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McNeil MJ, Garcia Quintero X, Gonzalez M, Zheng Y, Ugaz Olivares C, Morales R, Boldrini E, Rebollo de Campos D, Ferreira D, Coopasamy K, Caneba J, Padernilla ML, Friedrichsdorf S, Baker JN, Friedrich P. Preventing and Treating Pain and Anxiety during Needle-Based Procedures in Children with Cancer in Low- and Middle-Income Countries. Cancers (Basel) 2024; 16:1025. [PMID: 38473383 DOI: 10.3390/cancers16051025] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 02/23/2024] [Accepted: 02/27/2024] [Indexed: 03/14/2024] Open
Abstract
Introduction: Children with cancer experience significant pain and anxiety during needle-based procedures. Undertreated pain in children has long-lasting consequences and reduces the efficacy of subsequent analgesic efforts. A validated quality improvement (QI) intervention, known as the "Children's Comfort Promise", includes (1) topical anesthetics, (2) sucrose or breastfeeding for infants, (3) comfort positioning, and (4) distraction techniques, and has been shown to be highly effective in decreasing procedural pain and anxiety in children. However, there is limited data about the adoption, adaptation, and implementation of these interventions in low- and middle-income countries (LMICs). Methods: A QI pilot project utilizing the Model for Improvement of the "Global Comfort Promise" was implemented in four global pediatric cancer hospitals (Lima, Peru; Barretos, Brazil; Pietermaritzburg, South Africa; and Manila, Philippines). Between August 2021 and January 2023, the pilot sites identified a specific aim, co-designed the measurement strategy with St. Jude Children's Research Hospital, and adopted, adapted, and implemented the project at their individual sites. Results: A total of 2,185 different procedures were recorded in the first year of implementation. Most patients were less than 10 years old (60.5%) and solid tumors (37.9%) were the most common diagnosis. Overall, healthcare professionals (98.3%) were satisfied with the procedures. Parents and patients reported that only 33.7% of patients experienced pain during the procedure. All (100%) parents and patients felt the healthcare teams adequately addressed their child's pain. Median self-reported adherence to ≥2 interventions was 98.0%. Challenges to the implementation of the QI initiative included lack of training, turnover of the medical staff, maintaining staff enthusiasm, and access to topical anesthetics. Each site had unique change ideas to implement the initiative. Conclusions: This multi-site, multi-country QI initiative was feasible and was successfully adopted, adapted, and implemented in the LMIC context to improve procedural pain in children (Global Comfort Promise). Additionally, this intervention resulted in high satisfaction of both healthcare professionals and patients/families. Further work is needed to overcome the challenges of topical anesthetic access and education of the workforce. Additional plans include modifying the Global Comfort Promise to include high-quality communication and expanding to additional sites with further refinement of the implementation strategy.
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Affiliation(s)
- Michael J McNeil
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN 38105, USA
- Division of Quality of Life and Palliative Care, Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN 38105, USA
| | - Ximena Garcia Quintero
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN 38105, USA
| | - Miriam Gonzalez
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN 38105, USA
| | - Yawen Zheng
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN 38105, USA
| | | | - Roxana Morales
- Instituto Nacional de Enfermedades Neoplásicas, Lima 15038, Peru
| | - Erica Boldrini
- Hospital de Câncer Infantojuvenil de Barretos, Barretos 14784-400, Brazil
| | | | - Daiane Ferreira
- Hospital de Câncer Infantojuvenil de Barretos, Barretos 14784-400, Brazil
| | | | - Joliza Caneba
- Philippines General Hospital, Manila 1000, Philippines
| | | | - Stefan Friedrichsdorf
- Division of Pediatric Pain, Palliative Care & Integrative Medicine, University of California San Francisco, San Francisco, CA 94143, USA
| | - Justin N Baker
- Division of Quality of Life and Pediatric Palliative Care, Stanford University, Palo Alto, CA 94305, USA
| | - Paola Friedrich
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN 38105, USA
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Benini F, Papadatou D, Bernadá M, Craig F, De Zen L, Downing J, Drake R, Friedrichsdorf S, Garros D, Giacomelli L, Lacerda A, Lazzarin P, Marceglia S, Marston J, Muckaden MA, Papa S, Parravicini E, Pellegatta F, Wolfe J. International Standards for Pediatric Palliative Care: From IMPaCCT to GO-PPaCS. J Pain Symptom Manage 2022; 63:e529-e543. [PMID: 35031506 DOI: 10.1016/j.jpainsymman.2021.12.031] [Citation(s) in RCA: 48] [Impact Index Per Article: 24.0] [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: 08/17/2021] [Revised: 12/28/2021] [Accepted: 12/30/2021] [Indexed: 11/18/2022]
Abstract
CONTEXT Since the publication of the IMPaCCT project in 2007, much effort has been made to develop new approaches to pediatric palliative care (PPC). Fifteen years later, it is time to redefine the standards in PPC. OBJECTIVES An international group of experts in PPC has revised the standards in PPC through the GO-PPaCS project (Global Overview - PPC Standards). The goal was to update the PPC standards considering the specificity of different settings, resources, and emerging challenges. The present document is intended to reach all people directly or indirectly involved in PPC. METHODS A literature review in MEDLINE was conducted to expand on the fundamental points and current standards on PPC and to cover an international setting. The literature search (updated on the 15th of April 2021) was carried out using different combinations of keywords and focusing on papers published in English over the past 5 years (2016-2020), but older articles were considered when relevant. The consensus on the fundamental points, standards of care and paper contents was reached by open discussion. RESULTS Fundamental points were defined regarding the definition of PPC, eligibility criteria and the magnitude of the need for PPC, while standards were redefined for the following six areas: 1) clinical, developmental, psychological, social, ethical and spiritual needs; 2) end-of-life care; 3) care models and settings of care; 4) PPC in humanitarian emergencies; 5) care tools; and 6) education and training for healthcare providers. CONCLUSION The present document, developed with the contribution of an international group of experts from different countries, experiences and models of care, provides fundamental points and standards for a wider implementation of PPC worldwide.
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Affiliation(s)
- Franca Benini
- Paediatric Palliative Care, Pain Service, Department of Women's and Children's Health, University of Padua, Padua, Italy.
| | - Danai Papadatou
- Professor of Clinical Psychology, Department of Mental Health and Behavioral Studies, Faculty of Nursing, National and Kapodistrian University of Athens, Greece
| | - Mercedes Bernadá
- Associated Professor of Pediatrics, School of Medicine, Universidad de la República, Pereira Rossell Hospital Center, Pediatric Palliative Care Team Director, Montevideo, Uruguay
| | - Finella Craig
- Consultant in Paediatric Palliative Medicine at the Louis Dundas Centre, Great Ormond Street Hospital for Children, London, UK
| | - Lucia De Zen
- Pediatric Palliative Care and Pain Service, Institute for Maternal and Child Health Burlo Garofolo, Trieste, Italy
| | - Julia Downing
- International Children's Palliative Care Network (ICPCN), Uganda/UK
| | - Ross Drake
- Pediatric Palliative Care and Pain Services, Starship Children's Health, Auckland District Health Board, Auckland, New Zealand
| | - Stefan Friedrichsdorf
- Professor in Pediatrics, Medical Director, Center of Pediatric Pain, Palliative and Integrative Medicine at UCSF Benioff Children's Hospitals in Oakland and San Francisco, California, USA
| | - Daniel Garros
- Department of Pediatrics, Division of Critical Care, University of Alberta, Edmonton, Alberta, Canada; Stollery Children's Hospital PICU, Edmonton, Alberta, Canada
| | | | - Ana Lacerda
- Department of Pediatrics, Portuguese Institute of Oncology, Lisbon Centre, Lisbon, Portugal
| | - Pierina Lazzarin
- Paediatric Palliative Care, Pain Service, Department of Women's and Children's Health, University of Padua, Padua, Italy
| | - Sara Marceglia
- Department of Engineering and Architecture, University of Trieste, Trieste, Italy
| | - Joan Marston
- Sunflower Children's Hospice, Bloemfontein, South Africa
| | | | | | | | | | - Joanne Wolfe
- Department of Psychosocial Oncology, Dana-Farber Cancer Institute and Department of Pediatrics, Boston Children's Hospital, Boston, MA, USA
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Poonai N, Burke K, Brahmbhatt S, Boisvert L, Belisle S, McKelvie B, Patterson K, Stevenson A, Eull D, Friedrichsdorf S. 35 Implementation of a quality improvement initiative to reduce pain and anxiety associated with needle-related procedures in a Canadian paediatric emergency department. Paediatr Child Health 2021. [DOI: 10.1093/pch/pxab061.028] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Primary Subject area
Emergency Medicine - Paediatric
Background
Needle-related procedures such as intravenous (IV) insertion, venipuncture, and lumbar puncture (LP) are commonly performed in children, particularly in the emergency department (ED). Children consistently rate these needle-related procedures as very distressing. While topical anesthetics have been shown to be highly effective and are available, they are inconsistently used. The Children’s Comfort Promise was originally developed at the Minnesota Children’s Hospital. It requires nursing staff to use four strategies for children undergoing needle-related procedures: (1) topical anesthetic, (2) sucrose or breastfeeding if ≤ 12 months, (3) Comfort positioning (swaddling, skin-to-skin, or facilitated tucking if ≤ 12 months and sitting upright for children > 12 months), and (4) age-appropriate distraction.
Objectives
We sought to evaluate compliance with all 4 Comfort Promise strategies for managing children’s pain and anxiety during needle-related procedures in a Canadian paediatric ED.
Design/Methods
Implementation of The Comfort Promise in March 2020 included a focus group to perform a root cause analysis, designation of nurse champions, monthly steering committee and ED working group meetings, and didactic education sessions. Our institution’s decision support unit identified all encounters of children 0-17 years who underwent at least one needle-related procedure at our paediatric ED from January 1 to November 30, 2020. The outcome was compliance with all 4 Comfort Promise strategies. Balancing measures included adverse drug reactions and vasoconstriction. We used statistical process control to analyze the outcome from 2 months preceding and 7 months following implementation.
Results
From January 1 to November 30, 2020, 21,600 encounters were identified, of which 10,294/21,600 (47.7%) were female. Age ranged from 0-17 years with a mean (SD) of 6.9 (5.5) years. Needle-related procedures were performed in 730/21,600 (3.4%) encounters, most commonly IV insertion (289/730, 39.6%) and venipuncture for blood sampling (232/730, 31.8%). Half of all encounters had no compliance strategies electronically recorded (363/730, 49.7%). Compliance with all Comfort Promise strategies increased over the study period (Figure 1). Topical anesthetic increased from 3/35 (8.6%) to 35/83 (42.2%). Sucrose or breastfeeding increased from 0/6 (0%) to 2/16 (12.5%). Comfort positioning increased from 0/35 (0%) to 26/83 (31.3%). Distraction increased from 0/35 (0%) to 22/83 (26.5%). There were no adverse drug reactions or vasoconstriction.
Conclusion
Implementation of The Comfort Promise in a Canadian paediatric ED resulted in greater use of strategies, particularly topical anesthetic, to reduce needle-related distress in children. Ongoing compliance will depend on consistent electronic recording and provider education.
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Widger K, Wolfe J, Friedrichsdorf S, Pole JD, Brennenstuhl S, Liben S, Greenberg M, Bouffet E, Siden H, Husain A, Whitlock JA, Leyden M, Rapoport A. National Impact of the EPEC-Pediatrics Enhanced Train-the-Trainer Model for Delivering Education on Pediatric Palliative Care. J Palliat Med 2018; 21:1249-1256. [DOI: 10.1089/jpm.2017.0532] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Kimberley Widger
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
- Paediatric Advanced Care Team, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Joanne Wolfe
- Pediatric Palliative Care Service, Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Stefan Friedrichsdorf
- Department of Pain Medicine, Palliative Care and Integrative Medicine, Children's Hospitals and Clinics of Minnesota, Minneapolis, Minnesota
- Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Jason D. Pole
- Research, Pediatric Oncology Group of Ontario, Toronto, Ontario, Canada
| | - Sarah Brennenstuhl
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Stephen Liben
- Pediatric Palliative Care Program, The Montreal Children's Hospital, Montreal, Quebec, Canada
| | - Mark Greenberg
- Policy and Clinical Affairs, Pediatric Oncology Group of Ontario, Toronto, Ontario, Canada
| | - Eric Bouffet
- Department of Hematology/Oncology, Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Paediatrics, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Harold Siden
- Canuck Place Children's Hospice, Department of Pediatrics, University of British Columbia, Vancouver, Canada
| | - Amna Husain
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- Temmy Latner Centre for Palliative Care, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - James A. Whitlock
- Department of Hematology/Oncology, Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Paediatrics, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Myra Leyden
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Adam Rapoport
- Paediatric Advanced Care Team, Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Paediatrics, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- Emily's House Children's Hospice, Toronto, Ontario, Canada
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Abstract
ZusammenfassungFentanyl wird in der Pädiatrie seit vielen Jahren zur Analgesie und Analgosedierung eingesetzt. Weit verbreitet ist der intravenöse Einsatz vor schmerzhaften Eingriffen und die Analgosedierung beatmeter Kinder auf der Intensivstation. Zunehmende Bedeutung gewinnt die patientenkontrollierte Analgesie (PCA) postoperativer, onkologischer und palliativer pädiatrischer Patienten. Erfolgreiche Anwendungen im Kindesalter umfassen darüber hinaus das Fentanylpflaster (Fentanyl-TSS) und den transmukösen Fentanyllutscher. Die Autoren geben eine Übersicht zu Metabolismus, Pharmakokinetik, Nebenwirkungen, Dosierungsvorschlägen sowie Anwendungsformen von topischem, oralem und intravenösem Fentanyl im Kindesalter gestützt auf randomisierte Studien der Jahre 1989-2003.
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Widger K, Friedrichsdorf S, Wolfe J, Liben S, Pole JD, Bouffet E, Greenberg M, Husain A, Siden H, Whitlock JA, Rapoport A. Protocol: Evaluating the impact of a nation-wide train-the-trainer educational initiative to enhance the quality of palliative care for children with cancer. BMC Palliat Care 2016; 15:12. [PMID: 26818836 PMCID: PMC4729125 DOI: 10.1186/s12904-016-0085-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Accepted: 01/19/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There are identified gaps in the care provided to children with cancer based on the self-identified lack of education for health care professionals in pediatric palliative care and in the perceptions of bereaved parents who describe suboptimal care. In order to address these gaps, we will implement and evaluate a national roll-out of Education in Palliative and End-of-Life Care for Pediatrics (EPEC®-Pediatrics), using a 'Train-the-Trainer' model. METHODS/DESIGN In this study we are using a pre- post-test design and an integrated knowledge translation approach to assess the impact of the educational roll-out in four areas: 1) self-assessed knowledge of health professionals; 2) knowledge dissemination outcomes; 3) practice change outcomes; and 4) quality of palliative care. The quality of palliative care will be assessed using data from three sources: a) parent and child surveys about symptoms, quality of life and care provided; b) health record reviews of deceased patients; and c) bereaved parent surveys about end-of-life and bereavement care. After being trained in EPEC®-Pediatrics, 'Master Facilitators' will train 'Regional Teams' affiliated with 16 pediatric oncology programs in Canada. Each team will consist of three to five health professionals representing oncology, palliative care, and the community. Each team member will complete online modules and attend one of two face-to-face conferences, where they will receive training and materials to teach the EPEC®-Pediatrics curriculum to 'End-Users' in their region. Regional Teams will also choose a Tailored Implementation of Practice Standards (TIPS) Kit to guide implementation of a quality improvement project in their region; support will be provided via quarterly meetings with Co-Leads and via a listserv and webinars with other teams. DISCUSSION Through this study we aim to raise the level of pediatric palliative care education amongst health care professionals in Canada. Our study will be a significant step forward in evaluation of the impact of EPEC®-Pediatrics both on dissemination outcomes and on care quality at a national level. Based on the anticipated success of our project we hope to expand the EPEC®-Pediatrics roll-out to health professionals who care for children with non-oncological life-threatening conditions.
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Affiliation(s)
- Kimberley Widger
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, 130-155 College Street, Toronto, ON, M5T 1P8, Canada. .,Pediatric Advanced Care Team, Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada.
| | - Stefan Friedrichsdorf
- Department of Pain Medicine, Palliative Care & Integrative Medicine, Children's Hospitals and Clinics of Minnesota, 2525 Chicago Avenue South, Minneapolis, MN, 55404, USA.
| | - Joanne Wolfe
- Pediatric Palliative Care Service, Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA.
| | - Stephen Liben
- Pediatric Palliative Care Program, The Montreal Children's Hospital, 2300 Rue Tupper, Montréal, QC, H3H 1P3, Canada.
| | - Jason D Pole
- Pediatric Oncology Group of Ontario, 480 University Avenue, Suite 1014, Toronto, ON, M5G 1 V2, Canada.
| | - Eric Bouffet
- Brain Tumor Program, Division of Hematology/Oncology, Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada.
| | - Mark Greenberg
- Policy and Clinical Affairs, Pediatric Oncology Group of Ontario, 480 University Avenue, Suite 1014, Toronto, ON, M5G 1 V2, Canada.
| | - Amna Husain
- Department of Family and Community Medicine, University of Toronto, Temmy Latner Centre for Palliative Care, Mount Sinai Hospital, 60 Murray Street, 4th Floor, Toronto, ON, M5T 3 L9, Canada.
| | - Harold Siden
- Canuck Place Children's Hospice, Clinical Professor, Department of Pediatrics, University of British Columbia, 1690 Matthews Avenue, Vancouver, BC, V6J 2 T2, Canada.
| | - James A Whitlock
- Department of Hematology/Oncology, Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada.
| | - Adam Rapoport
- Pediatric Advanced Care Team, Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada.
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Widger K, Bouffet E, Friedrichsdorf S, Greenberg M, Husain A, Liben S, Pole JD, Siden H, Whitlock J, Wolfe J, Rapoport A. Enhancing the quality of palliative care for children with cancer: A nation-wide train-the-trainer educational initiative. Paediatr Child Health 2015. [DOI: 10.1093/pch/20.3.157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Friedrichsdorf S, Wheeler DM, Collins JJ. Prevention and treatment for constipation in chronically ill children or children undergoing palliative care. Hippokratia 2009. [DOI: 10.1002/14651858.cd005453.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Hechler T, Blankenburg M, Friedrichsdorf S, Garske D, Hübner B, Menke A, Wamsler C, Wolfe J, Zernikow B. Parents' Perspective on Symptoms, Quality of Life, Characteristics of Death and End-of-Life Decisions for Children Dying from Cancer. Klin Padiatr 2008; 220:166-74. [DOI: 10.1055/s-2008-1065347] [Citation(s) in RCA: 105] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Friedrichsdorf S, Wheeler DM, Collins JJ. Prevention and treatment for constipation in chronically ill children or children undergoing palliative care. Hippokratia 2005. [DOI: 10.1002/14651858.cd005453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Abstract
Green urine, a well described condition, can be caused by a variety of agents. Here we describe a case of green urine caused by blue food colouring during tube feeding. In the article, we list more than 20 drugs, chemical agents and microorganisms which have been associated with green urine.
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Friedrichsdorf S, Wamsler C, Zernikow B. Palliativmedizin im Kindesalter. Monatsschr Kinderheilkd 2002. [DOI: 10.1007/s00112-002-0460-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Schultz C, Klouche M, Friedrichsdorf S, Richter N, Kroehnert B, Bucsky P. Langerhans cell histiocytosis in children: does soluble interleukin-2-receptor correlate with both disease extent and activity? Med Pediatr Oncol 1998; 31:61-5. [PMID: 9680928 DOI: 10.1002/(sici)1096-911x(199808)31:2<61::aid-mpo3>3.0.co;2-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Langerhans cell histiocytosis (LCH) is characterized by monoclonal proliferation of activated Langerhans cells. Neither etiology nor pathomechanism of this disorder is presently known. However, despite monoclonality LCH might represent a reactive clonal disorder induced by immune dysfunction rather than a malignant process. To investigate a putative cytokine dysregulation in the pathogenesis of this disorder and searching for parameters of both disease activity and prognosis, serum concentrations of proinflammatory and T-cell derived cytokines were evaluated in LCH patients. MATERIALS AND METHODS Serum levels of IL-1 beta, IL-2, sIL-2R and TNF-alpha were determined by ELISA in seven children with different types of LCH: Three children (aged 6, 10 and 14 years, respectively) with single system/single bone disease; one child (11 years) with recurrent single system/multiple bone disease and three children (1, 2 and 2 years, respectively) with multisystem disease. RESULTS sIL-2R was elevated at diagnosis in seven children as compared to healthy adults (mean +/- SEM: 5,256 +/- 3,751 U/ml vs. 73 +/- 5.5 U/ml; P < 0.005) or healthy children (mean +/- SEM: 10,195 +/- 2,798 pg/ml vs. 2,638 +/- 156 pg/ml; P < 0.01). A positive correlation between serum levels of sIL-2R and extent of the disease could be observed. During remission, sIL-2R levels declined. IL-1 beta, IL-2, and TNF-alpha remained within the normal range during the study period. CONCLUSIONS Elevated sIL-2R levels seem to correlate positively with both extent and activity of LCH, thus indicating a pathological T-cell activation as a pathogenetic factor. sIL-2R level is a promising parameter to monitor disease activity in LCH and may also be of prognostic relevance.
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Affiliation(s)
- C Schultz
- Department of Pediatrics, Medical University of Lübeck, Germany
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