The temperature limit defining fever (TLDF) is based on scarce evidence. This study aimed to determine the rate of fever in neutropenia (FN) episodes additionally diagnosed by lower versus standard ...TLDF.
In a single center using a high TLDF (39.0°C tympanic temperature, LimitStandard), pediatric patients treated with chemotherapy for cancer were observed prospectively. Results of all temperature measurements and CBCs were recorded. The application of lower TLDFs (LimitLow; range, 37.5°C to 38.9°C) versus LimitStandard was simulated in silicon, resulting in three types of FN: simultaneous FN, diagnosed at both limits within 1 hour; earlier FN, diagnosed >1hour earlier at LimitLow; and additional FN, not diagnosed at LimitStandard.
In 39 patients, 8896 temperature measurements and 1873 CBCs were recorded during 289 months of chemotherapy. Virtually applying LimitStandard resulted in 34 FN diagnoses. The predefined relevantly (≥15%) increased FN rate was reached at LimitLow 38.4°C, with total 44 FN, 23 simultaneous, 11 earlier, and 10 additional (Poisson rate ratioAdditional/Standard, 0.29; 95% lower confidence bound, 0.16). Virtually applying 37.5°C as LimitLow led to earlier FN diagnosis (median, 4.5 hours; 95% CI, 1.0 to 20.8), and to 53 additional FN diagnosed. In 51 (96%) of them, spontaneous defervescence without specific therapy was observed in reality.
Lower TLDFs led to many additional FN diagnoses, implying overtreatment because spontaneous defervescence was observed in the vast majority. Lower TLDFs led as well to relevantly earlier diagnosis in a minority of FN episodes. The question if the high TLDF is not only efficacious but as well safe remains open.
Cancer survival comes at a price: pediatric cancer survivors bear a high risk for a wide range of cognitive difficulties. Therefore, interventions targeting these difficulties are required. The aim ...of the present clinical trial is to extend empirical evidence about efficacy of cognitive and physical training in pediatric cancer survivors. It is hypothesized that early cognitive and physical interventions affect the remediation of pediatric cancer survivors in terms of improved executive functions (primary outcome). Additional positive effects of cognitive and physical intervention to other areas such as memory and attention are expected (secondary outcome). Changes in cognitive performance are expected to be associated with structural and functional changes in the brain.
Overall, 150 pediatric cancer survivors and 50 matched controls will be included in this trial. The cancer survivors will be randomly assigned to either a computerized cognitive training, a physical training (exergaming) or a waiting control group. They will be assessed with neuropsychological tests, tests of sport motor performance and physical fitness before and after 8 weeks of training and again at a 3-months follow-up. Moreover, neuroimaging will be performed at each of the three time points to investigate the training impact on brain structure and function.
With increasing cancer survival rates, evidence-based interventions are of particular importance. New insights into training-related plasticity in the developing brain will further help to develop tailored rehabilitation programs for pediatric cancer survivors.
KEK BE 196/15; KEK ZH 2015-0397; ICTRP NCT02749877 ; date of registration: 30.11.2016; date of first participant enrolment: .18.01.2017.
There is no evidence-based definition of the temperature limit defining fever (TLDF) in children with neutropenia. Lowering the TLDF is known to increase the number of episodes of fever in ...neutropenia (FN). This study aimed to investigate the influence of a lower versus standard TLDF on diagnostics and therapy.
In a single pediatric cancer center using a high standard TLDF (39°C tympanic-temperature) patients were observed prospectively (NCT01683370). The effect of applying lower TLDFs (range 37.5°C to 38.9°C) versus 39.0°C on these measures was simulated in silicon.
In reality, 45 FN episodes were diagnosed. Of 3391 temperatures measured, 193 were ≥39.0°C, and 937 ≥38.0°C. For persisting fever ≥24 hours, additional blood cultures were taken in 31 (69%) episodes in reality. This number decreased to 22 (49%) when applying 39.0°C, and increased to 33 for 38.0°C (73%; plus 11 episodes; plus 24%). For persisting fever ≥48 hours, i.v.-antibiotics were escalated in 25 (56%) episodes. This number decreased to 15 (33%) when applying 39.0°C, and increased to 26 for 38.0°C (58%; plus 11 episodes; plus 24%). For persisting fever ≥120 hours, i.v.-antifungals were added in 4 (9%) episodes. This number increased to 6 (13%) by virtually applying 39.0°C, and to 11 for 38.0°C (24%; plus 5 episodes; plus 11%). The median length of stay was 5.7 days (range, 0.8 to 43.4). In 43 episodes with hospital discharge beyond 24 hours, applying 38.0°C led to discharge delay by ≥12 hours in 24 episodes (56%; 95% CI, 40 to 71), with a median delay of 13 hours, and a cumulative delay of 68 days.
Applying a low versus standard TLDF led to relevant increases of diagnostics, antimicrobial therapy, and length of stay. The differences between management in reality versus simply applying 39.0° as TLDF reflect the important impact of clinical assessment.
In couples dealing with health problems, we-disease appraisals can influence dyadic coping strategies to alleviate distress. This study describes the development and validation of a self-report scale ...to assess we-disease appraisals of health problems. The newly developed We-Disease Questionnaire (WDQ) was administered in three samples: parents of children with type 1 diabetes (
= 240) or cancer (
= 125) and individuals with visual impairment and their partners (
= 216). Reliability was measured by coefficient omega. To assess construct validity, correlations with other measures of individual and dyadic adjustment were examined. Descriptive statistics across all samples were compared. A 4-item version of the WDQ demonstrated good reliability and validity and showed meaningful associations with established scales. We-disease appraisals were highest among parents of children with cancer and lowest among couples with visual impairment. The WDQ is a reliable and valid measure that can be used across different health problems.
Background
Cancer survivorship is frequently associated with severe late effects. However, research into pediatric cancer survivors on late effects in motor ability, physical self‐concept and their ...relationship to quality of life is limited.
Methods
Using multiple regression analyses, 78 pediatric cancer survivors and 56 typically developing children were compared in motor ability, physical self‐concept and health‐related quality of life. In addition, mediational multi‐group analyses between motor ability (independent variable), physical self‐concept (mediator) and quality of life (dependent variable) were calculated.
Results
Pediatric cancer survivors had a lower motor ability (gHedges = 0.863), a lower physical self‐concept with regard to several scales of the PSDQ‐S (gHedges = 0.318–0.764) and a higher relative risk for a below average quality of life than controls (RR = 1.44). Children with a history of cancer involving the central nervous system showed poorer motor ability compared to those without central nervous system
involvement (gHedges = 0.591). Furthermore, the physical self‐concept significantly mediated the relationship between motor ability and quality of life in pediatric cancer survivors but not in typically developing children.
Conclusions
Results show the importance of monitoring and supporting the development of motor ability in the aftercare of pediatric cancer survivors. Physical activity interventions may be advisable to prevent physical activity‐related late effects and potentially improve related psychosocial variables such as quality of life.
This study shows that pediatric cancer survivors suffer from a lower motor ability, a lower physical self‐concept and a higher probability for a below average quality of life than controls. Both the motor ability and the physical self‐concept are related to quality of life, indicating that motor ability needs to be monitored in the aftercare of survivors of pediatric cancer.
Paediatric end-of-life care is challenging and requires a high level of professional expertise. It is important that healthcare teams have a thorough understanding of paediatric subspecialties and ...related knowledge of disease-specific aspects of paediatric end-of-life care. The aim of this study was to comprehensively describe, explore and compare current practices in paediatric end-of-life care in four distinct diagnostic groups across healthcare settings including all relevant levels of healthcare providers in Switzerland.
In this nationwide retrospective chart review study, data from paediatric patients who died in the years 2011 or 2012 due to a cardiac, neurological or oncological condition, or during the neonatal period were collected in 13 hospitals, two long-term institutions and 10 community-based healthcare service providers throughout Switzerland.
Ninety-three (62%) of the 149 reviewed patients died in intensive care units, 78 (84%) of them following withdrawal of life-sustaining treatment. Reliance on invasive medical interventions was prevalent, and the use of medication was high, with a median count of 12 different drugs during the last week of life. Patients experienced an average number of 6.42 symptoms. The prevalence of various types of symptoms differed significantly among the four diagnostic groups. Overall, our study patients stayed in the hospital for a median of six days during their last four weeks of life. Seventy-two patients (48%) stayed at home for at least one day and only half of those received community-based healthcare.
The study provides a wide-ranging overview of current end-of-life care practices in a real-life setting of different healthcare providers. The inclusion of patients with all major diagnoses leading to disease- and prematurity-related childhood deaths, as well as comparisons across the diagnostic groups, provides additional insight and understanding for healthcare professionals. The provision of specialised palliative and end-of-life care services in Switzerland, including the capacity of community healthcare services, need to be expanded to meet the specific needs of seriously ill children and their families.
Historically linked to sea voyagers in the 18th century, scurvy has become extremely rare during the last century in developed countries. However, it is still present in some at-risk populations and ...often overlooked in pediatric patients with restricted diets due to behavioral, neurodevelopmental, or psychiatric problems. So far, the only known etiology of developing scurvy is nutritional deficiency of vitamin C. In this report, we describe the case of a 3-year-old previously healthy Swiss girl without any history of previous poor dietary intake, who presented a picture of systemic inflammation including persisting fever, palpable purpura located on the extensor sides of the extremities, refusal to bear weight, and gingival bleeding. Blood tests revealed a significant increase of inflammatory markers and hypoalbuminemia. Full-body MRI revealed symmetrical bone marrow edema consistent with findings in previously reported cases of children with scurvy. After starting a high-dose oral vitamin C supplementation, the patient showed rapid clinical, laboratory, and radiologic improvement, but after stopping the treatment 4 months later, the patient developed relapse symptoms with pronounced fatigue, refusing to walk, and hair loss. These symptoms led us to restart the oral supplementation, which resulted in secondary normalization of her condition. The cause of her symptoms still remains unclear and presents the first case to our knowledge describing scurvy symptoms that are not directly linked to deficient dietary intake.
In children and adolescents with fever in neutropenia (FN) during chemotherapy for cancer, hemoglobin ≥90 g/L at presentation with FN had been associated with adverse events (AE). This analysis ...explored three hypothetical pathophysiological mechanisms potentially explaining this counterintuitive finding, and further analyzed the statistical association between hemoglobin and AE.
Two of 8 centers, reporting on 311 of 421 FN episodes in 138 of 215 patients participated in this retrospective analysis based on prospectively collected data from three databases (SPOG 2003 FN, transfusion and hematology laboratories). Associations with AE were analyzed using mixed logistic regression.
Hemoglobin was ≥90 g/L in 141 (45%) of 311 FN episodes, specifically in 59/103 (57%) episodes with AE, and in 82/208 (39%) without (OR, 2.3; 99%CI, 1.1-4.9; P = 0.004). In FN with AE, hemoglobin was bimodally distributed with a dip around 85 g/L. There were no significant interactions for center, age and sex. In multivariate mixed logistic regression, AE was significantly and independently associated with leukopenia (leukocytes <0.3 G/L; OR, 3.3; 99%CI, 1.1-99; P = 0.004), dehydration (hemoglobinPresentation/hemoglobin8-72 hours ≥1.10 in untransfused patients; OR, 3.5; 99%CI, 1.1-11.4; P = 0.006) and non-moderate anemia (difference from 85 g/L; 1.6 per 10 g/L; 1.0-2.6; P = 0.005), but not with recent transfusion of packed red blood cells (pRBC), very recent transfusion of pRBC or platelets, or with hemoglobin ≥90 g/L as such.
Non-moderate anemia and dehydration were significantly and relevantly associated with the risk of AE in children with cancer and FN. These results need validation in prospective cohorts before clinical implementation.
Introduction
Non‐central nervous system cancer in childhood (non‐CNS CC) and its treatments pose a major threat to brain development, with implications for functional networks. Structural and ...functional alterations might underlie the cognitive late‐effects identified in survivors of non‐CNS CC. The present study evaluated resting‐state functional networks and their associations with cognition in a mixed sample of non‐CNS CC survivors (i.e., leukemia, lymphoma, and other non‐CNS solid tumors).
Methods
Forty‐three patients (off‐therapy for at least 1 year and aged 7–16 years) were compared with 43 healthy controls matched for age and sex. High‐resolution T1‐weighted structural magnetic resonance and resting‐state functional magnetic resonance imaging were acquired. Executive functions, attention, processing speed, and memory were assessed outside the scanner.
Results
Cognitive performance was within the normal range for both groups; however, patients after CNS‐directed therapy showed lower executive functions than controls. Seed‐based connectivity analyses revealed that patients exhibited stronger functional connectivity between fronto‐ and temporo‐parietal pathways and weaker connectivity between parietal‐cerebellar and temporal‐occipital pathways in the right hemisphere than controls. Functional hyperconnectivity was related to weaker memory performance in the patients' group.
Conclusion
These data suggest that even in the absence of brain tumors, non‐CNS CC and its treatment can lead to persistent cerebral alterations in resting‐state network connectivity.
Non‐CNS childhood cancer is associated with alterations in functional connectivity. In patients, we observed both hyper‐ and hypoconnectivity when compared with healthy controls, however, altered functional connectivity was found only in the right hemisphere. Fronto‐parietal long‐range connections are more likely to be altered than short‐range connections. Stronger functional connectivity is associated with weaker verbal memory performance in survivors of childhood cancer.
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