Hemato-oncology Unit Research Articles

Parent's Perspectives on the End-of-life Care of their Child with Cancer: Indian Perspective.

Context:Parents report that end-of-life decisions are the most difficult treatment-related decisions that they face during their child cancer experience. Research from the parent's perspective of the quality of end-of-life care of their cancer children is scarce, particularly in developing countries like India.Aims:This study aimed to identify the symptoms (medical/social/emotional) that most concerned parents at the end-of-life care of their cancer child and to identify the strategies parents found to be helpful during this period.Settings and Design:We wanted to conduct this to focus on the parents perspectives on their cancer child's end-of-life care and to address the issues that could contribute to the comfort of the families witnessing their child's suffering.Materials and Methods:The study was conducted at Sri Ramachandra University, Chennai, a Tertiary Care Pediatric Hemato Oncology Unit. Parents who lost their child to cancer, treated in our institution were interviewed with a validated prepared questionnaire. Statistical analysis was performed using SAS statistical software package.Results:Toward death, dullness (30%), irritability (30%), and withdrawn from surroundings (10%) were the most common symptoms encountered. About 30% of the children had fear to be alone. About 50% of the children had the fear of death. Pain, fatigue, loss of appetite were the main distressful symptoms that these children suffered from parents’ perspective. Though the parents accepted that the child was treated for these symptoms, the symptom relief was seldom successful.Conclusion:The conclusion of the study was that at the end of their child's life, parents value obtaining adequate information and communication, being physically present with the child, preferred adequate pain management, social support, and empathic relationships by the health staff members.

Factors influencing antimicrobial resistance and outcome of Gram-negative bloodstream infections in children.

The aim of this study was to collect data about pediatric Gram-negative bloodstream infections (BSI) to determine the factors that influence multidrug resistance (MDR), clinical course and outcome of children affected by Gram-negative sepsis. In this observational, prospective, multicenter study we collected cases of pediatric Gram-negative BSI during a 2-year period. We analyzed epidemiological, microbiological and clinical factors that associated with acquisition of MDR infections and outcome. One-hundred and thirty-five BSI episodes were analyzed. Median age of children was 0.5years (IQR 0.1-6.17, range 0-17years). Predominant bacteria were Enterobacteriaceae (68.3%), and Pseudomonas spp. (17.9%). Multidrug resistance was detected in 45/134 cases (33.6%), with the highest rates in Escherichia coli, Enterobacter and Pseudomonas spp. Acquisition of MDR pathogens was significantly associated with prior cephalosporin treatment, older age, admission to hemato-oncology unit, polymicrobial infections, higher rate of development of septic shock, and multiple organ failures. All-cause mortality was 17.9%. Presence of septic shock at presentation and parenteral nutrition were associated with higher mortality. Pseudomonas spp., and Enterobacter spp. BSIs had the highest rate of mortality. Inappropriate empiric antibiotic therapy was more frequent in MDR patients, although not significantly associated with poor outcome. Rates of multidrug resistance and mortality in children with Gram-negative bloodstream infections remain high in our settings. Empiric broad-spectrum antibiotics and combination therapy could be recommended, especially in children with malignant diseases, patients admitted to the PICU, and for cases with septic shock, who have higher mortality risk.

Effects of My Child's Safety Web-Based Program for Caregivers of Children with Cancer in South Korea.

ObjectivesThe purposes of this study were to develop a Web-based education program, My Child's Safety, which includes patient safety education and information on the diagnosis, treatment, and management for caregivers of children with cancer, and to examine the efficacy of the My Child's Safety program in promoting the caregivers' awareness of patient safety.MethodsA one-group pre- and post-test design was adopted. The participants were the caregivers of children with cancer and were recruited from one pediatric hemato-oncology unit of a tertiary university hospital in a large metropolitan city of South Korea. They were asked to review the Web-based program for patient safety and then complete questionnaires developed to measure the awareness of patient safety among the caregivers.ResultsIn the study, the total score of the caregivers' awareness of patient safety had increased significantly after Web-based self-learning patient safety education. Also caregivers' awareness of their right to ask and know about procedures and treatments during hospitalization had increased after the program was used.ConclusionsThe Web-based patient safety education program effectively improved the awareness of patient safety and the awareness of the right to know and ask about procedures and treatments during hospitalization among the caregivers. Family caregivers were less likely to ask healthcare professionals questions related to safety.

Stress and coping among nurses of hemato-oncologic units

We analyzed stress and Coping strategies used by Hemato-Oncology Unit nurses of a Rio Grande do Sul University Hospital. This is a descriptive, cross-sectional and quantitative study, conducted between March and April 2010. We applied a Form to sociodemographic characterization, Nurses Stress Inventory and Occupational Coping Scale in 18 nurses. We identified 55.55% of nurses in low stress. "Intrinsic Factors for Job" and "Feel emotional distress with work" represented higher stress for nurses. Control was the factor more used to deal with stressors and, in this factor, "I try to do what i think is expected of me" the action more used to manage them. Nurses use problem-centered Copingstrategies, considered more effective to deal with stressors. Therefore, they can have evaluated work in hemato-oncology unit as low-stress.

Situación actual de los adolescentes con cáncer en las unidades de hemato-oncología pediátrica españolas

Little attention was paid to adolescents with Cancer in Spain up to 2010. In 2011 an “Adolescents with Cancer Committee” was established by the Spanish Society of Pediatric Hemato-Oncology (SEHOP) to care for the needs of these patients. The aim of this national survey was to outline the present situation of adolescents with cancer in Spanish Pediatric Hemato-Oncology units.A web based survey assessed institutional management of adolescents with cancer. The survey was personally sent to one member of the staff of each Pediatric Hemato-Oncology unit in Spain. It included questions about epidemiology, management, psycho-social coverage, specific facilities, and follow up of these patients.A total of 40 institutions out of 41 responded to the survey (overall response rate 98%). Fifty-six percent of the institutions had patients over 14, but only 36% of the institutions treated patients up to 18 years old. Only 25.6% of the units have more than 40 new pediatric cases every year. The percentage of patients between 14 and 18 years of age is below 10% in most of the units (77%).In 30.8% and 48.7% of the institutions, pediatric hemato-oncologists treat adolescents with hematological and solid tumors, respectively. The rest of the patients are seen by adult oncologists. There is only one institution that has a physician specifically dedicated to adolescent patients, and only two units have a “teenager's room”. Only 2 units have a psychologist specifically trained to treat adolescents with cancer.The survey shows that most adolescents with cancer in Spain between 14 and 18 years of age are treated by adult oncologists. Most pediatric institutions still do not have specific facilities and psychosocial support for adolescents. The SEHOP is working hard in order to improve the quality of cancer care, and the quality of survival of this population.

Central venous catheter‐associated bloodstream infections

To investigate the epidemiologic and microbiological aspects of long-term central vein catheter (CVC)-associated bloodstream infections (CABSI) in children <18 years old treated at the hemato-oncology unit during 1998-2008. The two long-term access devices used were Hickman and Port-A-Cath catheters. Information retrieved included demographic data, baseline pathologies, methods of insertion, anatomical insertion sites, duration of use, microbiological, and antibiotic susceptibility data and outcome. There were 178 CABSI episodes; average number of episodes/1,000 catheter days was 4.7. More CABSI episodes were recorded among patients with Hickman catheter than in patients with Port-A-Cath catheter (5.05 vs. 3.57/1,000 catheter days, P = 0.059). The CVC was removed due to BSI in 52/178 (29.2%) episodes. Overall, 243 pathogens were isolated (144 Gram-negative, 92 Gram-positive, and 7 Candida spp). More Enterobacteriaceae spp. were isolated in CABSI in patients with Hickman catheters than in patients with Port-A-Cath catheters (35/103, 34%, vs. 10/65, 15%, P = 0.008); more coagulase-negative staphylococci were isolated in patients with Port-A-Cath catheters than in patients with Hickman catheters (25/65, 38.5%, vs. 23/103, 22.3%, P = 0.02). No differences in pathogen distribution were found between CABSI recorded for jugular versus subclavian veins, open versus close inserted-CVC or for CVC requiring removal versus those treated conservatively. No fatalities directly related to CABSI were recorded. CABSI rates were higher in patients with Hickman catheters compared with those with Port-A-Cath catheters; Gram-negative organisms were the dominant etiologic agents of CABSI; CABSI in patients with Hickman catheters had different etiologies compared with patients with Port-A-Cath catheters.

Determinants of severe oral mucositis in paediatric cancer patients: a prospective study

To analyse the incidence and the determinants of severe oral mucositis (OM) in young cancer patients treated by standard chemotherapy. The study was carried out at the Pediatric Hemato-Oncology unit of Children's Hospital of Rabat. Patients under 16 years of age with malignant disease treated by chemotherapy between January 2001 and December 2006 were recorded. Consecutive patients (n = 970) with malignant disease were studied. The age ranges from 2 months to 16 years (mean, 6.8 ± 4.1 years). OM occurred in 540 (55.6%) patients, and 17.9% of them encountered severe grades. Mean time to onset of the lesions was 10.5 ± 6.8 (range, 1-22 days) and mean duration was 6.8 ± 3.1 (range, 2-23 days). All chemotherapeutic protocols were associated with OM development (range, 20-100%). Patients with severe OM were more likely to have undifferentiated carcinoma of nasopharyngeal type (RR = 2.6, 95% IC 1.1-6.1), non-Hodgkin lymphoma (RR = 2.1, 95% CI 1.2-2.4) and acute leukaemia (RR = 1.7, 95% CI 1.5-3.6). Methotrexate-based therapies were also associated with the worsening of OM (RR = 1.7, 95% IC 1.2-2.6). Underlying disease and chemotherapy regimens are the principal risk factors of OM development. This model can help in the identification of patients at risk for adequate preventive and therapeutic measures.

Mielodisplasia en Pacientes Pediátricos: Evaluación de Clasificaciones Actuales

ABSTRACT Myelodysplasia in Pediatric Patients. Evaluation of Current Classifications Introduction: Myelodysplastic Syndrome (MDS) in pediatrics is a rare and difficult clinical picture todiagnose. Classifications currently in use do not always help in identifying risk factors for leukemictransformation in children. Objective: To evaluate the value of current classifications by simultaneouslydetermining a) the frequency of MDS in a pediatric population b) applying CCC classification (category,cytopenias, cytogenetic) and Passmore score (risk score), and c) correlating with progression and evolutionto leukemia. Methods: Medical records of 56 children with cytopenias who were registered at the Hemato-oncology Unit, Hospital Roberto del Rio, were retrospectively reviewed from July 2000 to December 2007. Results: 13 patients met MDS diagnostic criteria (7.3% of the total hematological malignancies population).According to CCC classification, de novo MDS, refractory cytopenias with dysplasia and abnormalkaryotype were the most frequent features. All patients with a high Passmore score progressed toleukemia.

Rituximab Use in Children - A Single Center Experience.

Treatment of children with chronic refractory ITP often results in significant morbidity and current therapies induce remission in fewer than half of children with chronic ITP. Rituximab is a humanized mouse monoclonal antibody against the B cell antigen CD20 that results in the prolonged depletion of B cells. CD20 is relatively selectively expressed on pre-B and mature B cells and may selectively treat antibody-mediated disorders. Among the lymphomas that occur in children, diffuse large cell NHL (DLCL) and Burkitt's lymphoma both express high levels of CD20. Data from adult clinical trials demonstrated that rituximab is active against B-cell low-grade lymphomas, particularly follicular center cell lymphoma, and is also active against diffuse large cell lymphoma. Rituximab has been safely combined with standard doxorubicin, cyclophosphamide, vincristine, prednisone (CHOP) chemotherapy, with no substantial increase in toxicity. This study examined the efficacy and safety of rituximab in children with chronic immune thrombocytopenic purpura (ITP) and Burkitt's lymphoma. It was a retrospective analysis of all children who received one or more courses of Rituximab in Pediatric Hemato-Oncology unit at Sir Ganga Ram Hospital from January 2005 to January 2006, who met the criteria of minimum follow up of 6 months. Five children age ranging from 3 yr to 11 years received 18 courses of rituximab during the study period. Three patients had chronic ITP (mean duration 20 months) non-responsive to IVIG, prednisolone, cyclosporin etc. Baseline platelet count were 10,000–15000/mm3. Rituximab was tried in an effort to avoid splenectomy. Each patient received 375-mg/m2 dose per course weekly for 4 weeks except one patients who could afford only 2 courses. First patient had response with platelets > 100000/mm3 for 8 months after which they again dropped to 15000/mm3. In other 2 cases sustained response has been seen with platelets >l00000/mm3 till date after a follow up of more than 12 months. Fourth patient had developed ITP during treatment of Precursor B cell Acute lymphoblastic leukemia (ALL) and had no response to steroids and IVIG. He responded after 4 courses of weekly rituximab and has maintained his platelets >50,000 except during chemotherapy blocks with follow up of 10 months. Now he is in maintenance phase of treatment for ALL. Fifth patient had abdominal Burkitt's lymphoma resected but had residual local mass. Bone marrow and CSF were negative. Child was treated as per MCP842 protocol for B cell lymphoma with 4 courses of chemotherapy and Rituximab. Rituximab was given 24 hr prior to start of chemotherapy in each course. Residual tumor cleared after 2 courses of chemotherapy and Rituximab. Child is in remission for 12 months after finishing chemotherapy. In regard to side effects, one patient of chronic ITP developed hypotension and drowsiness 15 min after start of infusion during 1st course which improved after stopping infusion but later it was restarted with no problems and tolerated following 3 courses well. However this same patient developed white matter changes on MRI head done for headache 12 months in follow up. She was also treated with cyclosporin in past and had no neurological problems. Patient with Burkitt's lymphoma developed late onset asymptomatic neutropenia 5 weeks after last course and recovered in following 3 weeks. Rituximab has good efficacy in cases of chronic ITP and Burkitt's lymphoma. However patients should be monitored for acute reactions, late onset neutropenia and long-term effect on brain with white matter changes.

Effective Control of a Nosocomial Outbreak of Vancomycin-Resistant Enterococcus faecium in a Hemato-Oncology Unit in a Korean Tertiary Care Hospital

BACKGROUND/OBJECTIVES: To determine the risk factors and cost for nosocomial vancomycin-resistant enterococci (VRE) bacteremia and to control the outbreak of nosocomial VRE bacteremia in a hemato-oncology unit. METHODS: A total of 7 cases of VRE isolated patients were detected from Nov 13 to Dec 2, 2005 in a 69-bed hemato-oncology unit in a 1250-bed tertiary care hospital in Korea. Thirty patients were selected for control among the patients without VRE infection or colonization, who were admitted to the same unit during the same period. Risk factors for VRE bacteremia were analyzed with Mann-Whitney U test and Fishers exact test. Intensive infection control strategies were implemented to control the VRE outbreak: reinforcing strict isolation and hand hygiene for VRE isolated patients, health care workers (HCWs); surveillance cultures from patients, HCWs and environment; thorough environmental cleaning and disinfection; re-education for HCWs about VRE infection control policies. RESULTS: Among the enrolled 7 patients, 4cases had VRE bacteremia and 3 cases were VRE rectal colonizer. VRE were grown from 5 out of 72 surveillance cultures of environment during the outbreak period. Before the outbreak, patients with VRE bacteremia were only 2 cases in the unit from Jan 1, 2004 to Nov 13, 2005. Risk factors for VRE bacteremia were as follows: indwelling Hickman catheter (p = 0.003), duration of hospitalization (p > 0.001), admission to a multi-bed room (p = 0.016) , <i>C. difficile</i> positivity (p = 0.027), and duration of vancomycin usage (p > 0.001). PFGE for VRE revealed 3 different PFGE patterns. VRE from 4 cases showed the same PFGE pattern as that of environmental culture isolates. Intensive infection control implementation terminated outbreak promptly and no new cases were detected up to now (for more than 1 month) after the outbreak. We spent around $900∼950 for investigation and control of the outbreak, which was cheaper than the cost for an isolation private room fee ($4760∼5460). CONCLUSIONS: Our data suggest that early intervention was very effective to control the outbreak and to save the extra cost of strict isolation for VRE patients.

Intérêt d’Abelcet ® dans la prise en charge des enfants neutropéniques fébriles

Aim of study. – In order to optimise the use of new forms of Amphotéricine B (Ampho B), a decisional tree was created at the end of 2001 in the paediatric hemato-oncology unit for the empirical antifungal treatment in febrile neutropenic children : the standard remained conventional Ampho B and Abelcet ® was proposed in case of antecedent or occurrence of a deterioration of the renal function (DRF). In order to validate the place of Abelcet ® we initiated a retrospective study over year 2002. Results. – 21 treatments were begun in 14 children for a median duration of 8 days (1–48 days). Three kind of indications were found: DRF antecedent (10 episodes : A group), DRF occurrence during a treatment with conventional Ampho B (7 episodes: B group), age lower than 1 year (3 episodes). 81% of the children were thus treated according to the decisional tree. The clinical tolerance was good in 90% of the cases, with a premedication in half of the cases. The study of the renal function showed a good renal tolerance for 6 episodes out of 9 evaluable in A group, 3 resolutions and 2 stabilisation of the renal failure for the 5 evaluable episodes of the B group. Seven to ten days of treatment by Abelcet ® were necessary to obtain the renal failure resolved. Conclusion. – This study confirms the interest of Abelcet ® in the empirical antifungal treatment in febrile neutropenic children and specially in children having antecedents of DRF related or not to a treatment with conventional Ampho B.