.9%) of 161 who underwent orthoptic evaluation, and decreased visual acuity in 13 of 152 (8.6%) with reliable visual acuity testing. Forty-five of 69 youths (65.2%) without visual symptoms at diagnosis had ophthalmological abnormalities on examination. Conclusions and Relevance The results of this study suggest that there is a high prevalence of abnormal ophthalmological findings in youths at brain tumor diagnosis regardless of the presence of visual symptoms. These findings support the need of standardized ophthalmological examination and the awareness of ophthalmologists and referring oncologists, neurologists, and neurosurgeons for ophthalmological abnormalities in this patient group.
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Affiliation(s)
- Myrthe A. Nuijts
- Department of Ophthalmology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Inge Stegeman
- Department of Ophthalmology, University Medical Center Utrecht, Utrecht, the Netherlands
- Department of Otorhinolaryngology and Head & Neck Surgery University, University Medical Center Utrecht, Utrecht, the Netherlands
- Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, the Netherlands
- Epidemiology and Data Science, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Tom van Seeters
- Department of Radiology, Elisabeth-TweeSteden Hospital, Tilburg, the Netherlands
| | - Marloes D. Borst
- Faculty of Medicine, Utrecht University, Utrecht, the Netherlands
| | - Carlien A. M. Bennebroek
- Department of Ophthalmology, location AMC of Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Dennis R. Buis
- Department of Pediatric Neurosurgery, location AMC of Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Nicole C. Naus
- Department of Ophthalmology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Giorgio L. Porro
- Department of Ophthalmology, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | | | - JanWillem R. Pott
- Department of Ophthalmology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Niels E. Franke
- Department of Neuro-Oncology, Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - Evelien de Vos-Kerkhof
- Department of Neuro-Oncology, Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - Eelco W. Hoving
- Department of Neuro-Oncology, Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | | | - Saskia M. Imhof
- Department of Ophthalmology, University Medical Center Utrecht, Utrecht, the Netherlands
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8
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Nijstad AL, Chu WY, de Vos-Kerkhof E, Enters-Weijnen CF, van de Velde ME, Kaspers GJL, Barnett S, Veal GJ, Lalmohamed A, Zwaan CM, Huitema ADR. A Population Pharmacokinetic Modelling Approach to Unravel the Complex Pharmacokinetics of Vincristine in Children. Pharm Res 2022; 39:2487-2495. [PMID: 35986122 PMCID: PMC9556337 DOI: 10.1007/s11095-022-03364-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 08/09/2022] [Indexed: 11/30/2022]
Abstract
Abstract
Background
Vincristine, a chemotherapeutic agent that extensively binds to β-tubulin, is commonly dosed at 1.4–2.0 mg/m2 capped at 2 mg. For infants, doses vary from 0.025–0.05 mg/kg or 50–80% of the mg/m2 dose. However, evidence for lower doses in infants compared to older children is lacking. This study was conducted to unravel the complex pharmacokinetics of vincristine, including the effects of age, to assist optimal dosing in this population.
Methods
206 patients (0.04–33.9 years; 25 patients < 1 years), receiving vincristine, with 1297 plasma concentrations were included. Semi-mechanistic population pharmacokinetic analyses were performed using non-linear mixed effects modelling.
Results
A three-compartment model, with one saturable compartment resembling saturable binding to β-tubulin and thus, saturable distribution, best described vincristine pharmacokinetics. Body weight and age were covariates significantly influencing the maximal binding capacity to β-tubulin, which increased with increasing body weight and decreased with increasing age. Vincristine clearance (CL) was estimated as 30.6 L/h (95% confidence interval (CI) 27.6–33.0), intercompartmental CL (Q) as 63.2 L/h (95%CI 57.2–70.1), volume of distribution of the central compartment as 5.39 L (95%CI 4.23–6.46) and of the peripheral compartment as 400 L (95%CI 357–463) (all parameters correspond to a patient of 70 kg). The maximal binding capacity was 0.525 mg (95%CI 0.479–0.602) (for an 18 year old patient of 70 kg), with a high association rate constant, fixed at 1300 /h and a dissociation constant of 11.5 /h.
Interpretation
A decrease of vincristine β-tubulin binding capacity with increasing age suggests that young children tolerate higher doses of vincristine.
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Affiliation(s)
- A Laura Nijstad
- Department of Clinical Pharmacy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, the Netherlands.
- Department of Pharmacology, Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS, Utrecht, the Netherlands.
- Department of Clinical Pharmacy, University Medical Center Utrecht, Internal postal D.00.204, Postbus 85500, 3508 GA, Utrecht, The Netherlands.
| | - Wan-Yu Chu
- Department of Pharmacy & Pharmacology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, the Netherlands
| | - Evelien de Vos-Kerkhof
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS, Utrecht, The Netherlands
| | - Catherine F Enters-Weijnen
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS, Utrecht, The Netherlands
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Mirjam E van de Velde
- Emma Children's Hospital, Pediatric Oncology, Amsterdam UMC, Vrije Universiteit Amsterdam, 1105 AZ, Amsterdam, The Netherlands
| | - Gertjan J L Kaspers
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS, Utrecht, The Netherlands
- Emma Children's Hospital, Pediatric Oncology, Amsterdam UMC, Vrije Universiteit Amsterdam, 1105 AZ, Amsterdam, The Netherlands
| | - Shelby Barnett
- Newcastle University Centre for Cancer, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK
| | - Gareth J Veal
- Newcastle University Centre for Cancer, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK
| | - Arief Lalmohamed
- Department of Clinical Pharmacy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, the Netherlands
- Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Universiteitsweg 99, 3584 CG, Utrecht, the Netherlands
| | - C Michel Zwaan
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS, Utrecht, The Netherlands
- Department of Pediatric Oncology, Erasmus MC-Sophia Children's Hospital, Dr. Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
| | - Alwin D R Huitema
- Department of Clinical Pharmacy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, the Netherlands
- Department of Pharmacology, Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS, Utrecht, the Netherlands
- Department of Pharmacy & Pharmacology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, the Netherlands
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9
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van Schaik J, Kormelink E, Schouten-van Meeteren N, de Vos-Kerkhof E, Bakker B, Fiocco M, Hoving E, Tissing W, van Santen H. LTBK-02. Safety of growth hormone replacement therapy in childhood craniopharyngioma. Neuro Oncol 2022. [PMCID: PMC9189949 DOI: 10.1093/neuonc/noac079.714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Introduction: Treatment for childhood-onset craniopharyngioma (cCP) has shifted from complete to limited resection aiming to avoid additional hypothalamic morbidity. Up to 90% of cCP patients develop growth hormone deficiency (GHD). GH replacement therapy (GHRT) is of high importance for linear growth and metabolic state. Hardly any studies evaluated the optimal time to start GHRT in relation to tumor progression or recurrence. Our aim was to assess the effect of GHRT in cCP on tumor progression/recurrence. Methods: Patients with cCP diagnosed between 2001 and 2022, with at least one year of follow-up were included. Tumor progression/recurrence was defined as tumor progression/recurrence requiring intervention. Kaplan Meier and multivariable cox regression analyses were estimated for tumor progression/recurrence. Comparison was made between cCP patients with GHRT and without GHRT. Of the cCP patients receiving GHRT, those given GHRT ≤ 1 year of cCP diagnosis were compared to those given GHRT >1 year after cCP diagnosis. Results: Of 59 cCP patients, 52 were diagnosed with GHD and 51 (86.4%) received GHRT. Sixteen cCP patients (31.4%) developed tumor progression/recurrence during GHRT compared to four cCP patients (50.0%) without GHRT. Mean progression free survival (PFS) did not differ between cCP patients with or without GHRT (GHRT: 5.55 years 95% CI 3.74 - 7.36 vs. no GHRT: 3.69 years 95% CI 1.44 - 5.93). Of cCP patients who started GHRT ≤1 year after cCP diagnosis, 36.4% developed tumor progression/recurrence compared to 27.6% of cCP patients who received GHRT > 1 year after diagnosis (PFS: 8.45 years CI 95% 5.54 – 11.36 vs. 7.99 years CI 95% 6.03 – 9.94). Limited surgery was associated to tumor progression/recurrence (HR 6.99 CI 95% 2.10 – 23.25). Conclusion: GHRT does not seem to influence tumor progression/recurrence in cCP. These results support early initiation of GHRT in cCP patients to optimize linear growth and metabolic outcome.
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Affiliation(s)
- Jiska van Schaik
- Princess Máxima Center for pediatric oncology , Utrecht , Netherlands
- Division of Pediatric Endocrinology, Wilhelmina Children’s Hospital, University Medical Center Utrecht , Utrecht , Netherlands
| | - Eline Kormelink
- Division of Pediatric Endocrinology, Wilhelmina Children’s Hospital, University Medical Center Utrecht , Utrecht , Netherlands
| | | | | | - Boudewijn Bakker
- Division of Pediatric Endocrinology, Wilhelmina Children’s Hospital, University Medical Center Utrecht , Utrecht , Netherlands
| | - Marta Fiocco
- Institute of Mathematics, Leiden University , Leiden , Netherlands
- Princess Máxima Center for pediatric oncology , Utrecht , Netherlands
| | - Eelco Hoving
- Princess Máxima Center for pediatric oncology , Utrecht , Netherlands
| | - Wim Tissing
- Princess Máxima Center for pediatric oncology , Utrecht , Netherlands
- Department of pediatric oncology/ hematology, university of Groningen, University Medical Center Groningen , Groningen , Netherlands
| | - Hanneke van Santen
- Princess Máxima Center for pediatric oncology , Utrecht , Netherlands
- Division of Pediatric Endocrinology, Wilhelmina Children’s Hospital, University Medical Center Utrecht , Utrecht , Netherlands
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10
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Nijstad AL, de Vos-Kerkhof E, Enters-Weijnen CF, van de Wetering MD, Tissing WJE, Hanff LM, Lange R, Tibben MM, Rosing H, Lalmohamed A, Zwaan CM, Huitema ADR. A simple extemporaneous oral suspension of aprepitant yields sufficient pharmacokinetic exposure in children. J Oncol Pharm Pract 2022:10781552221089243. [PMID: 35377726 DOI: 10.1177/10781552221089243] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Aprepitant is used for the treatment of chemotherapy induced nausea and vomiting. A liquid formulation is needed for treatment of young children. However, the commercial (powder for) suspension was not available worldwide for a prolonged period of time and, therefore, a 10 mg/mL aprepitant oral suspension was extemporarily prepared to prevent suboptimal antiemetic treatment. The current pharmacokinetic study was developed to investigate whether this extemporaneous oral suspension offers an appropriate treatment option. METHODS From 49 pediatric patients (0.7-17.9 years) 235 plasma concentrations were collected. Patients were either treated with our extemporaneous oral suspension (n = 26; 53%), commercially available capsules (n = 18; 37%), or the intravenous prodrug formulation of aprepitant (fosaprepitant, n = 5; 10%). Pharmacokinetic analyses were performed using nonlinear mixed effects modelling. RESULTS A one-compartment model adequately described the pharmacokinetics of aprepitant in children. The bioavailability of the extemporaneous oral suspension was not significantly different to that of the capsules (P = 0.26). The observed bioavailability throughout the total population was 83% (95% CI 69%-97%). The absorption of the extemporaneous oral suspension was 39.4% (95%CI 19.5-57.4%) faster than that of capsules (mean absorption time of 1.78 h (95%CI 1.32-2.35), but was comparable to that of the commercial oral suspension. The median area under the curve after (fos)aprepitant was 22.2 mg/L*h (range 8.9-50.3 mg/L*h) on day 1. CONCLUSION Our extemporaneous oral suspension is an adequate alternative for the commercially (un)available oral suspension in young children. An adequate exposure to aprepitant in children was yielded and the bioavailability of the extemporaneous suspension was comparable to capsules.
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Affiliation(s)
- A Laura Nijstad
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht, The Netherlands.,Department of Pharmacology, Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | | | - Catherine F Enters-Weijnen
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands.,Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Wim J E Tissing
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands.,Department of Pediatric Oncology and Hematology, University of Groningen, 10173University Medical Center Groningen, Groningen, The Netherlands
| | - Lidwien M Hanff
- Department of Pharmacy, Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Rogier Lange
- Department of Pharmacy, Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Matthijs M Tibben
- Department of Pharmacy & Pharmacology, 1228Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Hilde Rosing
- Department of Pharmacy & Pharmacology, 1228Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Arief Lalmohamed
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht, The Netherlands.,Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - C Michel Zwaan
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands.,Department of Pediatric Oncology, 97759Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Alwin D R Huitema
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht, The Netherlands.,Department of Pharmacology, Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands.,Department of Pharmacy & Pharmacology, 1228Netherlands Cancer Institute, Amsterdam, The Netherlands
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11
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Nijstad AL, Tibben MM, Gebretensae A, Rosing H, de Vos-Kerkhof E, Zwaan CM, Huitema ADR, Beijnen JH. Development and validation of a combined liquid chromatography tandem-mass spectrometry assay for the quantification of aprepitant and dexamethasone in human plasma to support pharmacokinetic studies in pediatric patients. J Chromatogr B Analyt Technol Biomed Life Sci 2021; 1171:122639. [PMID: 33756449 DOI: 10.1016/j.jchromb.2021.122639] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 02/25/2021] [Accepted: 02/27/2021] [Indexed: 11/29/2022]
Abstract
A pharmacokinetic study was set up to investigate the pharmacokinetics of the anti-emetic agents aprepitant and dexamethasone and the drug-drug interaction between these drugs in children. In order to quantify aprepitant and dexamethasone, a liquid chromatography-tandem mass spectrometry assay was developed and validated for the simultaneous analysis of aprepitant and dexamethasone. Protein precipitation with acetonitrile-methanol (1:1, v/v) was used to extract the analytes from plasma. The assay was based on reversed-phase chromatography coupled with tandem mass spectrometry detection operating in the positive ion mode. The assay was validated based on the guidelines on bioanalytical methods by the US Food and Drug Administration and European Medicines Agency. The calibration model was linear and a weighting factor of 1/concentration2 was used over the range of 0.1-50 ng/mL for aprepitant and 1-500 ng/mL for dexamethasone. Intra-assay and inter-assay bias were within ±20% for all analytes at the lower limit of quantification and within ±15% at remaining concentrations. Dilution integrity tests showed that samples exceeding the upper limit of quantification can be diluted 100 times in control matrix. Stability experiments showed that the compounds are stable in the biomatrix for 25 h at room temperatures and 89 days at -20 °C. This assay is considered suitable for pharmacokinetic studies and will be used to study the drug-drug interaction between aprepitant and dexamethasone in pediatric patients.
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Affiliation(s)
- A Laura Nijstad
- Department of Clinical Pharmacy, Division Laboratories, Pharmacy and Biomedical Genetics, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands.
| | - Matthijs M Tibben
- Department of Pharmacy & Pharmacology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, the Netherlands
| | - Abadi Gebretensae
- Department of Pharmacy & Pharmacology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, the Netherlands
| | - Hilde Rosing
- Department of Pharmacy & Pharmacology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, the Netherlands
| | - Evelien de Vos-Kerkhof
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS Utrecht, the Netherlands
| | - C Michel Zwaan
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS Utrecht, the Netherlands; Department of Pediatric Oncology, Erasmus MC-Sophia Children's Hospital, Dr. Molewaterplein 40, 3015 GD Rotterdam, the Netherlands
| | - Alwin D R Huitema
- Department of Clinical Pharmacy, Division Laboratories, Pharmacy and Biomedical Genetics, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands; Department of Pharmacy & Pharmacology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, the Netherlands; Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS Utrecht, the Netherlands
| | - Jos H Beijnen
- Department of Pharmacy & Pharmacology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, the Netherlands
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12
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Vos-Kerkhof ED, Gomez B, Milcent K, Steyerberg EW, Nijman RG, Smit FJ, Mintegi S, Moll HA, Gajdos V, Oostenbrink R. Clinical prediction models for young febrile infants at the emergency department: an international validation study. Arch Dis Child 2018; 103:1033-1041. [PMID: 29794106 DOI: 10.1136/archdischild-2017-314011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Revised: 03/28/2018] [Accepted: 04/10/2018] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To assess the diagnostic value of existing clinical prediction models (CPM; ie, statistically derived) in febrile young infants at risk for serious bacterial infections. METHODS A systematic literature review identified eight CPMs for predicting serious bacterial infections in febrile children. We validated these CPMs on four validation cohorts of febrile children in Spain (age <3 months), France (age <3 months) and two cohorts in the Netherlands (age 1-3 months and >3-12 months). We evaluated the performance of the CPMs by sensitivity/specificity, area under the receiver operating characteristic curve (AUC) and calibration studies. RESULTS The original cohorts in which the prediction rules were developed (derivation cohorts) ranged from 381 to 15 781 children, with a prevalence of serious bacterial infections varying from 0.8% to 27% and spanned an age range of 0-16 years. All CPMs originally performed moderately to very well (AUC 0.60-0.93). The four validation cohorts included 159-2204 febrile children, with a median age range of 1.8 (1.2-2.4) months for the three cohorts <3 months and 8.4 (6.0-9.6) months for the cohort >3-12 months of age. The prevalence of serious bacterial infections varied between 15.1% and 17.2% in the three cohorts <3 months and was 9.8% for the cohort >3-12 months of age. Although discriminative values varied greatly, best performance was observed for four CPMs including clinical signs and symptoms, urine dipstick analyses and laboratory markers with AUC ranging from 0.68 to 0.94 in the three cohorts <3 months (ranges sensitivity: 0.48-0.94 and specificity: 0.71-0.97). For the >3-12 months' cohort AUC ranges from 0.80 to 0.89 (ranges sensitivity: 0.70-0.82 and specificity: 0.78-0.90). In general, the specificities exceeded sensitivities in our cohorts, in contrast to derivation cohorts with high sensitivities, although this effect was stronger in infants <3 months than in infants >3-12 months. CONCLUSION We identified four CPMs, including clinical signs and symptoms, urine dipstick analysis and laboratory markers, which can aid clinicians in identifying serious bacterial infections. We suggest clinicians should use CPMs as an adjunctive clinical tool when assessing the risk of serious bacterial infections in febrile young infants.
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Affiliation(s)
- Evelien de Vos-Kerkhof
- Department of General Paediatrics, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Borja Gomez
- Paediatric Emergency Department, Cruces University Hospital, Bilbao, Spain.,University of the Basque Country, Bilbao, Spain
| | - Karen Milcent
- AP-HP Department of Paediatrics, Hôpitaux Universitaires Paris Sud-Antoine Béclère, Clamart, France
| | - Ewout W Steyerberg
- Department of Public Health and Clinical Decision Making, Erasmus MC-University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Ruud Gerard Nijman
- Department of Paediatric Accident and Emergency, St Mary's Hospital, Imperial College-NHS Healthcare Trust, Rotterdam, The Netherlands
| | - Frank J Smit
- Department of General Paediatrics, Maasstad Hospital, Rotterdam, The Netherlands
| | - Santiago Mintegi
- Paediatric Emergency Department, Cruces University Hospital, Bilbao, Spain.,University of the Basque Country, Bilbao, Spain
| | - Henriette A Moll
- Department of General Paediatrics, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Vincent Gajdos
- Université Paris-Saclay, Université Paris-Sud, UVSQ, CESP, INSERM, Villejuif, France
| | - Rianne Oostenbrink
- Department of General Paediatrics, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
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13
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de Vos-Kerkhof E, Geurts DHF, Steyerberg EW, Lakhanpaul M, Moll HA, Oostenbrink R. Characteristics of revisits of children at risk for serious infections in pediatric emergency care. Eur J Pediatr 2018; 177:617-624. [PMID: 29397418 PMCID: PMC5851682 DOI: 10.1007/s00431-018-3095-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Revised: 12/14/2017] [Accepted: 01/17/2018] [Indexed: 01/27/2023]
Abstract
UNLABELLED In this study, we aimed to identify characteristics of (unscheduled) revisits and its optimal time frame after Emergency Department (ED) discharge. Children with fever, dyspnea, or vomiting/diarrhea (1 month-16 years) who attended the ED of Erasmus MC-Sophia, Rotterdam (2010-2013), the Netherlands, were prospectively included. Three days after ED discharge, we applied standardized telephonic questionnaires on disease course and revisits. Multivariable logistic regression analysis was used to identify independent characteristics of revisits. Young age, parental concern, and alarming signs and symptoms (chest wall retractions, ill appearance, clinical signs of dehydration, and tachypnea) were associated with revisits (n = 527) in children at risk for serious infections discharged from the ED (n = 1765). Children revisited the ED within a median of 2 days (IQR 1.0-3.0), but this was proven to be shorter in children with vomiting/diarrhea (1.0 day (IQR 1.0-2.0)) compared to children with fever or dyspnea (2.0 (IQR 1.0-3.0)). CONCLUSION Young age, parental concern, and alarming signs and symptoms (chest wall retractions, ill appearance, clinical signs of dehydration, and tachypnea) were associated with emergency health care revisits in children with fever, dyspnea, and vomiting/diarrhea. These characteristics could help to define targeted review of children during post-discharge period. We observed a disease specific and differential timing of control revisits after ED discharge. What is Known • Fever, dyspnea, and vomiting/diarrhea are major causes of emergency care attendance in children. • As uncertainty remains on uneventful recovery, patients at risk need to be identified on order to improve safety netting after discharge from the ED. What is New • In children with fever, dyspnea, and vomiting/diarrhea, young age, parental concern and chest wall retractions, ill appearance, clinical signs of dehydration, and tachypnea help to define targeted review of children during the post-discharge period. • A revisit after ED discharge is disease-specific and seems to be shorter for children with vomiting/diarrhea than others.
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Affiliation(s)
- Evelien de Vos-Kerkhof
- grid.416135.4Department of General Paediatrics, Erasmus MC-Sophia Children’s Hospital, Wytemaweg 80, 3015 Rotterdam, CN Netherlands
| | - Dorien H. F. Geurts
- grid.416135.4Department of General Paediatrics, Erasmus MC-Sophia Children’s Hospital, Wytemaweg 80, 3015 Rotterdam, CN Netherlands
| | - Ewout W. Steyerberg
- 000000040459992Xgrid.5645.2Department of Public Health, Erasmus MC - University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Monica Lakhanpaul
- 0000000121901201grid.83440.3bDepartment of Population, Policy and Practice UCL Great Ormond Street Institute of Child Health, Great Ormond Street, London, UK
| | - Henriette A. Moll
- grid.416135.4Department of General Paediatrics, Erasmus MC-Sophia Children’s Hospital, Wytemaweg 80, 3015 Rotterdam, CN Netherlands
| | - Rianne Oostenbrink
- grid.416135.4Department of General Paediatrics, Erasmus MC-Sophia Children’s Hospital, Wytemaweg 80, 3015 Rotterdam, CN Netherlands
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14
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Zachariasse JM, van der Lee D, Seiger N, de Vos-Kerkhof E, Oostenbrink R, Moll HA. The role of nurses' clinical impression in the first assessment of children at the emergency department. Arch Dis Child 2017; 102:1052-1056. [PMID: 28601795 DOI: 10.1136/archdischild-2017-312860] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 04/06/2017] [Accepted: 04/30/2017] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To assess the diagnostic value and determinants of nurses' clinical impression for the recognition of children with a serious illness on presentation to the emergency department (ED). DESIGN Secondary analysis of a prospective cohort. SETTING AND PATIENTS 6390 consecutive children <16 years of age presenting to a paediatric ED with a non-surgical chief complaint and complete data available. MAIN OUTCOME MEASURES Diagnostic accuracy of nurses' clinical impression for the prediction of serious illness, defined by intensive care unit (ICU) and hospital admission. Determinants of nurses' impression that a child appeared ill. RESULTS Nurses considered a total of 1279 (20.0%) children appearing ill. Sensitivity of nurses' clinical impression for the recognition of patients requiring ICU admission was 0.70 (95% CI 0.62 to 0.76) and specificity was 0.81 (95% CI 0.80 to 0.82). Sensitivity for hospital admission was 0.48 (95% CI 0.45 to 0.51) and specificity was 0.88 (95% CI 0.87 to 0.88). When adjusted for age, gender, triage urgency and abnormal vital signs, nurses' impression remained significantly associated with ICU (OR 4.54; 95% CI 3.09 to 6.66) and hospital admission (OR 4.00; 95% CI 3.40 to 4.69). Ill appearance was positively associated with triage urgency, fever and abnormal vital signs and negatively with self-referral and presentation outside of office hours. CONCLUSION The overall clinical impression of experienced nurses at the ED is on its own, not an accurate predictor of serious illness in children, but provides additional information above some well-established and objective predictors of illness severity.
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Affiliation(s)
- Joany M Zachariasse
- Department of General Paediatrics, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Dominique van der Lee
- Department of General Paediatrics, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Nienke Seiger
- Department of General Paediatrics, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Evelien de Vos-Kerkhof
- Department of General Paediatrics, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Rianne Oostenbrink
- Department of General Paediatrics, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Henriëtte A Moll
- Department of General Paediatrics, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
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15
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de Vos-Kerkhof E, Krecinic T, Vergouwe Y, Moll HA, Nijman RG, Oostenbrink R. Comparison of peripheral and central capillary refill time in febrile children presenting to a paediatric emergency department and its utility in identifying children with serious bacterial infection. Arch Dis Child 2017; 102:17-21. [PMID: 27339165 DOI: 10.1136/archdischild-2015-308519] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Revised: 05/05/2016] [Accepted: 06/03/2016] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To determine the agreement between peripheral and central capillary refill time (pCRT/cCRT) and their diagnostic values for detecting serious bacterial infection (SBI) in febrile children attending the paediatric emergency department (ED). DESIGN Prospective observational study. SETTING Paediatric ED, Erasmus Medium Care-Sophia Children's hospital, the Netherlands. PATIENTS 1193 consecutively included, previously healthy, febrile children (1 month-16 years) with both pCRT measurements and cCRT measurements available. SBI diagnosis was based on abnormal radiographic findings and/or positive cultures from normally sterile locations in addition to clinical criteria. MAIN OUTCOME MEASURES Agreement between pCRT and cCRT (Cohen's κ), overall and stratified for age and body temperature. The diagnostic value of pCRT and cCRT for SBI was assessed with logistic regression. RESULTS Overall agreement was 0.35 (95% CI 0.27 to 0.43; considered 'fair'). Although not significant, agreement was lower in children aged 1-<5 years (κ: 0.15 (95% CI 0.04 to 0.27)) and decreased with higher body temperatures with κ ranging from 0.55 (95% CI 0.32 to 0.79) for temperature <37.5°C to 0.21 (95% CI 0.07 to 0.34) for temperature >39.5°C. Abnormal pCRT (>2 s) was observed in 153 (12.8%; 95% CI 10.9% to 14.7%) and abnormal cCRT in 55 (4.6%; 95% CI 3.4% to 5.8%) children. The OR of abnormal pCRT (>2 s) for predicting SBI was 1.10 (95% CI 0.65 to 1.84). For abnormal cCRT (>2 s), the OR was 0.43 (95% CI 0.13 to 1.39). CONCLUSIONS The pCRT and cCRT values showed only fair agreement in a general population of febrile children at the ED, and no significant association with age or body temperature was found. Only a small part of febrile children at risk for serious infections at the ED show abnormal CRT values. Both abnormal pCRT and cCRT (defined as >2 s) performed poorly and were non-significant in this study detecting SBI in a general population of febrile children.
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Affiliation(s)
- Evelien de Vos-Kerkhof
- Department of General Paediatrics, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Tarik Krecinic
- Department of General Paediatrics, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Yvonne Vergouwe
- Department of Public Health, Centre for Medical Decision Making, Erasmus MC, Rotterdam, The Netherlands
| | - Henriëtte A Moll
- Department of General Paediatrics, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Ruud G Nijman
- Department of General Paediatrics, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Rianne Oostenbrink
- Department of General Paediatrics, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
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Geurts D, de Vos-Kerkhof E, Polinder S, Steyerberg E, van der Lei J, Moll H, Oostenbrink R. Implementation of clinical decision support in young children with acute gastroenteritis: a randomized controlled trial at the emergency department. Eur J Pediatr 2017; 176:173-181. [PMID: 27933399 PMCID: PMC5243872 DOI: 10.1007/s00431-016-2819-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Revised: 11/14/2016] [Accepted: 11/21/2016] [Indexed: 11/26/2022]
Abstract
UNLABELLED Acute gastroenteritis (AGE) is one of the most frequent reasons for young children to visit emergency departments (EDs). We aimed to evaluate (1) feasibility of a nurse-guided clinical decision support system for rehydration treatment in children with AGE and (2) the impact on diagnostics, treatment, and costs compared with usual care by attending physician. A randomized controlled trial was performed in 222 children, aged 1 month to 5 years at the ED of the Erasmus MC-Sophia Children's hospital in The Netherlands ( 2010-2012). Outcome included (1) feasibility, measured by compliance of the nurses, and (2) length of stay (LOS) at the ED, the number of diagnostic tests, treatment, follow-up, and costs. Due to failure of post-ED weight measurement, we could not evaluate weight difference as measure for dehydration. Patient characteristics were comparable between the intervention (N = 113) and the usual care group (N = 109). Implementation of the clinical decision support system proved a high compliance rate. The standardized use of oral ORS (oral rehydration solution) significantly increased from 52 to 65%(RR2.2, 95%CI 1.09-4.31 p < 0.05). We observed no differences in other outcome measures. CONCLUSION Implementation of nurse-guided clinical decision support system on rehydration treatment in children with AGE showed high compliance and increase standardized use of ORS, without differences in other outcome measures. What is Known: • Acute gastroenteritis is one of the most frequently encountered problems in pediatric emergency departments. • Guidelines advocate standardized oral treatment in children with mild to moderate dehydration, but appear to be applied infrequently in clinical practice. What is New: • Implementation of a nurse-guided clinical decision support system on treatment of AGE in young children showed good feasibility, resulting in a more standardized ORS use in children with mild to moderate dehydration, compared to usual care. • Given the challenges to perform research in emergency care setting, the ED should be experienced and adequately equipped, especially during peak times.
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Affiliation(s)
- Dorien Geurts
- Department of Pediatrics, Erasmus MC - Sophia children's hospital, Wytemaweg 80, Rotterdam, CN, 3015, The Netherlands.
| | - Evelien de Vos-Kerkhof
- Department of Pediatrics, Erasmus MC - Sophia children's hospital, Wytemaweg 80, Rotterdam, CN, 3015, The Netherlands
| | - Suzanne Polinder
- Department of Public Health, Erasmus MC, Rotterdam, The Netherlands
| | - Ewout Steyerberg
- Department of Public Health, Erasmus MC, Rotterdam, The Netherlands
| | - Johan van der Lei
- Department of Medical Informatics, Erasmus MC, Rotterdam, The Netherlands
| | - Henriëtte Moll
- Department of Pediatrics, Erasmus MC - Sophia children's hospital, Wytemaweg 80, Rotterdam, CN, 3015, The Netherlands
| | - Rianne Oostenbrink
- Department of Pediatrics, Erasmus MC - Sophia children's hospital, Wytemaweg 80, Rotterdam, CN, 3015, The Netherlands
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de Vos-Kerkhof E, Geurts DHF, Wiggers M, Moll HA, Oostenbrink R. Tools for 'safety netting' in common paediatric illnesses: a systematic review in emergency care. Arch Dis Child 2016; 101:131-9. [PMID: 26163122 DOI: 10.1136/archdischild-2014-306953] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2014] [Accepted: 06/17/2015] [Indexed: 11/04/2022]
Abstract
CONTEXT Follow-up strategies after emergency department (ED) discharge, alias safety netting, is often based on the gut feeling of the attending physician. OBJECTIVE To systematically identify evaluated safety-netting strategies after ED discharge and to describe determinants of paediatric ED revisits. DATA SOURCES MEDLINE, Embase, CINAHL, Cochrane central, OvidSP, Web of Science, Google Scholar, PubMed. STUDY SELECTION Studies of any design reporting on safety netting/follow-up after ED discharge and/or determinants of ED revisits for the total paediatric population or specifically for children with fever, dyspnoea and/or gastroenteritis. Outcomes included complicated course of disease after initial ED visit (eg, revisits, hospitalisation). DATA EXTRACTION Two reviewers independently assessed studies for eligibility and study quality. As meta-analysis was not possible due to heterogeneity of studies, we performed a narrative synthesis of study results. A best-evidence synthesis was used to identify the level of evidence. RESULTS We summarised 58 studies, 36% (21/58) were assessed as having low risk of bias. Limited evidence was observed for different strategies of safety netting, with educational interventions being mostly studied. Young children, a relevant medical history, infectious/respiratory symptoms or seizures and progression/persistence of symptoms were strongly associated with ED revisits. Gender, emergency crowding, physicians' characteristics and diagnostic tests and/or therapeutic interventions at the index visit were not associated with revisits. CONCLUSIONS Within the heterogeneous available evidence, we identified a set of strong determinants of revisits that identify high-risk groups in need for safety netting in paediatric emergency care being related to age and clinical symptoms. Gaps remain on intervention studies concerning specific application of a uniform safety-netting strategy and its included time frame.
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Affiliation(s)
- Evelien de Vos-Kerkhof
- Department of General Paediatrics, ErasmusMC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Dorien H F Geurts
- Department of General Paediatrics, ErasmusMC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | | | - Henriette A Moll
- Department of General Paediatrics, ErasmusMC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Rianne Oostenbrink
- Department of General Paediatrics, ErasmusMC-Sophia Children's Hospital, Rotterdam, The Netherlands
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de Vos-Kerkhof E, Nijman RG, Vergouwe Y, Polinder S, Steyerberg EW, van der Lei J, Moll HA, Oostenbrink R. Impact of a clinical decision model for febrile children at risk for serious bacterial infections at the emergency department: a randomized controlled trial. PLoS One 2015; 10:e0127620. [PMID: 26024532 PMCID: PMC4449197 DOI: 10.1371/journal.pone.0127620] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Accepted: 04/04/2015] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To assess the impact of a clinical decision model for febrile children at risk for serious bacterial infections (SBI) attending the emergency department (ED). METHODS Randomized controlled trial with 439 febrile children, aged 1 month-16 years, attending the pediatric ED of a Dutch university hospital during 2010-2012. Febrile children were randomly assigned to the intervention (clinical decision model; n = 219) or the control group (usual care; n = 220). The clinical decision model included clinical symptoms, vital signs, and C-reactive protein and provided high/low-risks for "pneumonia" and "other SBI". Nurses were guided by the intervention to initiate additional tests for high-risk children. The clinical decision model was evaluated by 1) area-under-the-receiver-operating-characteristic-curve (AUC) to indicate discriminative ability and 2) feasibility, to measure nurses' compliance to model recommendations. Primary patient outcome was defined as correct SBI diagnoses. Secondary process outcomes were defined as length of stay; diagnostic tests; antibiotic treatment; hospital admission; revisits and medical costs. RESULTS The decision model had good discriminative ability for both pneumonia (n = 33; AUC 0.83 (95% CI 0.75-0.90)) and other SBI (n = 22; AUC 0.81 (95% CI 0.72-0.90)). Compliance to model recommendations was high (86%). No differences in correct SBI determination were observed. Application of the clinical decision model resulted in less full-blood-counts (14% vs. 22%, p-value < 0.05) and more urine-dipstick testing (71% vs. 61%, p-value < 0.05). CONCLUSIONS In contrast to our expectations no substantial impact on patient outcome was perceived. The clinical decision model preserved, however, good discriminatory ability to detect SBI, achieved good compliance among nurses and resulted in a more standardized diagnostic approach towards febrile children, with less full blood-counts and more rightfully urine-dipstick testing. TRIAL REGISTRATION Nederlands Trial Register NTR2381.
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Affiliation(s)
- Evelien de Vos-Kerkhof
- Department of general pediatrics, ErasmusMC-Sophia Children’s Hospital, Rotterdam, the Netherlands
| | - Ruud G. Nijman
- Department of general pediatrics, ErasmusMC-Sophia Children’s Hospital, Rotterdam, the Netherlands
| | - Yvonne Vergouwe
- Department of Public Health, Center for Medical Decision Making, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Suzanne Polinder
- Department of Public Health, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Ewout W. Steyerberg
- Department of Public Health, Center for Medical Decision Making, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Johan van der Lei
- Department of Medical Informatics, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Henriëtte A. Moll
- Department of general pediatrics, ErasmusMC-Sophia Children’s Hospital, Rotterdam, the Netherlands
| | - Rianne Oostenbrink
- Department of general pediatrics, ErasmusMC-Sophia Children’s Hospital, Rotterdam, the Netherlands
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de Vos-Kerkhof E, Nijman RG, Vergouwe Y, Polinder S, Steyerberg EW, van der Lei J, Moll HA, Oostenbrink R. [Impact of a clinical decision model for febrile children at risk for serious bacterial infections at the emergency department: a randomized controlled trial]. Ned Tijdschr Geneeskd 2015; 159:A9552. [PMID: 26507069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
OBJECTIVE To assess the impact of a clinical decision model for febrile children at risk for serious bacterial infections (SBI) attending the emergency department (ED). METHOD Randomized controlled trial with 439 febrile children, aged 1 month-16 years, attending the pediatric ED of a Dutch university hospital during 2010-2012. Febrile children were randomly assigned to the intervention (clinical decision model; n=219) or the control group (usual care; n=220). The clinical decision model included clinical symptoms, vital signs, and C-reactive protein and provided high/low-risks for "pneumonia" and "other SBI". Nurses were guided by the intervention to initiate additional tests for high-risk children. Primary patient outcome was defined as correct SBI diagnoses. Secondary process outcomes were defined as length of stay; diagnostic tests; antibiotic treatment; hospital admission; revisits and medical costs. RESULTS The decision model had good discriminative ability for both pneumonia (n=33; AUC 0.83 (95% CI 0.75-0.90)) and other SBI (n=22; AUC 0.81 (95% CI 0.72-0.90)). Compliance to model recommendations was high (86%). No differences in correct SBI determination was observed. Application of the clinical decision model resulted in less full-blood-counts (14% vs. 22%, p-value<0.05) and more urine-dipstick testing (71% vs. 61%, p-value<0.05). CONCLUSION In contrast to our expectations no substantial impact on patient outcome was perceived. The clinical decision model preserved however, good discriminatory ability to detect SBI, achieved good compliance among nurses and resulted in a more standardized diagnostic approach towards febrile children, with less full blood-counts and more rightfully urine-dipstick testing. Trial registration: Trialregister.nl: NTR2381.
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Affiliation(s)
- Evelien de Vos-Kerkhof
- *Dit onderzoek werd eerder gepubliceerd in PLOS ONE (2015;10:e0127620) met als titel 'Impact of a clinical decision model for febrile children at risk for serious bacterial infections at the emergency department: a randomized controlled trial'. Afgedrukt met toestemming
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