Children's Cancer Center Research Articles

Pediatric Treatment Guidelines for Philadelphia Positive (Ph+) Chronic Myelogenous Leukemia (CML): What Are They in Today's Imatinib Era?

Background: The treatment of pediatric Philadelphia positive (Ph+) chronic myelogenous leukemia (CML) in the era of the tyrosine kinase inhibitors (TKI) continues to evolve with the role of allogeneic hematopoietic cell transplantation (allo-HCT) in these patients becoming more controversial. Imatinib has completely replaced allo-HCT for adult CML patients presenting in first chronic phase, reserving HCT for TKI resistant and/or advanced stage patients (accelerated phase and blast crisis). Whether treatment strategies in 2008 have changed for CML in pediatrics, from heavily allo-HCT based to TKI based medical therapy, is presently unclear.Methods: Thirty-two pediatric centers across the United States and Canada were surveyed regarding current treatment practices for CML in order to explore treatment practices in 2008. The survey targeted primary pediatric oncologists and bone marrow transplant physicians regarding their treatment approach for CML in terms of upfront therapy, utility of allo-HCT, use of TKI (including their role in the post-HCT setting) and how response to therapy was monitored.Results: Twenty-three of the thirty-two centers completed the survey to provide a completion rate of 72% (Table 1). Sixty-three percent of survey responders recommended allo-HCT, when a matched sibling donor was available, for patients with CML in first chronic phase. Regarding the use of TKI in the post-HCT setting, 9 of 27 (33%) physicians reported using imatinib as maintenance therapy post-HCT as a means to prevent relapse. All physicians reported using PCR techniques for bcr-abl of either bone marrow, peripheral blood or both to monitor treatment response with frequencies ranging from monthly to every six months.Conclusion: Treatment of pediatric CML appears variable and center dependent. This survey identified a trend toward less allo-HCT for CML in 2008 compared to years past. Despite the trend toward less HCT, the pediatric treatment consensus in 2008 for CML remains MSD allo-HCT when available. Use of imatinib was recognized by all survey responders as standard of care in upfront therapy, but the use of imatinib or other TKI in the post-HCT setting as maintenance therapy remains in question. Prospective pediatric clinical trials will be necessary to determine the optimal strategy for CML in children.Table 1. Pediatric CentersBritish Columbia's Children's HospitalChildren's Hospital of PittsburghChildren's Memorial Medical Center–NorthwesternCincinnati Children's Hospital Medical CenterCity of HopeColumbia Presbyterian College of Phys & SurgeonsDoernbecher Children's Hospital-OHSUDuke University Medical CenterMayo ClinicMedical College of WisconsinNationwide Children's HospitalSchneider Children's HospitalSt. Jude Children's Research HospitalStollery Children's Hospital–EdmontonTexas Children's Cancer Center at Baylor College of MedicineThe Children's Hospital of PhiladelphiaThe University of Chicago Comer Children's HospitalUniversity of California at San Diego/Rady Children's Hospital San DiegoUCSF School of MedicineUniversity of FloridaUniversity of Michigan–C.S. Mott Children's HospitalUniversity of Minnesota Children's Hospital, FairviewWashington University–St. Louis

Highly elevated ferritin levels and the diagnosis of HLH/sepsis/SIRS/MODS/MAS—Response

Pediatric Blood & CancerVolume 51, Issue 5 p. 710-711 Letter to the Editor Highly elevated ferritin levels and the diagnosis of HLH/sepsis/SIRS/MODS/MAS—Response Carl Allen MD, PhD, Carl Allen MD, PhD Clinical Fellow, Department of Pediatrics, Baylor College of Medicine/Texas, Children's Cancer Center, Houston, TexasSearch for more papers by this authorKenneth McClain MD, PhD, Corresponding Author Kenneth McClain MD, PhD klmcclai@txccc.org Past President, Histiocyte Society, Professor of Pediatrics, Baylor College of Medicine/Texas, Children's Cancer Center, Houston, TexasTexas Children's Cancer Center/Hematology Service, 6621 Fannin St., CC 1510.00, Houston, TX 77030.===Search for more papers by this authorLisa Filipovich MD, Lisa Filipovich MD President, Histiocyte Society, Professor of Pediatrics, Children's Hospital Medical Center, Cincinnati, OhioSearch for more papers by this author Carl Allen MD, PhD, Carl Allen MD, PhD Clinical Fellow, Department of Pediatrics, Baylor College of Medicine/Texas, Children's Cancer Center, Houston, TexasSearch for more papers by this authorKenneth McClain MD, PhD, Corresponding Author Kenneth McClain MD, PhD klmcclai@txccc.org Past President, Histiocyte Society, Professor of Pediatrics, Baylor College of Medicine/Texas, Children's Cancer Center, Houston, TexasTexas Children's Cancer Center/Hematology Service, 6621 Fannin St., CC 1510.00, Houston, TX 77030.===Search for more papers by this authorLisa Filipovich MD, Lisa Filipovich MD President, Histiocyte Society, Professor of Pediatrics, Children's Hospital Medical Center, Cincinnati, OhioSearch for more papers by this author First published: 25 July 2008 https://doi.org/10.1002/pbc.21679Citations: 2Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article.Citing Literature Volume51, Issue5November 2008Pages 710-711 RelatedInformation

Barriers to fertility preservation among pediatric oncologists

Objective: Limited research has been conducted on the extent to which fertility preservation is discussed by pediatric oncologists with patients and less is known about the discussion content. This study sought to examine factors that may influence the discussion with pediatric cancer patients and families. Methods: Qualitative data were collected using open-ended, in-depth interviews with 24 pediatric oncologists in Florida at 13 children's cancer centers, representing 87% of the centers in the state. Results: Providers practiced between 0.5 and 35 years, treated most types of pediatric cancers, and most were board certified in pediatric hematology/oncology. The main factors associated with a discussion of fertility preservation options were: (1) physician factors that contribute to communication issues with FP discussion (e.g., awareness and sense of comfort in discussing issues, perceptions of the priority); (2) parent factors (e.g., receptiveness and cultural background); (3) patient factors (e.g., receptiveness and age); and (4) institutional factors (e.g., referral sites and practice guidelines). Conclusions: Pediatric oncologists may benefit from education about fertility preservation options for pediatric cancer patients, particularly females. Practice implications: Training on how to address parents’ and patients’ emotions, culture, and other factors may also promote the discussion. Although guidelines have been established, barriers related to availability and affordability of resources must also be addressed.

Paediatric bone and soft tissue sarcoma

Paediatric bone and soft tissue sarcoma is a new text providing a comprehensive overview of paediatric sarcomas, largely with a North American perspective. Basic principles and recent concepts in the epidemiology, pathology, biology and clinical management are explored in 10 chapters. The text has 233 pages, 65 figures and 26 tables and is the effort of 27 North American contributors. The editor, Alberto Pappo, has recently joined the Texas Children's Cancer Centre as head of the solid tumour programme having worked previously in Toronto.

Nocturnal Awakenings, Sleep Environment Interruptions, and Fatigue in Hospitalized Children With Cancer

To describe nocturnal awakenings and sleep environment interruptions experienced by children and adolescents hospitalized for two to four days to receive chemotherapy and to assess the relationships among nocturnal awakenings, sleep environment interruptions, sleep duration, and fatigue. Longitudinal, descriptive design. St. Jude Children's Research Hospital and Texas Children's Cancer Center. 25 patients with solid tumors and 4 with acute myeloid leukemia. Actigraphy, fatigue instruments, sleep diary, room entry and exit checklists, and blood samples. Nocturnal awakenings, sleep environment interruptions, sleep duration, and fatigue. The number of nocturnal awakenings per night as measured by actigraphy ranged from 0-40. The number of room entries and exits by a staff member or parent was 3-22 times per eight-hour night shift. The number of nocturnal awakenings was related to fatigue by patient report; patients who experienced 20 or more awakenings had significantly higher fatigue scores than those with fewer awakenings. Nocturnal awakenings also were significantly associated with sleep duration by patient and parent report. Hospitalized pediatric patients with cancer who experience more nocturnal awakenings are more fatigued and sleep longer. Nurses may be able to control some of the factors that contribute to nocturnal awakenings and sleep environment interruptions that affect fatigue and sleep duration in hospitalized pediatric patients with cancer.

Solid-pseudopapillary tumor of the pancreas and pancreatoblastoma in children: Experience over 18 years at a Pediatric Oncology Center

9062 Background: Malignant pancreatic tumor is a rare disease in the pediatric population. Guidelines for treatment, including management in advanced disease are controversial until this moment (REBHANDL, 2001). Regarding to the pathology findings, pancreatoblastoma and solid-pseudopapillary tumor of the pancreas (Frantz’s tumor) are the more frequent pancreatic tumors in childhood. The aim of this study was a retrospective analysis of all malignant pancreatic tumors diagnosed at Boldrini’s Children Cancer Center during a period of 18 years. Methods: A retrospective analysis of eight cases of malignant pancreatic tumors, admitted at the Boldrini’s Children Cancer Center, from January 1987 to April 2005. All the data concerning age, sex, clinical presentation, stage, treatment and follow-up were collected. Results: The patient’s population refers to 8 children. There were 4 boys and 4 girls. Age ranged from 1 month to 15 years old (median age of 14 years). Main symptom was the increase of abdominal volume. None of them had metastatic disease at diagnosis. Regarding to pathology, 4 patients had pancreatoblastoma and 4 Frantz’s tumor. One patient (who had pancreatoblastoma) received chemotherapy before surgery, with a partial response, and then had a complete tumor ressection. All others (7 patients) had complete surgery as first treatment. Only one patient with Frantz’s tumor had pancreatic injury during tumor ressection and is now receiving enzimatic reposition. All the patients are alive, free of disease, from 6 months to 11 years (median follow-up of 2 years). Table I . Conclusions: Total pancreatectomy is the most important treatment in pancreatoblastoma and Frantz’s tumor. Neoadjuvant chemotherapy may be an important tool in unresectable tumors, increasing the disease-free survival. [Table: see text] No significant financial relationships to disclose.

Riley Children's Cancer Center (RCCC) quick reference guide

Riley Children's Cancer Center (RCCC) quick reference guide

High Rates of Epstein Barr Virus Expression in Hodgkin's Lymphoma in Lebanese Children.

Introduction: Hodgkin's disease (HD) accounts for around 6% of all cancers in Lebanese children ≤ 15 years of age. HD shows wide geographic variation in its association with EBV virus. The prognostic significance of Latent EBV infection in HD is still controversialPurpose: To examine EBV (LMP-1) positivity in pediatric patients treated for HL at the American University of Beirut-Medical Center and the Children's Cancer Center of Lebanon and its association with age, sex, histologic subtype and treatment outcome.Methods: The charts of all pediatric patients treated for Hodgkin's Lymphoma at the American University of Beirut Medical Center between 1980 and 1996, and at the Children's Cancer Center of Lebanon from 2002 to 2005 were reviewed. Their paraffin blocks were studied for Epstein-Barr virus association by latent membrane protein-1 (LMP-1) immunohistochemistry.Results: The charts of 34 patients with HD were reviewed. The median age was 7.5 years (range: 2–16 yrs); only 4 patients were above 13 years of age. The M: F ratio was 4.6:1, and the mean follow-up was 4.5 yrs (range 4 months −12y). 6 had stage I, 10 had stage II, 15 had stage III (5 patients IIIA and 10 patients IIIB disease), and 3 had stage IVA disease. 53% had advanced stage disease. 16 patients (47%) had mixed cellularity histologic subtype, 15 patients (44%) had nodular sclerosis subtype, and 3 patients had the lymphocyte predominance subtype. All nine patients who were tested for EBV- IgG were positive. Twenty-three patients were studied for the LMP-1 and 17 (74%) tested positive. These 17 patients make up 89% of the children under 13 years of age who were tested. LMP-1 positivity was associated with young age (≤13 yrs 100%), MC subtype (14 patients; 82.4%) and male sex (16 patients; 94%). Four patients with stage IIIB relapsed. Their treatment consisted of 6–9 cycles of COPP or COPP alternating with ABVD. Three of the relapsed patients were LMP-1 positive and had the MC subtype. Two patients had siblings who had HD; one of them who later relapsed was positive for LMP-1, had the MC subtype, and both he and his brother had immune deficiency and lymphoproliferative disorder.Conclusions: Our findings show a high prevalance of EBV expression in HD in Lebanese children. These rates are higher than those reported from other neighboring countries and much higher than those of North American and European countries. This may be related to earlier in life infection with EBV. LMP-1 positivity in Lebanese children was associated with younger age, male sex and mixed cellularity subtype. The impact of LMP-1 on treatment outcome remains to be determined.

Does intraveneous 6‐mercaptopurine decrease salvage after relapse in childhood acute lymphoblastic leukemia?

Pediatric Blood & CancerVolume 46, Issue 5 p. 660-661 Letter to the Editor Does intraveneous 6-mercaptopurine decrease salvage after relapse in childhood acute lymphoblastic leukemia? Donald H. Mahoney Jr. MD, Corresponding Author Donald H. Mahoney Jr. MD dmahoney@txccc.org Texas Children's Cancer Center & Hematology Service at Baylor College of Medicine, Houston, TexasTexas Children's Cancer Center at Baylor College of Medicine, Pediatric Oncology, 6621 Fannin Street, MC3-3320, Houston TX 77030-2399.===Search for more papers by this authorBruce M. Camitta MD, Bruce M. Camitta MD Midwest Children's Cancer Center, Milwaukee, WisconsinSearch for more papers by this authorMeenakshi Devidas PhD, Meenakshi Devidas PhD Children's Oncology Group and University Florida College of Medicine, Gainesville, FloridaSearch for more papers by this author Donald H. Mahoney Jr. MD, Corresponding Author Donald H. Mahoney Jr. MD dmahoney@txccc.org Texas Children's Cancer Center & Hematology Service at Baylor College of Medicine, Houston, TexasTexas Children's Cancer Center at Baylor College of Medicine, Pediatric Oncology, 6621 Fannin Street, MC3-3320, Houston TX 77030-2399.===Search for more papers by this authorBruce M. Camitta MD, Bruce M. Camitta MD Midwest Children's Cancer Center, Milwaukee, WisconsinSearch for more papers by this authorMeenakshi Devidas PhD, Meenakshi Devidas PhD Children's Oncology Group and University Florida College of Medicine, Gainesville, FloridaSearch for more papers by this author First published: 07 November 2005 https://doi.org/10.1002/pbc.20675Citations: 1Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article.Citing Literature Volume46, Issue51 May 2006Pages 660-661 RelatedInformation

Low risk episodes of fever and neutropenia in pediatric oncology: Is outpatient oral antibiotic therapy the new gold standard of care?

Pediatric Blood & CancerVolume 45, Issue 3 p. 244-247 Commentary Low risk episodes of fever and neutropenia in pediatric oncology: Is outpatient oral antibiotic therapy the new gold standard of care? Roland A. Ammann MD, Corresponding Author Roland A. Ammann MD [email protected] Pediatric Hematology/Oncology, University Children's Hospital, University of Bern, Bern, SwitzerlandPediatric Hematology/Oncology, University Children's Hospital, University of Bern, Inselspital, CH-3010 Bern, Switzerland.===Search for more papers by this authorArne Simon MD, Arne Simon MD Department of Pediatric Hematology and Oncology, University of Bonn, Bonn, GermanySearch for more papers by this authorEveline S.J.M. de Bont MD, PhD, Eveline S.J.M. de Bont MD, PhD Division of Pediatric Oncology, Children's Cancer Center, Beatrix Children's Hospital, Groningen, The NetherlandsSearch for more papers by this author Roland A. Ammann MD, Corresponding Author Roland A. Ammann MD [email protected] Pediatric Hematology/Oncology, University Children's Hospital, University of Bern, Bern, SwitzerlandPediatric Hematology/Oncology, University Children's Hospital, University of Bern, Inselspital, CH-3010 Bern, Switzerland.===Search for more papers by this authorArne Simon MD, Arne Simon MD Department of Pediatric Hematology and Oncology, University of Bonn, Bonn, GermanySearch for more papers by this authorEveline S.J.M. de Bont MD, PhD, Eveline S.J.M. de Bont MD, PhD Division of Pediatric Oncology, Children's Cancer Center, Beatrix Children's Hospital, Groningen, The NetherlandsSearch for more papers by this author First published: 03 March 2005 https://doi.org/10.1002/pbc.20287Citations: 20Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Citing Literature Volume45, Issue3September 2005Pages 244-247 RelatedInformation

13. Initial Antibiotic Timing and Administration for the Febrile/Neutropenic Pediatric Patient in the Emergency Department

Neutropenia is the body's inability to defend against infection due to insufficient white blood cell count. It leaves patients unable to combat bacterial infections usually deemed harmless in healthy children. Frequently, fever is the only sign of infection, which requires health care professionals to implement antibiotic therapy, the only means of defense. Inefficient antibiotic therapy initiation puts these patients at risk for sepsis and circulatory collapse. This project's purpose was to develop and implement a process of administering antibiotics safely and efficiently to the febrile/neutropenic pediatric patient in the emergency department to reduce risk of circulatory collapse. Conducted in a large urban pediatric emergency department in central Indiana, this project collaborated with the children's cancer center. A standard of care for the febrile/neutropenic patient, supported by administration, was developed. It consisted of laboratory studies prior to antibiotic initiation, maximum periods (physician assessment, antibiotic orders, and antibiotic initiation), and minimum patient monitoring standards during and immediately following initial antibiotic therapy. ED nursing, pharmacy, and medical staff were educated on these new procedures. Standard of care compliance was reviewed by quarterly chart audits for preantibiotic and postantibiotic timing. Staff knowledge of potential circulatory collapse for febrile/neutropenic patients increased following unit-based inservices. Staff nurses completed case studies following inservices to demonstrate content comprehension. Standardized practice of initial antibiotic administration to febrile/neutropenic patients was achieved. Cardiac and vital sign monitoring increased from 68% to 100% and from 34% to 90%, respectively. Time from triage to physician assessment/antibiotic orders written within 30 minutes increased to 100%. Antibiotics beginning within 45 minutes of triage increased from 50% to 90%. Initial doses of antibiotic split between the central venous catheter lumens increased from 40% to 100%. Circulatory collapse signs/symptoms were identified earlier, allowing caregivers opportunity to intervene. Overall, a safe passage for neutropenic patients through the emergency department was created. Based on this project's outcomes, developing a standard of practice for the febrile/neutropenic pediatric emergency department patient is highly recommended. Additionally, a Fever/Neutropenia Standard of Care should be added to ED staff orientation (nurses, physicians, and pharmacy). Future research should investigate the relationship from time of initial phone call to the oncologist (about fever) to time of the initial dose of antibiotics in the emergency department to investigate the time of fever onset to antibiotic initiation in evaluating signs/symptoms of circulatory collapse. Such information will assist both oncology and emergency departments in Indiana in serving this patient population, decreasing the need for these patients to travel into the city for immediate treatment. Finally, a root-cause analysis of febrile/neutropenic patients experiencing signs and symptoms of circulatory collapse may aid in identifying if standard of care noncompliance is associated with negative patient outcomes.

Experience with histoplasmosis in a children's cancer center

Adderson's retrospective review of 59 episodes of histoplasmosis over a 14-year period at St Jude Children's Research Hospital is an important addition to the medical literature. The article provides the clinician with a wealth of information regarding the presentation, diagnosis, clinical course, and management of children with histoplasmosis—some who had underlying malignancy and some whose infection led to referral, which subsequently excluded a malignancy.

Intravenous chemotherapy for children at home

Intravenous chemotherapy for children at home. It is becoming common practice for children with acute lymphoblastic leukaemia to receive the chemotherapy agent intravenous cytosine arabinoside (cytarabine, ara C), within the home. This practice is enabled by paediatric oncology outreach nurses based in a regional children's cancer centre and is administered by children's community nursing teams. This article discusses the role, development and audit of clinical practice guidelines relating to this work. An audit has found the guidelines to be a useful tool to inform clinical practice.

Neuroblastoma.

Clinical Professor of Pediatrics UCLA School of Medicine Los Angeles, California, USA Children's Cancer Center Miller Children's Hospital Long Beach, California, USA

Surveillance imaging in children with medulloblastoma (posterior fossa PNET).

The use of surveillance imaging in children with medulloblastoma has been criticised. The aim of this study was to determine what proportion of relapses are detected by surveillance and whether these are found at a relatively favourable stage. This study was a retrospective review of the medical charts and imaging studies of 89 patients treated at a single children's cancer centre. Relapse was defined as evidence of an increase in volume of residual tumour of greater than 25% or the presence of metastases, or new onset of positive CSF cytology. Relapse was termed symptomatic if it was diagnosed by tests performed because of new symptoms that occurred in the interval between surveillance examinations. Asymptomatic relapse was diagnosed solely on the basis of surveillance imaging. Survival time to relapse was calculated from the date of the first surgical procedure. Surveillance imaging detected 17 (71%) of the 24 relapses that occurred later than 6 months after diagnosis. All seven patients who presented with symptoms between scans have died, with a median survival from relapse of 5 months. Median survival from relapse in the patients detected by surveillance was 44 months, and four remain alive at 44-75 months. The patients detected by surveillance tended to have less advanced disease, which was more amenable to salvage therapy. This type of study cannot prove that surveillance imaging improves survival in children with medulloblastoma because of the effects of lead time and length biases. Despite this, surveillance does appear to be effective in detecting potentially curable medulloblastoma relapses and should be offered to all patients.

Riley Children's Cancer Center (RCCC) Quick Reference Guide

Riley Children's Cancer Center (RCCC) Quick Reference Guide

Sperm and ova conservation: existing standards of practice in North America.

Rapid advances have occurred in both reproductive medicine and survival from childhood cancer. To establish the current level of best clinical practice for sperm, ovarian, and prepubertal tissue collection and storage, a cross-sectional survey of a major pediatric oncology collaborative study group (Pediatric Oncology Group, POG) was performed. Of the 110 centers surveyed, 69 questionnaires (63%) were completed. No responding center had guidelines regarding which young people should be offered sperm, ovarian, or prepubertal testicular tissue conservation; 93% centers had offered sperm and 10% ova conservation; 15% had offered sperm conservation to males prior to completion of sexual development and 3% to girls prior to sexual maturation. All centers were more likely to offer sperm conservation than ova conservation for any given disease. The most common diseases for which conservation was offered were Hodgkin and non-Hodgkin lymphoma, and sarcomas. Fertility counseling was offered in a variety of settings by 71% of centers by health care professionals, including doctors, nurses, social workers, psychologists, and geneticists. There was little agreement regarding appropriate indications for, and method of, gamete preservation in children's cancer centers. It is hard to establish best clinical practice from these data. Unresolved medical, legal, and ethical issues necessitate the development of a voluntary code of practice and guidelines in order to ensure good clinical practice.

SELECTIVE SURGICAL INDICATION IN THE MANAGEMENT OF NEUTROPENIC CHILDREN PRESENTING WITH ACUTE ABDOMEN

As the treatment of pediatric malignancies improves and survival increases, the diagnosis of acute abdomen in these patients also becomes more common. Nevertheless, the management of this a condition is still controversial. The authors report their experience in treating 12 neutropenic children with acute abdomen. The charts of 12 neutropenic patients with a diagnosis of acute abdomen treated at Boldrini Children's Cancer Center in Campinas, Brazil, between 1991 and 1996, were reviewed. Therapeutic strategy included an initial period of bowel rest, general supportive measures, and broadspectrum antibiotics while waiting for the neutrophil count to rise. Three patients recovered completely without surgery, 8 under went late surgery without complications, and 1 died due to uncontrolled sepsis before surgery. The treatment of acute abdomen in neutropenic children remains controversial. As shown in the present series, an initial nonoperative approach with selective surgical indication appears to be safe and to yield good results. Supportive treatment, until the neutrophil count rises, followed by surgery, if necessary, appears to be a sound therapeutic approach for neutropenic children with acute abdomen.

Fatigue in children and adolescents with cancer

Fatigue is a common symptom found in the adult oncology literature. However, little is known about its occurrence, causes, conceptual and operational definitions, and effective interventions in children and adolescents with cancer. The purpose of this study was to define and describe fatigue experienced by children and adolescents receiving treatment for cancer. A focus group approach was used to reveal the contextual understanding of fatigue through discussions. Eleven focus groups were convened during a 2-month period at two major children's cancer centers. Twenty-nine children participated in the focus groups: 14 were 7 to 12 years of age and 15 were 13 to 16 years of age. Focus groups were held separately for each age group, lasted from 30 to 45 minutes, and were audiotaped. The audiotapes were transcribed verbatim, and Ethnograph software was used to number the data to sort and code the information. Researchers at both study sites coded the data independently within the context of the unit of analyses, which, in this study, were the study questions. Codes and descriptions were developed for the definitions of fatigue, causes of fatigue, and what helps. Eight codes emerged from the children groups and 12 from the adolescent groups to define fatigue. Six codes were developed from the children groups and 12 from the adolescent groups to describe causes of fatigue. Three codes from the children groups and eight from the adolescent groups described what helps. This study is the first to evaluate fatigue as a symptom in children and adolescents with cancer. Findings from this study will provide the foundation for developing a conceptual model for cancer-related fatigue in children and adolescents.

Fatigue in children and adolescents with cancer.

Fatigue is a common symptom found in the adult oncology literature. However, little is known about its occurrence, causes, conceptual and operational definitions, and effective interventions in children and adolescents with cancer. The purpose of this study was to define and describe fatigue experienced by children and adolescents receiving treatment for cancer. A focus group approach was used to reveal the contextual understanding of fatigue through discussions. Eleven focus groups were convened during a 2-month period at two major children's cancer centers. Twenty-nine children participated in the focus groups: 14 were 7 to 12 years of age and 15 were 13 to 16 years of age. Focus groups were held separately for each age group, lasted from 30 to 45 minutes, and were audiotaped. The audiotapes were transcribed verbatim, and Ethnograph software was used to number the data to sort and code the information. Researchers at both study sites coded the data independently within the context of the unit of analyses, which, in this study, were the study questions. Codes and descriptions were developed for the definitions of fatigue, causes of fatigue, and what helps. Eight codes emerged from the children groups and 12 from the adolescent groups to define fatigue. Six codes were developed from the children groups and 12 from the adolescent groups to describe causes of fatigue. Three codes from the children groups and eight from the adolescent groups described what helps. This study is the first to evaluate fatigue as a symptom in children and adolescents with cancer. Findings from this study will provide the foundation for developing a conceptual model for cancer-related fatigue in children and adolescents.