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Mustafa RA, Garcia CAC, Bhatt M, Riva JJ, Vesely S, Wiercioch W, Nieuwlaat R, Patel P, Hanson S, Newall F, Wiernikowski J, Monagle P, Schünemann HJ. GRADE notes: How to use GRADE when there is "no" evidence? A case study of the expert evidence approach. J Clin Epidemiol 2021; 137:231-235. [PMID: 33675954 DOI: 10.1016/j.jclinepi.2021.02.026] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [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: 10/23/2020] [Revised: 02/07/2021] [Accepted: 02/26/2021] [Indexed: 01/25/2023]
Abstract
OBJECTIVES One essential requirement of trustworthy guidelines is that they should be based on systematic reviews of the best available evidence. The GRADE Working Group has provided guidance for evaluating the certainty of evidence based on several domains. However, for many clinical questions, published evidence may be limited, too indirect or simply not exist. In this brief report (GRADE notes), we describe our method of developing evidence-based recommendations when publisheddirect evidence was lacking. STUDY DESIGN AND SETTING When direct published literature was absent, an expert evidence survey was administered to panel members about their unpublished observations and case series. Focus was on collecting data about cases and outcome, not panel opinions. RESULTS Out of 26 questions prioritized by the panel for pediatric venous thromboembolism, 12 had no, very limited, or very low certainty of evidence to inform them. The panel survey was administered for these questions. CONCLUSIONS Areas of sparse evidence often reflect key questions that are critical to address in clinical practice guidelines due to the uncertainty among health care providers. The expert evidence approach used in this study is one method for panels totransparently deal with the lack of published evidence to directly inform recommendations.
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Affiliation(s)
- Reem A Mustafa
- Department of Medicine, Division of Nephrology and Hypertension, University of Kansas Medical Center, 3901 Rainbow Blvd, MS3002, Kansas City, KS 66160, USA; Department of Health Research Methods, Evidence and Impact, McMaster University, 1280 Main St West, Hamilton, ON L8S 4L8, Canada.
| | - Carlos A Cuello Garcia
- Department of Health Research Methods, Evidence and Impact, McMaster University, 1280 Main St West, Hamilton, ON L8S 4L8, Canada; Departments of Pediatrics and Critical Care, McMaster University, Hamilton, ON L8S 4L8, Canada
| | - Meha Bhatt
- Department of Health Research Methods, Evidence and Impact, McMaster University, 1280 Main St West, Hamilton, ON L8S 4L8, Canada
| | - John J Riva
- Department of Health Research Methods, Evidence and Impact, McMaster University, 1280 Main St West, Hamilton, ON L8S 4L8, Canada; Department of Family Medicine, McMaster University, David Braley Health Sciences Centre, 100 Main Street West, 6th Floor, Hamilton, ON L8P 1H6, Canada
| | - Sara Vesely
- Department of Biostatistics and Epidemiology, Hudson College of Public Health, University of Oklahoma Health Sciences Center, 801 NE 13th, Oklahoma City, OK 73104, USA
| | - Wojtek Wiercioch
- Department of Health Research Methods, Evidence and Impact, McMaster University, 1280 Main St West, Hamilton, ON L8S 4L8, Canada
| | - Robby Nieuwlaat
- Department of Health Research Methods, Evidence and Impact, McMaster University, 1280 Main St West, Hamilton, ON L8S 4L8, Canada
| | - Payal Patel
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, Emory University, Atlanta, GA 30322, USA
| | - Sheila Hanson
- Department of Pediatrics, Medical College of Wisconsin and Critical Care Section, Children's Hospital of Wisconsin, Milwaukee, WI
| | - Fiona Newall
- Department of Nursing Research, Royal Children's Hospital, University of Melbourne, Murdoch Children's Research Institute, Melbourne, VIC, Australia; Department of Clinical Haematology, Royal Children's Hospital, University of Melbourne, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - John Wiernikowski
- Division of Hematology/Oncology, Department of Pediatrics, McMaster Children's Hospital, McMaster University, Hamilton, ON, Canada
| | - Paul Monagle
- Department of Clinical Haematology, Royal Children's Hospital, University of Melbourne, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Holger J Schünemann
- Department of Health Research Methods, Evidence and Impact, McMaster University, 1280 Main St West, Hamilton, ON L8S 4L8, Canada
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Polito S, MacDonald T, Romanick M, Jupp J, Wiernikowski J, Vennettilli A, Khanna M, Patel P, Ning W, Sung L, Dupuis LL. Safety and efficacy of nabilone for acute chemotherapy-induced vomiting prophylaxis in pediatric patients: A multicenter, retrospective review. Pediatr Blood Cancer 2018; 65:e27374. [PMID: 30051617 DOI: 10.1002/pbc.27374] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [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: 05/30/2018] [Revised: 06/29/2018] [Accepted: 07/05/2018] [Indexed: 11/10/2022]
Abstract
OBJECTIVES To describe the safety and efficacy of nabilone given to pediatric patients to prevent acute chemotherapy-induced nausea and vomiting (CINV). METHODS A multicenter, retrospective review of pediatric patients who received nabilone for acute CINV prophylaxis between December 1, 2010 and August 1, 2015 was undertaken. One course of nabilone was evaluated per patient. Adverse effects associated with nabilone use were noted. The proportion of patients who experienced complete acute chemotherapy-induced vomiting (CIV) control during the acute phase was determined. The acute phase was defined as starting with the first chemotherapy dose and continuing until 24 h after administration of the last chemotherapy dose of the chemotherapy block. RESULTS One hundred ten eligible patients (median age: 14.0 years, range: 1.1-18.0 years; 65 male) were identified. Most (109/110) received nabilone plus a 5-HT3 antagonist for CINV prophylaxis. Adverse effects associated with nabilone were experienced by 34% (37/110) of children. All were of CTCAE Version 4.03 Grade 2 or less. Sedation (20.0%), dizziness (10.0%), and euphoria (3.6%) were the most commonly reported adverse events. Nabilone was discontinued in 10 patients due to an adverse event. The proportions of patients receiving highly or moderately emetogenic chemotherapy who experienced complete acute CIV control were 50.6% (42/83) and 53.8% (14/26), respectively. CONCLUSION Adverse events associated with nabilone were common but of minor clinical significance. Acute CIV control in children receiving nabilone as a part of their antiemetic regimen was poor. Future work should focus on implementation of guideline-consistent CINV prophylaxis and treatment.
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Affiliation(s)
- Samantha Polito
- Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Tamara MacDonald
- Department of Pharmacy, IWK Health Centre, Halifax, Nova Scotia, Canada.,College of Pharmacy, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Marcel Romanick
- Pharmacy Services, Alberta Health Services, Edmonton, Alberta, Canada.,Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Jennifer Jupp
- Pharmacy Services, Alberta Health Services, Edmonton, Alberta, Canada.,Alberta Children's Hospital, Calgary, Alberta, Canada
| | - John Wiernikowski
- Department of Paediatrics, Faculty of Health Sciences, McMaster Children's Hospital, McMaster University, Hamilton, Ontario, Canada
| | - Ashlee Vennettilli
- Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Mila Khanna
- Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Priya Patel
- Department of Pharmacy, The Hospital for Sick Children, Toronto, Ontario, Canada.,Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Winnie Ning
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Lillian Sung
- Research Institute and Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada.,Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - L Lee Dupuis
- Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Pharmacy, The Hospital for Sick Children, Toronto, Ontario, Canada.,Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
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Monagle P, Cuello CA, Augustine C, Bonduel M, Brandão LR, Capman T, Chan AKC, Hanson S, Male C, Meerpohl J, Newall F, O'Brien SH, Raffini L, van Ommen H, Wiernikowski J, Williams S, Bhatt M, Riva JJ, Roldan Y, Schwab N, Mustafa RA, Vesely SK. American Society of Hematology 2018 Guidelines for management of venous thromboembolism: treatment of pediatric venous thromboembolism. Blood Adv 2018; 2:3292-3316. [PMID: 30482766 PMCID: PMC6258911 DOI: 10.1182/bloodadvances.2018024786] [Citation(s) in RCA: 216] [Impact Index Per Article: 36.0] [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: 08/19/2018] [Accepted: 09/24/2018] [Indexed: 10/27/2022] Open
Abstract
BACKGROUND Despite an increasing incidence of venous thromboembolism (VTE) in pediatric patients in tertiary care settings, relatively few pediatric physicians have experience with antithrombotic interventions. OBJECTIVE These guidelines of the American Society of Hematology (ASH), based on the best available evidence, are intended to support patients, clinicians, and other health care professionals in their decisions about management of pediatric VTE. METHODS ASH formed a multidisciplinary guideline panel that included 2 patient representatives and was balanced to minimize potential bias from conflicts of interest. The McMaster University GRADE Centre supported the guideline-development process, including updating or performing systematic evidence reviews (up to April of 2017). The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients. The panel used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach, including GRADE Evidence-to-Decision frameworks, to assess evidence and make recommendations, which were subject to public comment. RESULTS The panel agreed on 30 recommendations, covering symptomatic and asymptomatic deep vein thrombosis, with specific focus on management of central venous access device-associated VTE. The panel also addressed renal and portal vein thrombosis, cerebral sino venous thrombosis, and homozygous protein C deficiency. CONCLUSIONS Although the panel offered many recommendations, additional research is required. Priorities include understanding the natural history of asymptomatic thrombosis, determining subgroup boundaries that enable risk stratification of children for escalation of treatment, and appropriate study of newer anticoagulant agents in children.
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Affiliation(s)
- Paul Monagle
- Department of Clinical Haematology, Royal Children's Hospital, University of Melbourne and Murdoch Children's Research Institute, VIC, Australia
| | - Carlos A Cuello
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Tecnologico de Monterrey School of Medicine, Monterrey, Mexico
| | | | - Mariana Bonduel
- Department of Hematology/Oncology, Hospital de Pediatria "Prof. Dr. Juan P. Garrahan," Buenos Aires, Argentina
| | - Leonardo R Brandão
- Division of Haematology/Oncology, Department of Pediatrics, The Hospital for Sick Children, Toronto, ON, Canada
| | | | - Anthony K C Chan
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Sheila Hanson
- Department of Pediatrics, Medical College of Wisconsin and Critical Care Section, Children's Hospital of Wisconsin, Milwaukee, WI
| | - Christoph Male
- Department of Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Joerg Meerpohl
- Department of Medical Biometry and Statistics, Institute of Medical Biometry and Medical Informatics, University of Freiburg and University Medical Center Freiburg, Freiburg, Germany
| | - Fiona Newall
- Department of Clinical Haematology and
- Department of Nursing Research, Royal Children's Hospital, University of Melbourne, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Sarah H O'Brien
- Division of Pediatric Hematology/Oncology, Nationwide Children's Hospital, The Ohio State University, Columbus, OH
| | - Leslie Raffini
- Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Heleen van Ommen
- Department of Pediatric Hematology, Sophia Children's Hospital Erasmus MC, Rotterdam, The Netherlands
| | - John Wiernikowski
- Division of Hematology/Oncology, Department of Pediatrics, McMaster Children's Hospital, McMaster University, Hamilton, ON, Canada
| | - Suzan Williams
- Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Meha Bhatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - John J Riva
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Family Medicine, McMaster University, Hamilton, ON, Canada
| | - Yetiani Roldan
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Nicole Schwab
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Reem A Mustafa
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Division of Nephrology and Hypertension, Department of Medicine, University of Kansas Medical Center, Kansas City, KS; and
| | - Sara K Vesely
- Department of Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK
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Alexander S, Fisher BT, Gaur AH, Dvorak CC, Villa Luna D, Dang H, Chen L, Green M, Nieder ML, Fisher B, Bailey LC, Wiernikowski J, Sung L. Effect of Levofloxacin Prophylaxis on Bacteremia in Children With Acute Leukemia or Undergoing Hematopoietic Stem Cell Transplantation: A Randomized Clinical Trial. JAMA 2018; 320:995-1004. [PMID: 30208456 PMCID: PMC6143098 DOI: 10.1001/jama.2018.12512] [Citation(s) in RCA: 119] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Accepted: 08/03/2018] [Indexed: 11/14/2022]
Abstract
Importance Bacteremia causes considerable morbidity among children with acute leukemia and those undergoing hematopoietic stem cell transplantation (HSCT). There are limited data on the effect of antibiotic prophylaxis in children. Objective To determine the efficacy and risks of levofloxacin prophylaxis in children receiving intensive chemotherapy for acute leukemia or undergoing HSCT. Design, Setting, and Participants In this multicenter, open-label, randomized trial, patients (6 months-21 years) receiving intensive chemotherapy were enrolled (September 2011-April 2016) in 2 separate groups-acute leukemia, consisting of acute myeloid leukemia or relapsed acute lymphoblastic leukemia, and HSCT recipients-at 76 centers in the United States and Canada, with follow-up completed September 2017. Interventions Patients with acute leukemia were randomized to receive levofloxacin prophylaxis for 2 consecutive cycles of chemotherapy (n = 100) or no prophylaxis (n = 100). Those undergoing HSCT were randomized to receive levofloxacin prophylaxis during 1 HSCT procedure (n = 210) or no prophylaxis (n = 214). Main Outcomes and Measures The primary outcome was the occurrence of bacteremia during 2 chemotherapy cycles (acute leukemia) or 1 transplant procedure (HSCT). Secondary outcomes included fever and neutropenia, severe infection, invasive fungal disease, Clostridium difficile-associated diarrhea, and musculoskeletal toxic effects. Results A total of 624 patients, 200 with acute leukemia (median [interquartile range {IQR}] age, 11 years [6-15 years]; 46% female) and 424 undergoing HSCT (median [IQR] age, 7 years [3-14]; 38% female), were enrolled. Among 195 patients with acute leukemia, the likelihood of bacteremia was significantly lower in the levofloxacin prophylaxis group than in the control group (21.9% vs 43.4%; risk difference, 21.6%; 95% CI, 8.8%-34.4%, P = .001), whereas among 418 patients undergoing HSCT, the risk of bacteremia was not significantly lower in the levofloxacin prophylaxis group (11.0% vs 17.3%; risk difference, 6.3%; 95% CI, 0.3%-13.0%; P = .06). Fever and neutropenia were less common in the levofloxacin group (71.2% vs 82.1%; risk difference, 10.8%; 95% CI, 4.2%-17.5%; P = .002). There were no significant differences in severe infection (3.6% vs 5.9%; risk difference, 2.3%; 95% CI, -1.1% to 5.6%; P = .20), invasive fungal disease (2.9% vs 2.0%; risk difference, -1.0%; 95% CI, -3.4% to 1.5%, P = .41), C difficile-associated diarrhea (2.3% vs 5.2%; risk difference, 2.9%; 95% CI, -0.1% to 5.9%; P = .07), or musculoskeletal toxic effects at 2 months (11.4% vs 16.3%; risk difference, 4.8%; 95% CI, -1.6% to 11.2%; P = .15) or at 12 months (10.1% vs 14.4%; risk difference, 4.3%; 95% CI, -3.4% to 12.0%; P = .28) between the levofloxacin and control groups. Conclusions and Relevance Among children with acute leukemia receiving intensive chemotherapy, receipt of levofloxacin prophylaxis compared with no prophylaxis resulted in a significant reduction in bacteremia. However, there was no significant reduction in bacteremia for levofloxacin prophylaxis among children undergoing HSCT.
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Affiliation(s)
| | - Brian T. Fisher
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Aditya H. Gaur
- St Jude Children's Research Hospital, Memphis, Tennessee
| | | | | | - Ha Dang
- University of Southern California, Los Angeles, California
| | - Lu Chen
- City of Hope, Duarte, California
| | - Michael Green
- Children’s Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburg, Pennsylvania
| | | | - Beth Fisher
- Children's Healthcare of Atlanta, Egleston, Atlanta, Georgia
| | | | | | - Lillian Sung
- The Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluation Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
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MacDonald D, Crosbie T, Christofides A, Assaily W, Wiernikowski J. A Canadian perspective on the subcutaneous administration of rituximab in non-Hodgkin lymphoma. Curr Oncol 2017; 24:33-39. [PMID: 28270723 PMCID: PMC5330627 DOI: 10.3747/co.24.3470] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [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: 01/09/2023] Open
Abstract
Rituximab is widely used for the treatment of non-Hodgkin lymphoma, being a key component in most therapeutic regimens. Administration of the intravenous (IV) formulation is lengthy and places a significant burden on health care resources and patient quality of life. A subcutaneous (sc) formulation that provides a fixed dose of rituximab is being examined in a number of studies. Results indicate that the pharmacokinetics are noninferior and response rates are comparable to those obtained with the IV formulation. Moreover, the sc formulation is preferred by patients and health care providers and reduces administration and chair time. Additional advantages include a lesser potential for dosing errors, shorter preparation time, reduced drug wastage, and fewer infusion-related reactions. Despite the success of the sc formulation, correct administration is needed to reduce administration-related reactions. By using a careful procedure, the sc formulation can be given safely and effectively, potentially reducing the burden on health care resources and improving quality of life for patients.
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Affiliation(s)
- D. MacDonald
- Division of Hematology, Dalhousie University, and QEII Health Sciences Centre, Halifax, NS
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Freyer DR, Chen L, Krailo MD, Knight K, Villaluna D, Bliss B, Pollock BH, Ramdas J, Lange B, Van Hoff D, VanSoelen ML, Wiernikowski J, Neuwelt EA, Sung L. Effects of sodium thiosulfate versus observation on development of cisplatin-induced hearing loss in children with cancer (ACCL0431): a multicentre, randomised, controlled, open-label, phase 3 trial. Lancet Oncol 2016; 18:63-74. [PMID: 27914822 DOI: 10.1016/s1470-2045(16)30625-8] [Citation(s) in RCA: 141] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2016] [Revised: 09/20/2016] [Accepted: 10/04/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND Sodium thiosulfate is an antioxidant shown in preclinical studies in animals to prevent cisplatin-induced hearing loss with timed administration after cisplatin without compromising the antitumour efficacy of cisplatin. The primary aim of this study was to assess sodium thiosulfate for prevention of cisplatin-induced hearing loss in children and adolescents. METHODS ACCL0431 was a multicentre, randomised, open-label, phase 3 trial that enrolled participants at 38 participating Children's Oncology Group hospitals in the USA and Canada. Eligible participants aged 1-18 years with newly diagnosed cancer and normal audiometry were randomly assigned (1:1) to receive sodium thiosulfate or observation (control group) in addition to their planned cisplatin-containing chemotherapy regimen, using permuted blocks of four. Randomisation was initially stratified by age and duration of cisplatin infusion. Stratification by previous cranial irradiation was added later as a protocol amendment. The allocation sequence was computer-generated centrally and concealed to all personnel. Participants received sodium thiosulfate 16 g/m2 intravenously 6 h after each cisplatin dose or observation. The primary endpoint was incidence of hearing loss 4 weeks after final cisplatin dose. Hearing was measured using standard audiometry and reviewed centrally by audiologists masked to allocation using American Speech-Language-Hearing Association criteria but treatment was not masked for participants or clinicians. Analysis of the primary endpoint was by modified intention to treat, which included all randomly assigned patients irrespective of treatment received but restricted to those assessable for hearing loss. Enrolment is complete and this report represents the final analysis. This trial is registered with ClinicalTrials.gov, number NCT00716976. FINDINGS Between June 23, 2008, and Sept 28, 2012, 125 eligible participants were randomly assigned to either sodium thiosulfate (n=61) or observation (n=64). Of these, 104 participants were assessable for the primary endpoint (sodium thiosulfate, n=49; control, n=55). Hearing loss was identified in 14 (28·6%; 95% CI 16·6-43·3) participants in the sodium thiosulfate group compared with 31 (56·4%; 42·3-69·7) in the control group (p=0·00022). Adjusted for stratification variables, the likelihood of hearing loss was significantly lower in the sodium thiosulfate group compared with the control group (odds ratio 0·31, 95% CI 0·13-0·73; p=0·0036). The most common grade 3-4 haematological adverse events reported, irrespective of attribution, were neutropenia (117 [66%] of 177 participant cycles in the sodium thiosulfate group vs 145 [65%] of 223 in the control group), whereas the most common non-haematological adverse event was hypokalaemia (25 [17%] of 147 vs 22 [12%] of 187). Of 194 serious adverse events reported in 26 participants who had received sodium thiosulfate, none were deemed probably or definitely related to sodium thiosulfate; the most common serious adverse event was decreased neutrophil count: 26 episodes in 14 participants. INTERPRETATION Sodium thiosulfate protects against cisplatin-induced hearing loss in children and is not associated with serious adverse events attributed to its use. Further research is needed to define the appropriate role for sodium thiosulfate among emerging otoprotection strategies. FUNDING US National Cancer Institute.
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Affiliation(s)
- David R Freyer
- Children's Center for Cancer and Blood Diseases, Children's Hospital Los Angeles, Los Angeles, CA, USA; Departments of Pediatrics and Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
| | - Lu Chen
- Children's Oncology Group, Monrovia, CA, USA
| | - Mark D Krailo
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA; Children's Oncology Group, Monrovia, CA, USA
| | - Kristin Knight
- Doernbecher Children's Hospital, Oregon Health and Science University, Portland, OR, USA
| | | | | | - Brad H Pollock
- Department of Public Health Sciences, University of California Davis, Davis, CA, USA
| | - Jagadeesh Ramdas
- Pediatric Hematology/Oncology, Geisinger Medical Center, Danville, PA, USA
| | - Beverly Lange
- Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | | | | | | | - Edward A Neuwelt
- Doernbecher Children's Hospital, Oregon Health and Science University, Portland, OR, USA
| | - Lillian Sung
- Hematology/Oncology, Hospital for Sick Children, Toronto, ON, Canada
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Sung L, Robinson P, Treister N, Baggott T, Gibson P, Tissing W, Wiernikowski J, Brinklow J, Dupuis LL. Guideline for the prevention of oral and oropharyngeal mucositis in children receiving treatment for cancer or undergoing haematopoietic stem cell transplantation. BMJ Support Palliat Care 2015; 7:7-16. [PMID: 25818385 PMCID: PMC5339548 DOI: 10.1136/bmjspcare-2014-000804] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [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: 10/21/2014] [Revised: 02/25/2015] [Accepted: 03/11/2015] [Indexed: 11/03/2022]
Abstract
PURPOSE To develop an evidence-based clinical practice guideline for the prevention of oral mucositis in children (0-18 years) receiving treatment for cancer or undergoing haematopoietic stem cell transplantation (HSCT). METHODS The Mucositis Prevention Guideline Development Group was interdisciplinary and included internationally recognised experts in paediatric mucositis. For the evidence review, we included randomised controlled trials (RCTs) conducted in either children or adults evaluating the following interventions selected according to prespecified criteria: cryotherapy, low level light therapy (LLLT) and keratinocyte growth factor (KGF). We also examined RCTs of any intervention conducted in children. For all systematic reviews, we synthesised the occurrence of severe oral mucositis. The Grades of Recommendation, Assessment, Development and Evaluation approach was used to describe quality of evidence and strength of recommendations. RESULTS We suggest cryotherapy or LLLT may be offered to cooperative children receiving chemotherapy or HSCT conditioning with regimens associated with a high rate of mucositis. We also suggest KGF may be offered to children receiving HSCT conditioning with regimens associated with a high rate of severe mucositis. However, KGF use merits caution as there is a lack of efficacy and toxicity data in children, and a lack of long-term follow-up data in paediatric cancers. No other interventions were recommended for oral mucositis prevention in children. CONCLUSIONS All three specific interventions evaluated in this clinical practice guideline were associated with a weak recommendation for use. There may be important organisational and cost barriers to the adoption of LLLT and KGF. Considerations for implementation and key research gaps are highlighted.
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Affiliation(s)
- Lillian Sung
- Division of Haematology/Oncology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Paula Robinson
- Pediatric Oncology Group of Ontario, Toronto, Ontario, Canada
| | - Nathaniel Treister
- Division of Oral Medicine and Dentistry, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Tina Baggott
- Cancer Clinical Trials Office, Stanford University, Stanford, California, USA
| | - Paul Gibson
- Section of Hematology and Oncology, Children's Hospital, Western University, London, Ontario, Canada
| | - Wim Tissing
- Department of Pediatric Oncology/Hematology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - John Wiernikowski
- Division of Pediatric Hematology/Oncology, McMaster University, McMaster Children's Hospital, Hamilton, Ontario, Canada
| | - Jennifer Brinklow
- Division of Pediatric Hematology/Oncology, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - L Lee Dupuis
- Division of Haematology/Oncology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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Koolwine J, Crosbie T, Gazzé G, Turner R, Wiernikowski J, Assaily W. Corrigendum: A Canadian Perspective on the Safe Administration of Bendamustine and the Prevention and Management of Adverse Events. Curr Oncol 2014. [DOI: 10.3747/co.21.2027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
In the top right-hand corner of Figure 1 [...]
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Koolwine J, Crosbie T, Gazzé G, Turner R, Wiernikowski J, Assaily W. A Canadian perspective on the safe administration of bendamustine and the prevention and management of adverse events. Curr Oncol 2014; 21:35-42. [PMID: 24523603 PMCID: PMC3921029 DOI: 10.3747/co.21.1855] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [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: 01/06/2023] Open
Abstract
Although bendamustine has been used to treat lymphoproliferative disorders for decades, it has only recently been approved for use in Canada. Thus, Canadian recommendations on the administration of bendamustine and the management of common adverse events (aes) are needed. This article highlights effective management and assessment strategies recommended by Canadian nurses and pharmacists for the most common aes arising from the use of bendamustine in patients with chronic lymphocytic leukemia and indolent non-Hodgkin lymphoma. Those strategies include administering bendamustine over 60 minutes instead of 30 minutes, administering pre-medications to control infusion-related reactions and nausea, hydrating patients to minimize fatigue, and using free-flowing saline at the closest port to prevent phlebitis.
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Affiliation(s)
| | | | - G. Gazzé
- McGill University Health Centre, Montreal, QC
| | - R. Turner
- Princess Margaret Hospital, Toronto, ON
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Chander A, Nagel K, Wiernikowski J, Paes B, Chan AK. Evaluation of the use of low-molecular-weight heparin in neonates: a retrospective, single-center study. Clin Appl Thromb Hemost 2013; 19:488-93. [PMID: 23478571 DOI: 10.1177/1076029613480557] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [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: 11/17/2022] Open
Abstract
Controversies exist over the currently recommended guidelines for the use of low-molecular-weight heparin (LMWH) in neonates. We retrospectively studied 30 neonates treated with LMWH and found a poor therapeutic response to recommended doses as measured by anti-Xa levels. Sixty percent of the study participants required their doses to be increased because of subtherapeutic anti-Xa levels during the initial course of their treatment. The mean starting enoxaparin dose was 1.53 ± 0.38 mg/kg. The mean enoxaparin dose, once therapeutic anti-Xa levels had been achieved, was 1.86 ± 0.50 mg/kg. Preterm and term infants required doses of 2.06 ± 0.61 mg/kg and 1.67 ± 0.26 mg/kg, respectively, to achieve therapeutic anti-Xa levels. In summary, our results suggest that higher initial doses are required to achieve therapeutic anticoagulation in neonates.
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Affiliation(s)
- Ankush Chander
- 1Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
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Grunfeld E, Levine MN, Julian JA, Pond GR, Maunsell E, Folkes A, Dent SF, Joy AA, Paszat LF, Pritchard KI, Porter GA, Rayson D, Robidoux A, Smith S, Sussman J, Provencher L, Wiernikowski J, Sisler JJ. Results of a multicenter randomized trial to evaluate a survivorship care plan for breast cancer survivors. J Clin Oncol 2011. [DOI: 10.1200/jco.2011.29.15_suppl.9005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Lethaby C, Wiernikowski J, Sala A, Naronha M, Webber C, Barr RD. Bisphosphonate therapy for reduced bone mineral density during treatment of acute lymphoblastic leukemia in childhood and adolescence: a report of preliminary experience. J Pediatr Hematol Oncol 2007; 29:613-6. [PMID: 17805035 DOI: 10.1097/mph.0b013e318142b7a1] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Osteopenia is a common consequence of the treatment of acute lymphoblastic leukemia (ALL) in children and adolescents, due predominantly to glucocorticosteroid therapy. The pathogenesis relates to an imbalance of resorption over formation of bone. METHODS Alendronate (Fosamax), an inhibitor of osteoclastic bone resorption, was administered for at least 6 months to 15 children with ALL during maintenance chemotherapy, after the diagnosis of osteopenia/osteoporosis by dual energy x-ray absorptiometry. The height velocity was also measured during the administration of alendronate and again 2 years later. RESULTS Areal bone mineral density Z scores of the lumbar spine had a median value of -1.32 before administration of alendronate and a median gain of +0.64, with 14/15 children showing improvement. There was no adverse effect of alendronate on height velocity, and the drug was well tolerated with no short-term toxicity. CONCLUSIONS This preliminary experience suggests a potential value in the use of alendronate for the treatment of osteopenia/osteoporosis in children with ALL and points to the need for a randomized controlled trial of this intervention.
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Affiliation(s)
- Christopher Lethaby
- University of Leeds, Leeds, United Kingdom, and McMaster Children's Hospital, Hamilton, Canada
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Barr RD, Sala A, Wiernikowski J, Masera G, Mato G, Antillon F, Castillo L, Petrilli S, Quintana J, Ribeiro R, Agarwal B, Hesseling P. A formulary for pediatric oncology in developing countries. Pediatr Blood Cancer 2005; 44:433-5. [PMID: 15761839 DOI: 10.1002/pbc.20367] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Ronald D Barr
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
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Barr RD, Guo CY, Wiernikowski J, Webber C, Wright M, Atkinson S. Osteopenia in children with acute lymphoblastic leukemia: a pilot study of amelioration with Pamidronate. Med Pediatr Oncol 2002; 39:44-6. [PMID: 12116079 DOI: 10.1002/mpo.10057] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Ronald D Barr
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
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16
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Dawson S, Fitzgerald P, Langer JC, Walton M, Winthrop A, Lau G, Wiernikowski J, Barr RD. A preoperative protocol for the prevention of infection in children with tunnelled right atrial catheters. Oncol Rep 2000; 7:1239-42. [PMID: 11032922 DOI: 10.3892/or.7.6.1239] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
The use of central venous lines has come to be widely accepted by children with cancer and their families. However, attendant infection is a cause of considerable morbidity. Coagulase-negative staphylococci, the predominant aerobic species on the skin, are now the commonest cause of catheter-related bacteremia. We introduced a protocol to reduce the colonization of the skin at the catheter insertion site. Antiseptic skin scrubs, with 4% chlorhexidine gluconate, were performed on the neck and anterior chest the night before and again on the morning of the surgical procedure. A single dose of cephalothin (or vancomycin for penicillin-allergic patients) was administered IV immediately before the operation. Compared to the 12 month period prior to initiation of this protocol, the rate of infections (occurring within 30 days of catheter placement) in the 3.5 year period of intervention dropped from 8 to 4.9 per 1,000 catheter days. The proportion of infections that were staphylococcal was reduced from 93 to 63% and the proportion of non-ports removed within 30 days of placement fell from 45 to 0%. Despite these changes, the major contribution to improved infection control appeared to be the use of an increased proportion of ports (a rise from <10 to almost 60%).
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Affiliation(s)
- S Dawson
- Children's Hospital, Hamilton Health Sciences Corporation, Hamilton, Ontario L8S 4J9, Canada
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17
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Wiernikowski J. The Ontario Breast Cancer Information Exchange becomes a partnership. Can Oncol Nurs J 1998; 8:192-3. [PMID: 9814157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023] Open
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Halton J, Whitton A, Wiernikowski J, Barr RD. Disseminated Langerhans cell histiocytosis in identical twins unresponsive to recombinant human alpha-interferon and total body irradiation. Am J Pediatr Hematol Oncol 1992; 14:269-72. [PMID: 1510199 DOI: 10.1097/00043426-199208000-00016] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Monozygotic twin boys presented at 1 year of age with seborrheic skin rash, otorrhea, and hepatosplenomegaly. Skin biopsy confirmed Langerhans cell histiocytosis. Treatment with conventional antineoplastic drugs and with calf thymus extract was ineffective. The disease remained refractory to recombinant human alpha-interferon and to low-dose total body irradiation, and the children died between 3 and 3 1/2 years of age.
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Affiliation(s)
- J Halton
- Children's Hospital at Chedoke-McMaster, Hamilton, Ontario, Canada
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Mayhew E, Cimino M, Klemperer J, Lazo R, Wiernikowski J, Arbuck S. Free and liposomal doxorubicin treatment of intraperitoneal colon 26 tumor: therapeutic and pharmacologic studies. Sel Cancer Ther 1990; 6:193-209. [PMID: 2094939 DOI: 10.1089/sct.1990.6.193] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Intraperitoneal (i.p.) chemotherapy is being investigated as an adjunct to surgery to kill residual cancer cells, inhibit cancer cell seeding, local recurrence, and metastases for ovarian, gastric, and colon cancers. In this report, the therapeutic effects of Doxorubicin (Dox) and liposome-entrapped Dox (Dox-Lip) against i.p. mouse colon 26 (C26) tumor were compared. It was found that Dox-Lip was less toxic than Dox after i.p. administration in non-tumor bearing animals. I.P. Dox and Dox-Lip significantly inhibited the growth of C26 tumor when the treatment was initiated 1 day after tumor cell inoculation, but both administration forms were ineffective against well-established (8-day) tumors. Multiple dose schedules did not improve the therapeutic response. Dox-Lip was not therapeutically superior to Dox at equal doses or at approximately equi-toxic doses. In addition, the relative retention of Dox and Dox-Lip in the peritoneal cavity and their plasma pharmacokinetics were investigated. It was found that Dox levels in the peritoneal cavity were maintained for longer periods after i.p. Dox-Lip was administered. However, the results show that maintenance of elevated drug levels in the peritoneal cavity does not necessarily lead to increased therapeutic effects.
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Affiliation(s)
- E Mayhew
- Department of Experimental Pathology, Roswell Park Cancer Institute, Buffalo, New York
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