Airborne Fungal Spore Concentrations Research Articles

Measurement and prediction of the detachment of Aspergillus niger spores in turbulent flows

Aspergillus niger (A. niger) spores can induce numerous health problems. Once the airflow-imposed drag force on an A. niger spore exceeds its binding force with the colony, the spore is detached. Turbulent flow may considerably increase the spore detachment. No method is currently available for prediction of the drag force on a spore and its detachment in turbulent flows. This investigation measured the turbulent velocities and detachment of A. niger colonies in a wind tunnel. Computational fluid dynamics (CFD) was employed to model an A. niger unit subjected to turbulent flow blowing. The top 1 % quantile instantaneous velocity of the turbulent flow was specified as the steady entry flow boundary condition for solving the peak velocity distribution and the peak drag forces onto spores. The predicted spore detachment ratios were compared with the measurement data for model validation. The results revealed that the spore detachment ratios with a turbulence intensity of 17 % to 20 % can be twice to triple the ratio with a turbulence intensity of approximately 1 %, when the average velocity for blowing remains the same. The proposed CFD model can accurately predict the detachment ratios of the A. niger spores. Environmental ImplicationSome people are sensitive to the Aspergillus niger (A. niger) spores, and excessive exposure can cause nasal congestion, skin tingling, coughing, and even asthma. Turbulent flow can considerably increase the spore detachment, due to the increased airflow-imposed drag force on the spores during turbulence. This investigation developed a numerical model to solve for the peak velocity distribution and the peak drag forces onto spores in turbulent flows to predict the spore detachment. With the numerical tool, the airborne fungal spore concentrations would be predictable, which paves a way for intelligent and precise control of fungal aerosol pollution.

Risk Factors and Environmental Preventive Actions for Aspergillosis in Patients with Hematological Malignancies.

(1) Background: Aspergillus spp. is a widely distributed filamentous fungus in the environment due to its high sporulation capacity. Currently, invasive aspergillosis (IA) is the most common invasive fungal infection in patients with hematologic malignancies, with high rates of mortality and morbidity. The multifactorial nature of the disease requires appropriate risk stratification to enable the most appropriate preventive measures to be adapted and implemented according to the characteristics of the patient. In this sense, the present research aims to identify recent risk factors and environmental control measures against invasive aspergillosis to establish preventive actions to reduce the incidence of invasive aspergillosis in hospitals. (2) Methods: We conducted a qualitative systematic review of the scientific literature on environmental risk factors and preventive measures for invasive aspergillosis in patients with hematologic malignancies. The Medline, Cochrane, and Scopus databases were consulted, following the PRISMA and STROBE guidelines. (3) Results: Adequate implementation of environmental control measures is presented as the most efficient intervention in terms of prevention to decrease the incidence of invasive aspergillosis in hospitals. Neutropenia, fungal contamination, insufficient environmental control measures in hospital and home settings, length of hospital stay, and anemia, are identified as independent risk factors. We show that HEPA, LAF, and Plasmair® systems are suitable methods to reduce the concentration of airborne fungal spores. Antifungal prophylaxis did not significantly influence IA reduction in our study. (4) Conclusions: Proper professional training and environmental control measures in hospitals are essential for the prevention of invasive aspergillosis. We should optimize risk stratification for patients with hematologic malignancies. Antifungal prophylaxis should be complementary to environmental control measures and should never be substituted for the latter. Studies should also be undertaken to evaluate the efficiency of environmental control measures against IA at patients' homes.

Comparison of the Airborne Fungal Spore Concentrations in Las Vegas and the Mojave Desert From 2020 - 2022

Comparison of the Airborne Fungal Spore Concentrations in Las Vegas and the Mojave Desert From 2020 - 2022

Features of the seasonal dynamics of airborne fungal spore concentrations in Ukraine

Fungi represent a distinct kingdom of ubiquitous living beings. Most other organisms are constantly in contact with elements of the fungal body. In particular, the widespread vegetation of fungi in the environment, their sporulation and the further spread of spores and mycelia by air currents make the contact of fungal particles with human respiratory organs inevitable. This can lead to the development of sensitization and allergies. Therefore, the aim of the presented study was to determine the taxonomy of airborne fungal spores, the qualitative and quantitative changes in this composition at different times of the year compared with previous sporulation seasons, as well as the prevention of allergic diseases. The study of fungal sporulation was carried out from 2011 to 2021 by volumetric method using Burkard trap of a Hirst type in a 24-hour mode (from February to November). The device was installed on the roof of the chemical building of the National Pirogov Memorial Medical University, Vinnytsya. Reading of the microscopic slides obtained from air samples was carried out using light microscopes with a magnification of 400 and 1000 by the method of 12 vertical transects. It was found that spores of various taxonomic groups of fungi, namely, of Asco- and Basidiomycetes were observed throughout the growing season from March to October with the highest concentrations in mid and late summer. Thus, in June, July and August, peak concentrations of spores of the fungi Ganoderma, Coprinus, Cladosporium were observed; in July, September and October – of Ustilaginales; from July to November – of Alternaria, Epicoccum; in October – of different Basidiospores, and also Periconia, Stemphylium and Uredinales; in September – of Agrocybe. Among all studied micromycetes, concentrations of Cladosporium spores were the highest. However, significant sporulation persisted even in the autumn period, which made fungal spores a specific causative agent of airborne respiratory diseases at this time, especially against the background of low pollen concentrations. Climate change can lead to modification in the length of the fungal growing season. This information should be taken into account when predicting the symptoms of seasonal allergies in the population.

Fungal Contamination of Building Materials and the Aerosolization of Particles and Toxins in Indoor Air and Their Associated Risks to Health: A Review.

It is now well established that biological pollution is a major cause of the degradation of indoor air quality. It has been shown that microbial communities from the outdoors may significantly impact the communities detected indoors. One can reasonably assume that the fungal contamination of the surfaces of building materials and their release into indoor air may also significantly impact indoor air quality. Fungi are well known as common contaminants of the indoor environment with the ability to grow on many types of building materials and to subsequently release biological particles into the indoor air. The aerosolization of allergenic compounds or mycotoxins borne by fungal particles or vehiculated by dust may have a direct impact on the occupant's health. However, to date, very few studies have investigated such an impact. The present paper reviewed the available data on indoor fungal contamination in different types of buildings with the aim of highlighting the direct connections between the growth on indoor building materials and the degradation of indoor air quality through the aerosolization of mycotoxins. Some studies showed that average airborne fungal spore concentrations were higher in buildings where mould was a contaminant than in normal buildings and that there was a strong association between fungal contamination and health problems for occupants. In addition, the most frequent fungal species on surfaces are also those most commonly identified in indoor air, regardless the geographical location in Europe or the USA. Some fungal species contaminating the indoors may be dangerous for human health as they produce mycotoxins. These contaminants, when aerosolized with fungal particles, can be inhaled and may endanger human health. However, it appears that more work is needed to characterize the direct impact of surface contamination on the airborne fungal particle concentration. In addition, fungal species growing in buildings and their known mycotoxins are different from those contaminating foods. This is why further in situ studies to identify fungal contaminants at the species level and to quantify their average concentration on both surfaces and in the air are needed to be better predict health risks due to mycotoxin aerosolization.

First volumetric records of airborne Cladosporium and Alternaria spores in the atmosphere of Al Khor (northern Qatar): a preliminary survey

Daily monitoring of airborne fungal spores was carried out for the first time in Al Khor city, Qatar, using a Hirst type 7-day recording volumetric spore trap, from May 2017 to May 2019. During the sampling period, the annual and monthly fluctuations, as well as intradiurnal variations of airborne fungal spore concentrations, were evaluated. Cladosporium, followed by Alternaria, were the spore types most abundant in the atmosphere of the city, with a strong interannual variability in the atmospheric concentrations being observed. The Annual Spore Integrals (ASIns) were 3334 and 1172 spore * day/m3 (2017–2018), and 6796 and 1538 spore * day/m3 (2018–2019) for Cladosporium and Alternaria, respectively. Total daily spore concentrations showed significantly positive correlations with mean, minimum, and maximum temperatures but significantly negative correlations with relative humidity. However, due to the scarce rainfalls’ days, we did not find a statistically significant correlations between Cladosporium and Alternaria spore concentrations and this parameter. Despite this, the spore peaks were strongly related to precipitations that occurred during the previous month. In general, no significant correlations were found with wind speed but, regarding wind direction, the higher percentage of spores were collected when wind blows from the 4th quadrant (NW). According to the intradiurnal pattern, Cladosporium fungal spores displayed their maximum daily concentration during 8:00–10:00 h in the morning, with a second peak in the afternoon, while for Alternaria, the maximum peaks were observed between 08:00 and 14:00 h. Because no consistent previous aerobiological studies exist from Qatar, the aim of this study is to define the seasonality and intradiurnal behaviour of these two airborne fungal spore and the role that, in such arid scene, the meteorological parameters play on the spore concentrations.

A study on correlations between precipitation ETCCDI and airborne pollen/fungal spore parameters in the NE Iberian Peninsula

Precipitation is one of the meteorological variables usually involved in the aerobiological studies, which presents a complex relationship with atmospheric levels of pollen and fungal spores and the temporal characteristics of their seasons. This complexity is due in a large part to rainfall's twofold impact of having, prior to pollination, a positive influence on subsequent pollen production and of contributing, during pollination, to pollen removal from the air through a wash-out effect. To better explore this impact, we place particular emphasis on extreme rainfall by calculating the correlation between airborne pollen and fungal spore parameters and the precipitation indices that the Expert Team on Climate Change Detection and Indices (ETCCDI) proposed for characterising climate extremes. Parameters for twenty-seven pollen and fungal spore taxa measured in six aerobiological stations in the NE Iberian Peninsula have been considered. We have distinguished between annual and winter ETCCDI in order to compare the correlations between extreme rainfall and airborne pollen concentrations and to avoid the wash-out effect as far as possible. Results show a positive influence from an increase in moderately extreme winter rainfall, specifically on subsequent pollen/fungal spore production: the percentage of all possible significant correlations is higher for winter than for annual rainfall. Furthermore, while annual rainfall in this region has nearly the same number of positive as negative correlations, the positive correlations for winter rainfall are more than twice that of the negative ones. The seasonal consideration on rainfall ETCCDI made with the aim to avoid the confounding overlapping of different rainfall impacts has led to more sharpened observations of its positive and negative effects on airborne pollen and fungal spore concentrations.

Spatiotemporal assessment of aeromycoflora under differing urban green space, sampling height, and meteorological regimes: the atmospheric fungiscape of Thessaloniki, Greece.

We studied the diversity and abundance of the airborne fungal spores in the city of Thessaloniki, Greece, for two consecutive years. Air samples were collected at one rooftop station (at 30m) and six near-ground stations (at 1.5m) that differed in the size and composition of adjacent green spaces. The effects of meteorological factors on airborne fungal spore concentrations were also explored. Cladosporium spores were dominant everywhere in the air of the city. The total concentration of the airborne fungal spores at 30m was 10 times lower than near the ground. Differences in concentration and composition were far less pronounced among near-ground stations. The attributes of the fungal spore season did not change in a consistent way among stations and years. Concentrations at the near-ground stations matched the grouping of the latter into stations of high, intermediate, and low urban greenspace. Minimum air temperature was the primary meteorological factor affecting spore abundance, followed by relative humidity. Airborne fungal spores are more homogeneously distributed in the air of the city, but their concentrations decrease more rapidly with height than pollen.

Comparison of the Airborne Fungal Spore Concentrations in the Mojave Desert and Las Vegas From 2016-2020

Airborne fungal spores are common allergens present in urban and surrounding environments. Data comparing the abundance of airborne fungi are lacking, especially in desert climates. This study aims to compare fungal spore concentrations between Las Vegas and the surrounding Mojave Desert from 2016-2020.

Temporal variations in fungal spores in Mardin city atmosphere, upper Mesopotamia, SE-Turkey

The present study aimed to determine the fungal spores and their concentrations in the atmosphere of Mardin (southeast Turkey) in 2014 and 2015 using the volumetric method. A total of 43 taxa, hyphal fragments, and single septate ascospores were identified by light microscopy. It was determined that the dominant fungal spores included Cladosporium (51.5%), Ustilaginales species spores (13.9%), Alternaria (6.9%), Pucciniales species spores (1.6%), Agrocybe (1.2%), Pleospora (1.1%) and hyphal fragments (15.5%). The highest atmospheric spore concentrations were observed in May and the lowest levels were determined in February in both years. Dry air spores constituted a significant ratio of the total count (73.9%) in the atmosphere of Mardin. There were significant positive correlations between atmospheric concentrations of Alternaria, Cladosporium, Ustilaginales, and Pucciniales spores and temperatures. There were significant negative correlations between airborne fungal spore concentrations and daily mean humidity. There was a significant negative correlation between Agrocybe spore concentrations and daily mean temperature and a significant positive correlation between the same and humidity and precipitation. No significant correlation was determined between the meteorological variables and Pleospora and Aspergillus/Penicillium spore concentrations.

Abundance of Ganoderma sp. in Europe and SW Asia: modelling the pathogen infection levels in local trees using the proxy of airborne fungal spore concentrations

Ganoderma comprises a common bracket fungal genus that causes basal stem rot in deciduous and coniferous trees and palms, thus having a large economic impact on forestry production. We estimated pathogen abundance using long-term, daily spore concentration data collected in five biogeographic regions in Europe and SW Asia. We hypothesized that pathogen abundance in the air depends on the density of potential hosts (trees) in the surrounding area, and that its spores originate locally. We tested this hypothesis by (1) calculating tree cover density, (2) assessing the impact of local meteorological variables on spore concentration, (3) computing back trajectories, (4) developing random forest models predicting daily spore concentration. The area covered by trees was calculated based on Tree Density Datasets within a 30 km radius from sampling sites. Variations in daily and seasonal spore concentrations were cross-examined between sites using a selection of statistical tools including HYSPLIT and random forest models.Our results showed that spore concentrations were higher in Northern and Central Europe than in South Europe and SW Asia. High and unusually high spore concentrations (> 90th and > 98th percentile, respectively) were partially associated with long distance transported spores: at least 33% of Ganoderma spores recorded in Madeira during days with high concentrations originated from the Iberian Peninsula located >900 km away. Random forest models developed on local meteorological data performed better in sites where the contribution of long distance transported spores was lower. We found that high concentrations were recorded in sites with low host density (Leicester, Worcester), and low concentrations in Kastamonu with high host density. This suggests that south European and SW Asian forests may be less severely affected by Ganoderma. This study highlights the effectiveness of monitoring airborne Ganoderma spore concentrations as a tool for assessing local Ganoderma pathogen infection levels.

Airborne fungal spore concentration in an industrial township: distribution and relation with meteorological parameters

Bioaerosols are reported to affect human health and cause chronic inflammation to the respiratory system, leading to its temporary or permanent damage. This study aims to perform the qualitative assessment of ambient air of Barrackpore, an industrial township of West Bengal, India, by analysing the airborne fungal spore diversity for two consecutive years. The spores of ambient air were trapped using Burkard 7-day volumetric sampler from June 2014 to May 2016. The association of major fungal taxa with environmental parameters was analysed by Spearman’s rank correlation coefficient and multiple regression analysis to identify the significant predictors. The daily average ambient fungal spore concentration was 3526.38 ± 2709.32 spores m−3. Ascospore, basidiospore, Periconia and Aspergillus/Penicillium spp. accounted for more than 65% of observed fungi, resulting in the major fungal taxa. A significant association of dominant fungi with meteorological parameters and air pollutants was observed. Additionally, stepwise multiple regression analysis pointed out that dewpoint, wind speed, particulate matter with an aerodynamic diameter ≤ 2.5(PM2.5) and atmospheric nitrogen dioxide concentration (NO2) are the significant predictors for dominant fungi. Analysis of daily ambient fungal spore concentration and determining their environmental determinants will give an insight into the ambient air quality of the residential area of Barrackpore, for the first time. The acquired data can be used to evaluate the health impact on the residents of an unevaluated industrial township of India.

Airborne fungal spore concentration in some selected indoor and outdoor sites: Threats of respiratory problems

Airborne fungal spore concentration in some selected indoor and outdoor sites: Threats of respiratory problems

The fluctuations of airborne fungal components in western Romania

Outdoor regional concentrations of airborne fungal spores and fungal fragments were measured using the 7-day Lanzoni sampler. The daily and intradiurnal fluctuations recorded during the monitored period have been studied. The multiple regression analysis was performed in order to determine how much of the total variance in these concentrations could be explained by meteorological parameters. Daytime periodicity statistically significant was established only in a few cases. As the relative importance of the weather factors varied, they could not be ranked according to their effect.

Height and hourly variations in the concentration of airborne pollen grains and fungal spores in Sosnowiec (Poland)

The aim of the work was to compare the qualitative and quantitative composition of aeroplankton in Sosnowiec (Poland) at three heights. The research was conducted on July 3rd, 4th and 5th, 2018 with the help of three Burkard spore traps: one stationary and two portable ones. The analyses were carried out at an altitude of 83 m, 15 m and at the ground level. Aerobiological data was recorded every hour and the collected pollen grains and fungal spores were determined later on. The relationships between individual meteorological conditions and different features of the alder pollen season were determined using Spearman’s rank correlation coefficients. The research has shown that the greatest fluctuations in the daily pollen count occurred at the lowest measuring point, i.e. at the ground level. The largest part of the determined palynomorphs were fungal spores, the most numerous of which was Cladosporium, followed by Alternaria, Epicoccum and Botrytis. Statistical analysis showed that the highest concentrations of fungal spores and plant pollen grains were influenced by wind speed, maximum gust of wind and solar radiation.

Intradiurnal variation of predominant airborne fungal spore biopollutants in the Central European urban environment.

Fungal spores are an important cause of allergic respiratory diseases worldwide. However, little is known about the intradiurnal pattern of spore concentrations of different fungal spore types in the air of the urban area. In this study, we evaluated bihourly variation in spore concentration of eight predominant fungal spore types in the atmosphere of Bratislava city (Agrocybe, Alternaria, Cladosporium, Coprinus, Exosporium, Epicoccum, Ganoderma, Leptosphaeria) with the aim to understand the relationships between the spore concentrations against associated environmental variables. Spore samples were collected using a Hirst-type volumetric aerospore trap from January to December 2016. Alternaria, Cladosporium, Epicoccum and Exosporium peaked during the daytime period between 10:00 and 16:00, while for Agrocybe, Ganoderma, Coprinus and Leptosphaeria, the nighttime peaks (20:00 and 04:00) were observed. Effect of a complex of environmental variables on bihourly concentrations of selected airborne fungal spore taxa was evaluated through multiple regression analysis. Air temperature, wind speed, sunshine duration and precipitation were positively associated with daytime spore types, while the association with nighttime spores was negative. In contrast, relative air humidity influenced negatively Exosporium daytime spore type but positively the Leptosphaeria nighttime spore type. Moreover, a circadian cycle of light and darkness was considered as an important predictor of nighttime spore levels. Among the atmospheric pollutants, PM10 was positively associated with all analysed daytime spores, while except for Leptosphaeria, O3 was negatively associated with nighttime spore types. NO2 and PM10 had mixed effects on nighttime spore levels. In general, air temperature, PM10 and wind speed were environmental parameters with great influence on airborne fungal spore concentration, being present in eight, seven and four regression models, respectively. Constructed regression models which the best explained variation in fungal spore concentrations were those for Ganoderma (R2 = 0.38) and Alternaria (R2 = 0.31).

Variability and Geographical Origin of Five Years Airborne Fungal Spore Concentrations Measured at Saclay, France from 2014 to 2018

Airborne fungal spores (AFS) represent the major fraction of primary biological aerosol particles (PBAPs), and they are studied worldwide largely due to their important role within the Earth system. They have an impact on climate and human health, and they contribute to the propagation of diseases. As their presence in the air depends largely on studied ecosystems, a spore trap was used to monitor their atmospheric concentrations from 2014 to December 2018 in Saclay, a suburban area in the megacity of Paris. The main objective of this work was: (1) to understand the atmospheric variability of AFS in relation to different variables such as meteorological factors, agricultural practice, and (2) to identify their geographical origin by using a source receptor model. During our period of observation, 30 taxa have been identified under a light microscope. In order of importance, Ascospores, Cladosporium, Basidiospores, Tilletiopsis, Alternaria were found to be the most abundant types respectively (50.8%, 33.6%, 7.6%, 1.8%, and 1.3%) accounting for 95% of the atmospheric concentrations. We observed a general decrease associated with a strong interannual variability. A bimodal seasonal cycle was identified with a first maximum in July and a second in October. The main parameters driving the atmospheric concentration are temperature and precipitation. The daily variability is strongly activated by successive periods of hot weather and rainfall, multiplying the concentration by a factor of 1000 in less than 12 hours. Results from the source receptor model ZeFir point out unambiguous different origins of AFS due to specific sources impacting the observation site. Our study also indicated that a hydrological stress has a direct effect on the daily concentrations. This last point should be taken into account for every stressed ecosystem studied in a global warming context. This is particularly important for Mediterranean areas where water is a key control of the growth and dispersion of fungal spores.

Temporal variations in the diversity of airborne fungal spores in a Mediterranean high altitude site

Relationships between meteorological factors and airborne fungal spore concentrations at high altitudes are virtually unknown. We used cross-correlation analyses to test the relationships between daily variation in meteorological factors (i.e., temperature, humidity and wind speed) and airborne spore concentration, diversity (Shannon and Simpson indices) and evenness (Pielou index) in an Apennine high altitude site (Gran Sasso Massif, 2117 m elevation). Daily average concentration of spores in this high altitude site was much lower than that observed at a low altitude site in the same area, which can be explained by the environmental conditions at high altitudes. We found that diversity and evenness tended to be negatively correlated with temperature and positively with humidity and wind speed with some delay, whereas abundance tended to be positively correlated with temperature and wind, but negatively with humidity. These relationships can be explained by the fact that rain increases turnover by removing dry spores of Cladosporium (the most abundant taxon) and aerosolizing wet ones. The high dominance of the most abundant taxon is a reflection of the extreme climatic conditions at high altitudes.

Variation in airborne fungal spore concentrations among five monitoring locations in a desert urban environment

Fungal spores are biological particles that are ubiquitous in the outdoor air. Spores of several very common fungal species are known allergens, with the potential to cause respiratory illnesses by exacerbating asthma and allergic rhinitis. The National Allergy Bureau typically has one monitoring station established per city to determine fungal spore counts for an entire metropolitan area. However, variations in fungal spore concentrations could occur among different locations. The objective of this study was to measure and compare airborne fungal spore concentrations in five locations in Las Vegas for the year 2015 to determine if there are differences among microenvironments in the city. Twenty-four-hour or 7-day air samples were collected from five sites across the Las Vegas Valley. Samples were analyzed with a light microscope for fungal spores and counts were converted to concentrations of spores per volume of air. Mixed-model methods were used to evaluate mean differences. Results showed that smuts (basidiomycetes) were the dominant spore type for all five sites during the spring season. Cladosporium species were responsible for the second most dominant spore type with the highest concentrations occurring during the summer and fall months. Results obtained from the five stations established in Las Vegas show that there are important variations among the sites regarding fungal spore concentrations. The data suggest that more sites and additional monitoring of outdoor allergens are needed to provide information necessary to inform the community of outdoor air quality conditions and their potential effects on public health. This study presents new outdoor fungal spore data for the southwest region of the USA, focused in the Las Vegas Valley.

Antimicrobial Prophylaxis for Adult Patients With Cancer-Related Immunosuppression: ASCO and IDSA Clinical Practice Guideline Update

To provide an updated joint ASCO/Infectious Diseases Society of America (IDSA) guideline on antimicrobial prophylaxis for adult patients with immunosuppression associated with cancer and its treatment. ASCO and IDSA convened an update Expert Panel and conducted a systematic review of relevant studies from May 2011 to November 2016. The guideline recommendations were based on the review of evidence by the Expert Panel. Six new or updated meta-analyses and six new primary studies were added to the updated systematic review. Antibacterial and antifungal prophylaxis is recommended for patients who are at high risk of infection, including patients who are expected to have profound, protracted neutropenia, which is defined as < 100 neutrophils/µL for > 7 days or other risk factors. Herpes simplex virus-seropositive patients undergoing allogeneic hematopoietic stem-cell transplantation or leukemia induction therapy should receive nucleoside analog-based antiviral prophylaxis, such as acyclovir. Pneumocystis jirovecii prophylaxis is recommended for patients receiving chemotherapy regimens that are associated with a > 3.5% risk for pneumonia as a result of this organism (eg, those with ≥ 20 mg prednisone equivalents daily for ≥ 1 month or on the basis of purine analog usage). Treatment with a nucleoside reverse transcription inhibitor (eg, entecavir or tenofovir) is recommended for patients at high risk of hepatitis B virus reactivation. Recommendations for vaccination and avoidance of prolonged contact with environments that have high concentrations of airborne fungal spores are also provided within the updated guideline. Additional information is available at www.asco.org/supportive-care-guidelines .