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Evans AM, Thabrew H, Arroll B, Cole N, Drake R. Audit of Psychosocial and Palliative Care Support for Children Having Allogeneic Stem Cell Transplants at the New Zealand National Allogeneic Transplant Centre. CHILDREN (BASEL, SWITZERLAND) 2021; 8:356. [PMID: 33946879 PMCID: PMC8146388 DOI: 10.3390/children8050356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 04/19/2021] [Accepted: 04/26/2021] [Indexed: 11/17/2022]
Abstract
Psychosocial and palliative care support during stem cell transplants (SCT) is known to improve outcomes. AIM evaluate the support provided to children and families at the New Zealand National Allogeneic Stem Cell Transplant unit (NATC). METHOD the psychosocial and palliative care support for children who received SCT between December 2012 and April 2018 was audited. RESULTS of the 101 children who received SCT, 97% were reviewed by the social work team (SW) and 82% by the psychiatric consult liaison team (CLT) at least once during their illness. However, pre-transplant psychological assessment only occurred in 16%, and during the SCT admission, only 55% received SW support, and 67% received CLT support. Eight out of eighty-five families (9%) were offered support for siblings. Eight of the sixteen children who died were referred for pediatric palliative care (PPC) with all supported and half the families who experienced a death (n = 8; 50%) received bereavement follow up. CONCLUSION although the majority received some social work and psychological support, auditing against the standards suggests the consistency of involvement could be improved. Referrals for PPC were inadequate and largely for end-of-life phase. Sibling support, in particular donor siblings, had insufficient psychological assessment and support. Key recommendations are provided to address this underperformance.
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Affiliation(s)
- Amanda M. Evans
- Paediatric Palliative Care Service, Starship Children’s Health, Auckland and Mary Potter Hospice, Wellington 6242, New Zealand
| | - Hiran Thabrew
- Consult Liaison Psychiatry Team, Starship Children’s Health and University of Auckland, Auckland 1010, New Zealand;
| | - Bruce Arroll
- Department of General Practice and Primary Health Care, University of Auckland, Auckland 1010, New Zealand;
| | - Nyree Cole
- Oncology and Haematogy Service, Birmingham Women’s and Children’s, Birmingham B15 2TG, UK;
| | - Ross Drake
- Paediatric Palliative Care and Pain Service, Starship Children’s Health, Auckland 1023, New Zealand;
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2
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Ghafoor S, Fan K, Williams S, Brown A, Bowman S, Pettit KL, Gorantla S, Quillivan R, Schwartzberg S, Curry A, Parkhurst L, James M, Smith J, Canavera K, Elliott A, Frett M, Trone D, Butrum-Sullivan J, Barger C, Lorino M, Mazur J, Dodson M, Melancon M, Hall LA, Rains J, Avent Y, Burlison J, Wang F, Pan H, Lenk MA, Morrison RR, Kudchadkar SR. Beginning Restorative Activities Very Early: Implementation of an Early Mobility Initiative in a Pediatric Onco-Critical Care Unit. Front Oncol 2021; 11:645716. [PMID: 33763377 PMCID: PMC7982584 DOI: 10.3389/fonc.2021.645716] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 02/01/2021] [Indexed: 12/23/2022] Open
Abstract
Introduction Children with underlying oncologic and hematologic diseases who require critical care services have unique risk factors for developing functional impairments from pediatric post-intensive care syndrome (PICS-p). Early mobilization and rehabilitation programs offer a promising approach for mitigating the effects of PICS-p in oncology patients but have not yet been studied in this high-risk population. Methods We describe the development and feasibility of implementing an early mobility quality improvement initiative in a dedicated pediatric onco-critical care unit. Our primary outcomes include the percentage of patients with consults for rehabilitation services within 72 h of admission, the percentage of patients who are mobilized within 72 h of admission, and the percentage of patients with a positive delirium screen after 48 h of admission. Results Between January 2019 and June 2020, we significantly increased the proportion of patients with consults ordered for rehabilitation services within 72 h of admission from 25 to 56% (p<0.001), increased the percentage of patients who were mobilized within 72 h of admission to the intensive care unit from 21 to 30% (p=0.02), and observed a decrease in patients with positive delirium screens from 43 to 37% (p=0.46). The early mobility initiative was not associated with an increase in unplanned extubations, unintentional removal of central venous catheters, or injury to patient or staff. Conclusions Our experience supports the safety and feasibility of early mobility initiatives in pediatric onco-critical care. Additional evaluation is needed to determine the effects of early mobilization on patient outcomes.
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Affiliation(s)
- Saad Ghafoor
- Division of Critical Care Medicine, Department of Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Kimberly Fan
- Department of Pediatric Critical Care, University of Tennessee Health Science Center, Memphis, TN, United States
| | - Sarah Williams
- Division of Critical Care Medicine, Department of Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Amanda Brown
- Division of Critical Care Medicine, Department of Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Sarah Bowman
- Division of Critical Care Medicine, Department of Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Kenneth L Pettit
- Office of Quality and Patient Care, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Shilpa Gorantla
- Office of Quality and Patient Care, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Rebecca Quillivan
- Office of Quality and Patient Care, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Sarah Schwartzberg
- Department of Rehabilitation Services, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Amanda Curry
- Department of Rehabilitation Services, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Lucy Parkhurst
- Department of Rehabilitation Services, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Marshay James
- Division of Critical Care Medicine, Department of Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Jennifer Smith
- Department of Child Life, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Kristin Canavera
- Department of Psychology, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Andrew Elliott
- Division of Psychiatry, Department of Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Michael Frett
- Division of Anesthesiology, Department of Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Deni Trone
- Department of Pharmaceutical Services, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Jacqueline Butrum-Sullivan
- Department Critical Care/Pulmonary Medicine-Respiratory Therapy, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Cynthia Barger
- Department of Inpatient Units-Nursing, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Mary Lorino
- Department of Inpatient Units-Nursing, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Jennifer Mazur
- Department of Nursing Administration- Nursing Education, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Mandi Dodson
- Department of Nursing Administration- Nursing Education, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Morgan Melancon
- Department of Nursing Administration- Nursing Education, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Leigh Anne Hall
- Department of Inpatient Units-Nursing, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Jason Rains
- Department Critical Care/Pulmonary Medicine-Respiratory Therapy, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Yvonne Avent
- Division of Critical Care Medicine, Department of Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Jonathan Burlison
- Department of Pharmaceutical Sciences- Patient Safety, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Fang Wang
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Haitao Pan
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Mary Anne Lenk
- Department of Quality Improvement Education and Training, Cincinnati Children's Hospital- James M. Anderson Center for Health Systems Excellence, Cincinnati, OH, United States
| | - R Ray Morrison
- Division of Critical Care Medicine, Department of Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Sapna R Kudchadkar
- Departments of Anesthesiology and Critical Care Medicine, Pediatrics and Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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Ahmad AH, Mahadeo KM. Perspective: A Framework to Screen Pediatric and Adolescent Hematopoietic Cellular Therapy Patients for Organ Dysfunction: Time for a Multi-Disciplinary and Longitudinal Approach. Front Oncol 2021; 11:622630. [PMID: 33718184 PMCID: PMC7943835 DOI: 10.3389/fonc.2021.622630] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 01/05/2021] [Indexed: 12/23/2022] Open
Abstract
Hematopoietic Cell Transplantation (HCT) is a potentially curative therapy for children and adolescent/young adults (AYA) with high-risk malignancies as well as some non-malignant genetic diseases. However, HCT may be associated with endotheliopathies and/or organ dysfunction that may progress to pediatric multi-organ dysfunction syndrome (pMODS) and require critical care intervention. Discipline specific scoring systems may be used to characterize individual organ dysfunction, but the extent to which they are used to prospectively monitor HCT patients with mild dysfunction is unknown. Further, separate scoring systems may be used to define risk of mortality and inform prognostication among those who require critical care support. Our understanding of the epidemiology, risk factors, morbidity, mortality, required monitoring, optimal prevention strategies and appropriate management of children undergoing HCT who develop organ dysfunction, endotheliopathies and/or progress to pMODS is poor. Discipline-specific registries and clinical studies have described improving outcomes for children undergoing HCT, including those who require critical care support; however, longitudinal studies/prospective registries that capture common data elements among HCT patients with and without organ dysfunction, endotheliopathies and pMODS are needed to facilitate inter-disciplinary collaboration and optimally characterize the risk profiles, define screening and prophylaxis regimens and mitigate toxicity.
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Affiliation(s)
- Ali H Ahmad
- Pediatric Critical Care Medicine, University of Texas at MD Anderson Cancer Center, Houston, TX, United States
| | - Kris M Mahadeo
- Pediatric Stem Cell Transplantation and Cellular Therapy and CARTOX Program, University of Texas at MD Anderson Cancer Center, Houston, TX, United States
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Lau-Braunhut SA, Smith AM, Steurer MA, Murray BL, Sawe H, Matthay MA, Reynolds T, Kortz TB. Functional Outcomes and Morbidity in Pediatric Sepsis Survivors: A Tanzanian Experience. Front Pediatr 2021; 9:805518. [PMID: 35111705 PMCID: PMC8801911 DOI: 10.3389/fped.2021.805518] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Accepted: 12/22/2021] [Indexed: 11/21/2022] Open
Abstract
Pediatric sepsis remains a significant cause of childhood morbidity and mortality, disproportionately affecting resource-limited settings. As more patients survive, it is paramount that we improve our understanding of post-sepsis morbidity and its impact on functional outcomes. The functional status scale (FSS) is a pediatric validated outcome measure quantifying functional impairment, previously demonstrating decreased function following critical illnesses, including sepsis, in resource-rich settings. However, functional outcomes utilizing the FSS in pediatric sepsis survivors have never been studied in resource-limited settings or in non-critically ill septic children. In a Tanzanian cohort of pediatric sepsis patients, we aimed to evaluate morbidity associated with an acute septic episode using the FSS modified for resource-limited settings. This was a prospective cohort study at an urban referral hospital in Tanzania, including children with sepsis aged 28 days to 14 years old over a 12-month period. The FSS was adapted to the site's available resources. Functional status scale scores were obtained by interviewing guardians both at the time of presentation to determine the child's baseline and at 28-day follow-up. The primary outcome was "decline in functional status," as defined by a change in FSS score of at least 3. In this cohort, 4.3% of the 1,359 surviving children completing 28-day follow-up had a "decline in functional status." Conversely, 13.8% of guardians reported that their child was not yet back to their pre-illness state. Three-quarters of children reported as not fully recovered were not identified via the FSS as having a decline in functional status. In our cohort of pediatric sepsis patients, we identified a low rate of decline in functional status when using the FSS adapted for resource-limited settings. A higher proportion of children were subjectively identified as not being recovered to baseline. This suggests that the FSS has limitations in this population, despite being adapted for resource-limited settings. Next steps include developing and validating a further revised FSS to better capture patients identified as not recovered but missed by the current FSS.
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Affiliation(s)
- Sarah A Lau-Braunhut
- Department of Pediatric Critical Care, Banner Children's at Desert Hospital, Mesa, AZ, United States.,Division of Critical Care, Department of Pediatrics, University of California, San Francisco, San Francisco, CA, United States
| | - Audrey M Smith
- Institute for Global Health Sciences, University of California, San Francisco, San Francisco, CA, United States
| | - Martina A Steurer
- Division of Critical Care, Department of Pediatrics, University of California, San Francisco, San Francisco, CA, United States
| | - Brittany L Murray
- Department of Pediatrics and Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, United States
| | - Hendry Sawe
- Department of Emergency Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Michael A Matthay
- Departments of Medicine and Anesthesia, Cardiovascular Research Institute, University of California, San Francisco, San Francisco, CA, United States
| | | | - Teresa Bleakly Kortz
- Division of Critical Care, Department of Pediatrics, University of California, San Francisco, San Francisco, CA, United States.,Institute for Global Health Sciences, University of California, San Francisco, San Francisco, CA, United States
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Zinter MS, Dvorak CC, Auletta JJ. How We Treat Fever and Hypotension in Pediatric Hematopoietic Cell Transplant Patients. Front Oncol 2020; 10:581447. [PMID: 33042850 PMCID: PMC7526343 DOI: 10.3389/fonc.2020.581447] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 08/24/2020] [Indexed: 11/13/2022] Open
Abstract
Pediatric allogeneic hematopoietic cell transplant (HCT) survival is limited by the development of post-transplant infections. In this overview, we discuss a clinical approach to the prompt recognition and treatment of fever and hypotension in pediatric HCT patients. Special attention is paid to individualized hemodynamic resuscitation, thorough diagnostic testing, novel anti-pathogen therapies, and the multimodal support required for recovery. We present three case vignettes that illustrate the complexities of post-HCT sepsis and highlight best practices that contribute to optimal transplant survival in children.
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Affiliation(s)
- Matt S Zinter
- Division of Critical Care Medicine, UCSF Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA, United States
| | - Christopher C Dvorak
- Division of Allergy, Immunology, and Blood and Marrow Transplantation, UCSF Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA, United States
| | - Jeffery J Auletta
- Division of Hematology, Oncology, Blood and Marrow Transplantation, Nationwide Children's Hospital, Columbus, OH, United States.,Division of Infectious Diseases, Nationwide Children's Hospital, Columbus, OH, United States
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Characteristics and Outcomes of Critical Illness in Children With Feeding and Respiratory Technology Dependence. Pediatr Crit Care Med 2019; 20:417-425. [PMID: 30676492 PMCID: PMC6502673 DOI: 10.1097/pcc.0000000000001868] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Children with dependence on respiratory or feeding technologies are frequently admitted to the PICU, but little is known about their characteristics or outcomes. We hypothesized that they are at increased risk of critical illness-related morbidity and mortality compared with children without technology dependence. DESIGN Secondary analysis of prospective, probability-sampled cohort study of children from birth to 18 years old. Demographic and clinical characteristics were assessed. Outcomes included death, survival with new morbidity, intact survival, and survival with functional status improvement. SETTING General and cardiovascular PICUs at seven participating children's hospitals as part of the Trichotomous Outcome Prediction in Critical Care study. SUBJECTS Children from birth to 18 years of age as part of the Trichotomous Outcome Prediction in Critical Care study. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Children with technology dependence composed 19.7% (1,989/10,078) of PICU admissions. Compared with those without these forms of technology dependence, these children were younger, received more ICU-specific therapeutics, and were more frequently readmitted to the ICU. Death occurred in 3.7% of technology-dependent patients (n = 74), and new morbidities developed in 4.5% (n = 89). Technology-dependent children who developed new morbidities had higher Pediatric Risk of Mortality scores and received more ICU therapies than those who did not. A total of 3.0% of technology-dependent survivors (n = 57) showed improved functional status at hospital discharge. CONCLUSIONS Children with feeding and respiratory technology dependence composed approximately 20% of PICU admissions. Their new morbidity rates are similar to those without technology dependence, which contradicts our hypothesis that children with technology dependence would demonstrate worse outcomes. These comparable outcomes, however, were achieved with additional resources, including the use of more ICU therapies and longer lengths of stay. Improvement in functional status was seen in some technology-dependent survivors of critical illness.
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Frascino AV, Costa C, de Andrade Salgado DMR, Coracin FL, Fava M, Odone-Filho V. Mandibular radiomorphometric assessment of bone mineral density in survivors of pediatric hematopoietic stem-cell transplantation. Clinics (Sao Paulo) 2019; 74:e929. [PMID: 31166472 PMCID: PMC6530437 DOI: 10.6061/clinics/2019/e929] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2018] [Accepted: 02/27/2019] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE Hematopoietic stem-cell transplantation (HSCT) childhood survivors of hematologic malignancies are prone to develop late osteopenia and osteoporosis. The purpose of this retrospective study was to quantitatively and qualitatively assess bone mineral density (BMD) in HSCT childhood survivors and to compare the effectiveness of both qualitative and quantitative assessment methods. METHODS DESIGN BMD assessment using panoramic radiographs of childhood HSCT survivors aged 3.69-18.88 years using two radiomorphometric indexes. Case-control double-blinded comparison of panoramic radiographic images from childhood HSCT survivors and age- and sex-matched healthy controls. Quantitative assessment was performed by measuring the cortical bone width bilaterally at the mental foramen level. Qualitative assessment was performed using the mandibular cortical index bilaterally on all panoramic images. RESULTS Radiographs were taken 6.59-83.95 months after bone marrow transplantation [median±SD=25.92±24.9 months]. Fifty-two panoramic radiographic images were analyzed: 21 from HSCT survivors and 31 from healthy controls aged 3.69-25.1 years [mean±SD=11.89±5.28 years]. The mandibular cortical bone width was 17% smaller in childhood HSCT survivors than in healthy controls (case group: 2.420, control group: 3.307; p=0.00617). Qualitative analysis revealed an increased frequency of severe mandibular cortical erosion in childhood HSCT survivors, although no significant difference was observed (case group: 1.540, control group: 1.490; p=0.32). The interobserver agreement was 85% (Kappa index). CONCLUSIONS HSCT childhood survivors exhibit quantitative and qualitative mandibular bone impairments. Further studies are needed to establish an association between mandibular cortical bone impairment and osteoporosis.
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Affiliation(s)
- Alexandre Viana Frascino
- Departamento de Pediatria, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, São Paulo, SP, BR
- Corresponding author. E-mail:
| | - Claudio Costa
- Departamento de Estomatologia, Faculdade de Odontologia, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | | | - Fabio Luiz Coracin
- Departamento de Saude, Faculdade de Odontologia, Universidade Nove de Julho, Sao Paulo, SP, BR
| | - Marcelo Fava
- Odontologia Pediatrica, Faculdade de Odontologia, Universidade Estadual Paulista (UNESP), Sao Jose dos Campos, SP, BR
| | - Vicente Odone-Filho
- Departamento de Pediatria, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, São Paulo, SP, BR
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Critical Care Management: Sepsis and Disseminated and Local Infections. CRITICAL CARE OF THE PEDIATRIC IMMUNOCOMPROMISED HEMATOLOGY/ONCOLOGY PATIENT 2019. [PMCID: PMC7123939 DOI: 10.1007/978-3-030-01322-6_14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Local and systemic infections are a significant cause of morbidity and mortality among immunocompromised children, including but not limited to patients with hematologic and solid malignancies, congenital or acquired immunodeficiencies, or hematopoietic cell or solid organ transplantation patients. Progression to septic shock can be rapid and profound and thus requires specific diagnostic and treatment approaches. This chapter will discuss the diagnosis and the initial hemodynamic management strategies of septic shock in immunocompromised children, including strategies to improve oxygen delivery, reduce metabolic demand, and monitor hemodynamic response to resuscitation. This chapter also discusses strategies to reverse septic shock pathobiology, including the use of both empiric and targeted anti-infective strategies and pharmacologic and cell therapy-based immunomodulation. Specific consideration is also paid to the management of high-risk subpopulations and the care of septic shock patients with resolving injury.
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9
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Frascino AV, Fava M, Cominato L, Odone-Filho V. Review of a three-year study on the dental care of onco-hematological pediatric patients. Clinics (Sao Paulo) 2018; 73:e721. [PMID: 30517306 PMCID: PMC6251250 DOI: 10.6061/clinics/2017/e721] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 08/20/2018] [Indexed: 11/18/2022] Open
Abstract
The aim of this study was to provide an updated review of dental procedures undertaken at the dental unit of the Onco-hematology service of the Instituto da Criança at the Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (ICr/HC-FMUSP). We retrospectively reviewed 565 of 1902 medical and dental records of patients diagnosed with onco-hematological diseases who were seen in a 3-year study (January 2015 to December 2017). We assessed data regarding population characteristics, onco-hematological diagnosis and dental procedures performed. Of the selected medical records, preventive dentistry was the most common procedure undertaken in this population, followed by oral maxillofacial surgeries, restorative dentistry and oral mucositis treatment. The most prevalent malignant diagnosis was acute lymphocytic leukemia, and the most prevalent nonmalignant diagnosis was sickle-cell anemia. Preventive dental procedures represent most of the dental procedures undertaken in hospitalized onco-hematological pediatric patients.
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Affiliation(s)
- Alexandre Viana Frascino
- Instituto da Crianca (ICr), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
- *Corresponding author. E-mail:
| | - Marcelo Fava
- Instituto da Crianca (ICr), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Louise Cominato
- Instituto da Crianca (ICr), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Vicente Odone-Filho
- Instituto da Crianca (ICr), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
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Thomas NJ, Spear D, Wasserman E, Pon S, Markovitz B, Singh AR, Li S, Gertz SJ, Rowan CM, Kunselman A, Tamburro RF. CALIPSO: A Randomized Controlled Trial of Calfactant for Acute Lung Injury in Pediatric Stem Cell and Oncology Patients. Biol Blood Marrow Transplant 2018; 24:2479-2486. [PMID: 30059785 PMCID: PMC10479933 DOI: 10.1016/j.bbmt.2018.07.023] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 07/14/2018] [Indexed: 11/23/2022]
Abstract
To assess if calfactant reduces mortality among children with leukemia/lymphoma or after hematopoietic cell transplantation (HCT) with pediatric acute respiratory distress syndrome (PARDS), we conducted a multicenter, randomized, placebo-controlled, double-blinded trial in 17 pediatric intensive care units (PICUs) of tertiary care children's hospitals. Patients ages 18 months to 25 years with leukemia/lymphoma or having undergone HCT who required invasive mechanical ventilation for bilateral lung disease with an oxygenation index (OI) > 10 and <37 were studied. Interventions used were intratracheal instillation of either calfactant or air placebo (1 or 2 doses). Forty-three subjects were enrolled between November 2010 and June 2015: 26 assigned to calfactant and 17 to placebo. There were no significant differences in the primary outcome, which was survival to PICU discharge (adjusted hazard ratio of mortality for calfactant versus placebo, 1.78; 95% confidence interval, .53 to 6.05; P = .35), OI, functional outcomes, or ventilator-free days, adjusting for risk strata and Pediatric Risk of Mortality (PRISM) score. Despite the risk-stratified randomization, more allogeneic HCT patients received calfactant (76% and 39%, respectively) due to low recruitment at various sites. This imbalance is important because independent of treatment arm and while adjusting for PRISM score, those with allogeneic HCT had a nonsignificant higher likelihood of death at PICU discharge (adjusted odds ratio, 3.02; 95% confidence interval, .76 to 12.06; P = .12). Overall, 86% of the patients who survived to PICU discharge also were successfully discharged from the hospital. These data do not support the use of calfactant among this high mortality group of pediatric leukemia/lymphoma and/or HCT patients with PARDS to increase survival. In spite of poor enrollment, allogeneic HCT patients with PARDS appeared to be characterized by higher mortality than even other high-risk immunosuppressed groups. Conducting research among these children is challenging but necessary, because survival to PICU discharge usually results in successful discharge to home.
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Affiliation(s)
- Neal J Thomas
- Department of Pediatrics, Pediatric Critical Care Medicine, Penn State College of Medicine, Hershey, Pennsylvania; Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania.
| | - Debbie Spear
- Department of Pediatrics, Pediatric Critical Care Medicine, Penn State College of Medicine, Hershey, Pennsylvania
| | - Emily Wasserman
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania
| | - Steven Pon
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Weill Cornell Medicine, New York, New York
| | - Barry Markovitz
- Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles, USC Keck School of Medicine, Los Angeles, California
| | - Aalok R Singh
- Maria Fareri Children's Hospital at Westchester Medical Center, New York Medical College, Valhalla, New York
| | - Simon Li
- Maria Fareri Children's Hospital at Westchester Medical Center, New York Medical College, Valhalla, New York
| | - Shira J Gertz
- Department of Pediatrics, Saint Barnabas Medical Center, Livingston, New Jersey
| | - Courtney M Rowan
- Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, Indiana
| | - Allen Kunselman
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania
| | - Robert F Tamburro
- Department of Pediatrics, Pediatric Critical Care Medicine, Penn State College of Medicine, Hershey, Pennsylvania; Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania
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The Association Between the Functional Status Scale and the Pediatric Functional Independence Measure in Children Who Survive Traumatic Brain Injury. Pediatr Crit Care Med 2018; 19:1046-1053. [PMID: 30119094 PMCID: PMC6218283 DOI: 10.1097/pcc.0000000000001710] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To determine the association between the Functional Status Scale and Pediatric Functional Independence Measure scores during the rehabilitation stay in children who survive traumatic brain injury. DESIGN Secondary analysis of a prospective observational cohort study. SETTING Tertiary care children's hospital with a level 1 trauma center and inpatient rehabilitation service. PATIENTS Sixty-five children less than 18 years old admitted to an ICU with acute traumatic brain injury and subsequently transferred to the inpatient rehabilitation service. INTERVENTIONS Not applicable. MEASUREMENTS AND MAIN RESULTS Functional Status Scale and Pediatric Functional Independence Measure at transfer to rehabilitation and Pediatric Functional Independence Measure at discharge from rehabilitation. The median age of the cohort was 7.1 years (interquartile range, 0.8-12.3 yr), and 29% were female. Nearly all of the children were healthy prior to the traumatic brain injury: six patients (9.2%) had a baseline Functional Status Scale score greater than 6. At the time of transfer to inpatient rehabilitation, total Functional Status Scale and Pediatric Functional Independence Measure scores had the expected negative correlation due to increasing disability resulting in lower scores in Pediatric Functional Independence Measure and higher scores in Functional Status Scale (r = -0.49; 95% CI, -0.62 to -0.35). Among subjects with less disability as measured by lower total Functional Status Scale scores, we found substantial variability in the total Pediatric Functional Independence Measure scores. In contrast, Pediatric Functional Independence Measure scores were consistently low among subjects with a wide range of higher total Functional Status Scale scores (more disability). CONCLUSIONS Although proprietary and more time-intensive, the Pediatric Functional Independence Measure has advantages relative to the Functional Status Scale for less severely injured patients and task-specific measurements. The Functional Status Scale may have advantages relative to the Pediatric Functional Independence Measure for more severely injured patients. Further investigations are needed to characterize changes in the Functional Status Scale during the rehabilitation stay and after discharge.
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Abstract
OBJECTIVES To describe practical considerations related to discussions about death or possible death of a critically ill child. DATA SOURCES Personal experience and reflection. Published English language literature. STUDY SELECTION Selected illustrative studies. DATA EXTRACTION Not available. DATA SYNTHESIS Narrative and experiential review were used to describe the following areas benefits and potential adverse consequences of conversations about risk of death and the timing of, preparation for, and conduct of conversations about risk of death. CONCLUSIONS Timely conversations about death as a possible outcome of PICU care are an important part of high-quality ICU care. Not all patients "require" these conversations; however, identifying patients for whom conversations are indicated should be an active process. Informed conversations require preparation to provide the best available objective information. Information should include distillation of local experience, incorporate the patients' clinical trajectory, the potential impact(s) of alternate treatments, describe possible modes of death, and acknowledge the extent of uncertainty. We suggest the more factual understanding of risk of death should be initially separated from the more inherent value-laden treatment recommendations and decisions. Gathering and sharing of collective knowledge, conduct of additional investigations, and time can increase the factual content of risk of death discussions. Timely and sensitive delivery of this best available knowledge then provides foundation for high-quality treatment recommendations and decision-making.
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