CC BY
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SUPPORTIVE CARE/PALLIATIVE CARE
ABSTRACT NO.: 0P-101
Atypical presentation, diagnostic challenges and outcome of dengue infection in immnocompromised children with cancer: experience from India
Vasudeva Bhat, Shripad Banavali, Girish Chinnaswamy, Tushar Vora, Gaurav Narula, Maya Prasad, Sanjay Biswas,
Rohini Kelkar, Brijesh Arora
Tata Memorial Hospital, Mumbai, India
Key words: dengue, pediatric cancer
Introduction. Dengue Infection has varied immune-mediated clinical manifestations from minor self limiting flu like illness to severe shock. There is very little knowledge about its clinical presentation and outcome in immunocompromised patients with cancer and that prompted us to conduct this study. Aim. To study the clinical profile, diagnostics and complications in children with cancer infected with Dengue Virus.
Materials and methods. 78 patients with Dengue fever in children < 15 years with malignancies on active chemotherapy at Tata memorial Hospital from September 2013
to September 2015 were retrospectively analysed. ^
Results. Sixty one (78 %) were males and mean age was 8.53 years (range, 1-15 years). Fifty five (71 %) patients had a hematolymphoid malignancy with majority (42) <
on intensive chemotherapy phase (Induction or consolidation). Fever was the most common and universal presenting complaint. Myalgia was second commonest symptom seen in ^
65 % of patients, flushing was seen only in 16 (21 %)patients and bone pains were uncommon. In all the patients, only NS1 antigen was positive and both IgG and IgM were negative. >
Haemoglobin and hematocrit were in normal range in majority (97 %) of patients. Platelets on presentation ranged between 7-384 x109/L which steadily decreased to a range of <c
4-232 x109/L during the course of illness. Platelets recovered at a mean period of 7 days (range, 1-20 days). Platelet transfusions were required in 36 (46 %) patients; of which
25 (69 %) were refractory to platelets. Transaminits was common with mean AST and ALT values of 337 and 156 U/L respectively. CRP was low in 62 (79 %) with mean CRP value <C
1.78 mg/L (range, 0.02-19.2). Most common complication was ascites, which was seen in 23 patients (29 %) followed by pleural effusion which was seen in 12 patients (15 %).
The most serious complication was Hemophagolymphohistiocytosis (HLH) seen in 10 (13 %) patients. There were five deaths secondary to Dengue; two died of HLH and rest three
deaths due to immune reconstitution and capillary leak syndrome. U
Conclusion. In immunocompromised children with cancer presenting with fever, a high suspicion has to be kept for Dengue fever during Dengue endemic seasons as fever may be the >
only manifestation without classical flushing and bone or body pain. NS1 antigen should be used for diagnosis as antibody response is muted. Unlike general population, hematocrit ¡^
is normal is most children and platelet refractoriness is common. HLH is a common life-threatening complication and a high index of suspicion for HLH should be kept as timely use of q
steroids may be life-saving. Late immune reconstitution may be fatal; hence, children should be admitted for a period after recovery of blood counts. g-
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SIOP ASIA CONGRESS
ABSTRACT NO.: Q-160
Organization of nutritional support in a children's cancer hospital (the experience of our centre)
A.Yu. Vashura, E.S. Vasilyeva, Yu.V. Isarevich, D.V. Litvinov
Federal Research Center of Pediatric Hematology, Oncology and Immunology named after Dmitriy Rogachev, Moscow, Russia
Key words: children, pediatric oncology, nutrition, algorithm of nutrition support
Introduction. Nutritional deficiency and problems associated with it are registered with the incidence rate of 10-50 % in first-time hospitalized children with oncological diseases. During radiochemotherapy nutritional deficiency is diagnosed in 75-80 % of patients, and after hematopoietic stem cell transplantation (HSCT) it is registered in the ovewhelming majority of cases. The causes of nutritional deficiency include tumour intoxication, radiochemotherapy toxicity, diseases of the digestive system, eating disorder. Subjective causes, such as the delayed start of nutrition support (NS), inadequate adjustment of clinical nutrition, lack of motivation of treating physicians, exacerbate negative effects of these problems and nutritional disorders themselves. Nutritional deficiency increases the rate and intensity of complications, decreases survival rates, and makes treatment more expensive. Aim. In practice, it is important to detect nutritional disorders timely, at early stages of special treatment, and to correct them adequately. Nutritional support is a mandatory component of accompanying therapy at all stages of treatment and rehabilitation.
Materials and methods. The key principles of the organization of clinical nutrition in a children's cancer hospital are creation of nutritional support groups (NSG) and an algorithm of nutrition support (ANS). The aim of ANS is to optimize work associated with nutritional support of children at the children's cancer hospital, increase its efficiency, create and improve the necessary compliance between a treating physician and a specialist of NSG. We developed an ANS that is a main flowchart representing a certain sequence of actions and detailed comments. These comments allows a treating physician to orient in a situation as fast as possible.
Results. The actions of ANS include: daily screening of nutritional status (clinical and laboratory, findings, anthropometry); detailed nutritional assessment (bioelectrical impedance analysis, indirect calorymetry) for indications; calculation of actual food consumption; daily nutrient and energy requirements; NS (enteral nutrition, parenteral nutrition, mixed nutrition); monitoring of nutritional status (at least once a week); timely adjustment of recommendations that have already been made. Our long-term task appears to be a design of software, that will include ANS.
Conclusion. An important part of the nutrition support is the interest and proper motivation of treating physicians, because otherwise the provision of adequate nutritional support is impossible. Adherence to the formulated organizational and methodological principles is an essential prerequisite for provision of NS in pediatric oncology.
ABSTRACT NO.: PP-161
The results of screening for nutritional status of patients at a childrens' cancer hospital
E.S. Vasilyeva, A.Yu. Vashura, S.S. Lukina, D.V. Litvinov
Federal Research Center of Pediatric Hematology, Oncology and Immunology named after Dmitriy Rogachev, Moscow, Russia
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^ Introduction. Children who undergo treatment for oncological diseases have high risk of nutrition disorders. A series of studies has shown that nutrition deficiency in oncological
patients reduces tumour cell responsiveness to radiation and chemotherapy, significantly affecting treatment efficacy and causing more severe side effects of antitumour therapy. In view of this, the issue of state and dynamics of nutritional status of this category of patients seems to be of topical interest. Ij Aim. To analyze the screening results of the nutritional status of patients at hospitalization and during the course of chemotherapy.
< Materials and methods. In the FRC PHOI n.a. D. Rogachev the screening of our patients' nutritional status is carried out. The following anthropometric measures are estimated: \ height, body mass, body mass index (BMI), upper arm circumference, triceps skinfold, upper arm muscle circumference (UAMC). The examination is carried out once a week, or more oc often, if indicated. The assessment of the nutritional status also includes the investigation of the tissue composition of the body by the bioelectrical impedance analysis of patients U over 5 years old. The investigation results are entered into the electronic database and a case history (nutritional status assessment sheet).
w Results. The analysis of nutritional status screening data has revealed that the majority of children at hospitalization in children's cancer hospital have nutritional deficiency. So, body
¡H mass index (BMI) less than the 15th percentile at first examination was registered in 38 % of children with retroperitoneal neuroblastoma, in 29 % of children with nephroblastoma,
g in 37 % of children with CNS tumours, in 21 % and 35 % of children with acute lymphoblastic leukemia (ALL) and acute myeloblastic leukemia (AML) accordingly. Among the patients
Q- with bone tumours (74 % of which were diagnosed with osteosarcoma, 21 % of children had Ewing sarcoma and 5 % - other types of bone tumours) BMI less than the 15th percentile
3 at hospitalization was observed in 32 % of patients. The largest amount of patients with nutritional deficiency at the initial phase of study was registered among the children with
00 soft tissue sarcoma (54 %). We have also noted the lowering of upper arm muscle circumference indicator less than the 10th percentile in patients with nutritional status disorder,
that indicates a marked deficiency of somatic protein pool. The analysis of nutritional status screening data over time on week 5 and 10 has shown that the majority of the patients have negative dynamics of anthropometric measures caused both by the presence of main disease and by the influence of specific radiochemotherapy that was carried out. So, by the 10th week of the study, the number of patients with BMI less than the 15th percentile in the group of children with neuroblastoma has increased from 38 to 49 %, in patients with
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AML - from 35 to 43 %, in patients with nephroblastoma - from 29 to 43 %. In the group of patients with soft tissue sarcoma a number of children with nutritional deficiency by the 10th week remained considerable and amounted to 44 %. Upper arm muscle circumference indicators in these patients have also demonstrated negative dynamics that indicates progressive deficiency of somatic protein pool and muscle mass in patients in the setting of antitumour therapy being carried out.
Conclusion. The data we have collected demonstrate the need of correction of nutritional status in this category of patients as well as the advisability of preventive nutrition support.
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OF PEDIATRIC HEMATOLOGY and ONCOLOGY
ABSTRACT NO.: P-1 79
Thrombus depositions as a risk factor for the development of catheter-associated deep venous thrombosis in children
P.A. Zharkov, D.V. Fedorova
Federal Research Center of Pediatric Hematology, Oncology and Immunology named after Dmitry Rogachev, Moscow, Russia Key words: thrombosis, DVT, central venous line, CVL-related DVT, fibrin coat
Introduction. The presence of central venous line (CVL) is a risk factor for the development of deep venous thrombosis (DVT) especially in patients with malignant neoplasms (MN). Except "true", mural thrombosis, the presence of CVL in the central vein is often accompanied by the occurrence of the so-called "thrombus depositions" (TD) on the surface of the catheter that encircle the CVL in the form of "sleeve" or "cover", but do not involve the vessel wall. Despite frequent development of TDs on CVLs, data on their clinical relevance are very limited and controversial.
Aim. To estimate the role of TDs as a risk factor for the development of DVT in children with MN. To estimate the efficacy of antithrombotic agents in preventive care of DVT in patients with TD.
Materials and methods. Our analysis included retrospective data from electronic case report forms on 182 CVL that were inserted to 113 patients at the age of 1-19 years old who underwent therapy for acute lymphoblastic leukemia at FRC PHOI n.a. Dmitry Rogachev from August 2012 to December 2014. The presence of DVT and TD was estimated by echocardiography and Doppler ultrasound study of the extracranial parts of brachiocephalic veins. Statistical analysis was conducted with the use of IBM SPSS Statistics 20 software. Results. At least one detection of TD was registered on 63 (35 %) CVLs. The rate of TD occurrence was 2.71 per 1000 catheter-days. Odds-ratio for DVT development in patients with previous TD was 2.75 (95 % CI 1.32-5.74; P = 0.003). The efficacy of antithrombotic agents for the elimination of TD was assessed on the sample of 26 CVLs for which data on the delivery/absence of therapy and sizes of TD over time were available. In case of antithrombotic agents administration (low-molecular heparins, therapeutic doses) positive dynamics was registered in 7 (41 %) out of the 17 cases, without therapy - in 4 (44 %) out of the 9 cases. Statistically significant relation between the use of antithrombotic agents and the resolution of TD was not found (P = 0.598). The analysis of the influence of antithrombotic prophylaxis on the risk of DVT development in patients with TD revealed that in a group with antithrombotic agents administration DVT was detected in 15 (48%) out of the 31 CVLs, and in a group without antithrombotic agents administration DVT was detected in 9 (32 %) out of the 28 cases (P = 0.908).
Conclusion. TDs are a risk factor for the development of CVL-associated DVT; however, the efficacy of antithrombotic agents for prevention of TD and DVT in patients with TD is doubtful.
ABSTRACT NO.: P-180
Hypercoagulation phenomenon in children with deep venous thrombosis in the setting of treatment of malignant neoplasms
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P.A. Zharkov, M.A. Gracheva, E.N. Seregina, A.V. Poletaev, A.V. Pshonkin oc
Federal Research Center of Pediatric Hematology, Oncology and Immunology named after Dmitriy Rogachev, Moscow, Russia u
Key words: thrombosis, DVT, cancer, hypercoaguable state, thrombodynamics, clotting
Introduction. State of hypercoagulation is a laboratory phenomenon demonstrating a tendency to acceleration of thrombosis in vitro. Deep venous thrombosis (DVT) is a quite frequent comorbidity in children with solid tumours (ST), however, the relation of this complication with the state of hypercoagulation in children is not well studied. Aim. To estimate the presence of hypercoagulation state in children with newly diagnosed DVT in the setting of treatment of SD. cC
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Materials and methods. The investigation included 27 children undergoing treatment for SD at the age of 2-16 years old who were newly diagnosed with DVT based on the findings ^
of visualization (duplex sonography/computed tomography/magnetic resonance tomography/angiography). The distribution of the patients according to nosology: neuroblastoma - 7 (26 %), <
sarcomas - 8 (30 %), central nervous system tumours - 1 (19 %), hepatoblastoma - 2 (7 %), other tumours - 5 (19 %) детей. Before the start of anticoagulation therapy, D-dimer ш
concentrations were estimated (in 22 children) as well as a global hemostatic coagulation assay - Thrombodynamics - was performed. D-dimer values over 243 ng/ml and the enhancement of the velocity of clot growth (Vst) of more than 30 mcm/min according to the results of Thrombodynamics were taken as indicators of the presence of hypercoagulation. qc
Results. The presence of one or another indicator of coagulation was registered in 20 (91 %) out of the 22 patients, and the absence of these indicators was found in only 2 (9 %) О
out of the 22 patients. The increase in D-dimer concentration was detected in 17 (77 %) out of the 22 patients, and the increase in Vst - in 17 (63 %) out of the 27 examined patients. Q-
Given that, the increase in D-dimer concentrations was isolated in 5 (23 %) out of the 22 patients, and the isolated increase in Vst was found in 3 (14 %) children. A combination of oo
increased D-dimer concentration with the increase in Vst was registered in 12 (55%) out of the 22 patients.
Conclusion. One or another markers of hypercoagulation are detected in 91 % of children with DVT in the setting of treatment for ST, at the same time, the combination of increased D-dimer concentration with the increase in Vst is registered in 55 % of children. Further investigations are required in order to estimate the prognostic value of the detection of hypercoagulation markers in children with ST.
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SIOP ASIA CONGRESS
ABSTRACT NO.: OP-213
Time-to-antibiotic administration in children with febrile neutropenia:
a quality of care initiative
Namrata Todurkar, Amita Trehan, Deepak Bansal
Postgraduate Institute of Medical Education & Research, Chandigarh, India
Key words: time to antibiotics, febrile neutropenia
Introduction. Febrile neutropenia (FN) is on oncological emergency needing admission with prompt administration of antibiotics with time to antibiotics (TTA) being a quality of care measure.
Aim. To estimate the TTA in FN patients & evaluate causes for delay.
Materials and methods. Prospective study (July 2014 - June 2015) of patients admitted for FN. Transplant, relapsed & those presenting with hemodynamic instability were excluded. Primary outcome: patients who received antibiotics within 60 minutes of triage assessment (TTA). Age, time of day, weekday, level of doctor performing assessment, area of assessment & focus of infection were evaluated as predictor variables. A root cause analysis was done in cases of delayed TTA (DTTA).
Results. 211 children, age 6 years (0.6-15), with FN were evaluated. Median TTA: 60 minutes (IQR: 30-120). 78 % were examined by a senior physician (Registrar/Consultant), 28: intermediate level (3rd-6th semester residents) 18 were seen by junior physician (172nd semester residents). 120/211 were assessed during working hours, 59 in the evening and 32 at night. 105/211 evaluated in day care, 69: ward & 37 in clinic. 92 children were below 5 years. 65 % & 79 % received antibiotics within 1& 2 hours. Evaluating the predictor variables, odds of DTTA were 2.11 (P=ns) when assessed by a senior physician. Odds of DTTA were 1.37 & 1.02 (P=ns) when assessed during working hours and weekend. Odds were 1.37 (P = ns) when assessed in clinic/day care compared to ward. Age less than 5 years had an OR of 2.0 for DTTA. (P=0.018) DTTA odds were 1.72 (P = ns) in cases with no focus of infection vs. those with a focus of infection. There was no correlation between DTTA and duration of admission /mortality.
On doing a root cause analysis, waiting for blood results (29 %), delay in preparing antibiotics (32 %) & time taken for getting a file and allotment of bed (45 %) were the major causes of delay.
Conclusion. 65 % children got antibiotics within 1 hour of triage. Senior physician examination resulted in delay, possibly as they follow clinical judgement more than a junior resident following instructions for FN. Delay (P = ns) was seen during working hours & day care assessment, which could be attributed to a busy day care with other jobs in the daytime taking precedence. Weekend delay (P=ns) could be accounted for by less medical staff being on duty. Delay in children less than 5 years, which was significant, was difficult to rationalize. Time to complete admission formalities was the major root cause for delay accounting for 45 % of delays. No comment on prognostic significance of a prolonged TTA in pediatric FN cases can be made.
ABSTRACT NO.: PP-214
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Evaluating the effectiveness of ketamine plus atropine as anaesthesia for intrathecal chemotherapy and bone marrow aspiration at hospital, Vietnam
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Hue Central Hospital, Vietnam
Key words: ketamine, atropine
Introduction. Ketamine is a phencyclidine and cyclohexamine derivative. It is unique among the sedative analgesics in producing a dissociative state between the thalamus and the limbic system characterized by four features: sedation, analgesia, amnaesia and catalepsy. Ketamine and atropine have increasingly been used in recent years as an effective form of deep sedation/anaesthesia in children in developed countries, but not in developing countries like Vietnam. < Aim. This pioneer trial aimed to evaluate the effectiveness of using ketamine plus atropine as anaesthetic agents for paediatric oncology procedures. From this study, we establish
lu a protocol for anaesthesia in paediatric oncology procedures.
Materials and methods. A descriptive and prospective study on 52 paediatric patients of both sexes (33 males and 19 females) aged 7 months to 14 years (median age: 4.5 ± 3.2 oc years) and with body weight between 4.5 to 40 kg (median weight: 15.3 ± 6.2 kg) was carried out from January 2015 to January 2016. The patients had been diagnosed with either
2 acute lymphoblastic leukaemia or acute myeloid leukaemia. They underwent intrathecal chemotherapy and bone marrow aspirations for diagnostic as well as therapeutic purposes.
After obtaining informed consent from their parents, the research was performed. Datas were analysed by Medcalc software. oo Results. The total number of procedures was 127. Bone marrow aspiration was performed 59 times and intrathecal chemotherapy given 68 times. All procedures were successfully
completed. The dose of ketamine and atropine used 1.55 ± 0.31 mg/kg and 0.100 ± 0.029 mg respectively. The time taken for anaesthesia to wear off was short: 9.7 ± 9.5 minutes. Only 0.8 % experienced apnoea; 3.1 % convulsion; 1.6 % nystagmus, and hyperactivity; 2.4 % excess salivation, and dreaming; 7.1 % vomiting; none of the patients had laryngospasm or transient rash. All of the patients' parents were satisfied with the use of anaesthetics.
Conclusion. This is a pioneer trial for children in Vietnam. 1.5 mg/kg intravenous ketamine and 0.1 mg atropine were found to be effective and suitable dose in children requiring deep sedation for painful procedures and produce only minimal side effects. We established a protocol with the above doses and continue to apply this in order to reduce pain, trauma, and complications and to practice safely.
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ABSTRACT NO.: OP-223
Features of enteral nutrition and anorexia overcoming in hematopoietic stem cell transplantation in children
M. Kucher1, O. Pirogova1, O. Goloshchapov1, V. Karev2, A. Schvetsov1, B. Afanasyev1
1Raisa Gorbacheva Memorial Research Institute of Children Oncology, Hematology and Transplantation, First Pavlov State Medical University of St. Petersburg, Russia; 2Research institute for children's diseases, Saint-Petersburg, Russia
Key words: hematopoietic stem cell transplantation, nutrition support, anorexia
Introduction. Hematopoietic stem cell transplantation (HSCT) is a modern and effective method of treatment for oncological, hematological and inherited diseases. It's associated with many complications, among others special place take malnutrition which is formed as a result of anorexia, mucositis, "graft versus host disease"(GvHD) and reduces the effectiveness of treatment. Aim. To evaluate the effectiveness of enteral feeding and appetite stimulants in pediatric patients with HSCT.
Materials and methods. We analyze 143 cases (40 of them were secondary) of clinical nutritionist consultations for patients with different types of chemotherapy and HSCT in 2015. The age of patients ranged from 4 months to 21 years (median 11.6 years). 109 patients underwent HSCT: allogeneic unrelative (n = 55), allogeneic relative (n = 13), autologous (n = 4), haploidentical (n = 37); chemotherapy (n = 30); immunotherapy (n = 3). For the assessment of nutritional status anthropometry, biochemical markers were applied. To assess the severity of GvHD - histological examination of biopsy specimens of the stomach and intestine was performed.
Results. The main syndromes were: lack of body mass of 75.5 % (n = 108), anorexia 63,6 % (n = 91), intestinal dyspepsia of 25.2 % (n = 36), malabsorption of 14.7 % (n = 21). The greatest negative impact on nutritional status had intestinal GVHD (P = 0.0001). For prevention and correction of malnutrition, depending on type of HSCT, time after treatment and the extent of damage of gastrointestinal tract, patients received various types of nutritional support (NS): low-microbial diet (n = 51), sipping/enteral nutrition (n = 67), combination of methods with parenteral nutrition (n = 25). Primary NS was ineffective in 60.8 % of cases - further decrease in anthropometric parameters and biochemical markers of nutritional status were observed. To correct malnutrition second line NS therapy was provided (n = 40), which includes appetite stimulants, complex enzymes of the digestive system, change of enteral nutrition regimens from polymeric mixtures to semielemental and specialized depending on the clinical situation. Second-line therapy was more effective: "megestrol acetate + diet" in 72.3 % of cases; "megestrol acetate + Pediasure" in 65.3 % of cases. In the case of malabsorption syndrome greatest efficacy and compliance - 31.5 % of cases were noted in "megestrol acetate + Peptamen" group.
Conclusion. Patients with HSCT are at high risk to develop malnutrition due to severe violations of digestion process, anorexia, hypercatabolism in the case of GvHD. Correction of malnutrition is complicated by low tolerance for enteral nutrition formulas. Higher efficacy was observed when using specialized semielemental mixtures in combination with appetite stimulants (megestrol acetate) and enzymes compared to the standard schemes of NS.
ABSTRACT NO.: PP-230
Patient-controlled analgesia with tramadol in children and adolescents with gastro-intestinal mucositis after high-dose chemotherapy with autologous
hematopoietic stem cell transplantation %
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E. Goncharova, A. Kozlov, A. Potemkin, L. Zubarovskaya, B. Afanasyev p
Raisa Gorbacheva Memorial Research Institute of Children Oncology, <
Hematology and Transplantation, First Pavlov State Medical University of St. Petersburg, Russia z!
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Key words: pain, PCA, mucositis, tramadol w
Introduction. Gastro-intestinal acute mucositis (GI AM) is one of the most frequent complications after high-dose chemotherapy with autologous hematopoietic stem cell <
transplantation (HDCT with auto-HSCT). The incidence of GI AM varies from 75 to 99 % (L. Vagliano et al., 2011). Typical feature of GI AM is a various intensity pain syndrome. According ^
to European Pain Federation EFIC recommendations patient-controlled analgesia (PCA) was used in the study. >
Tramadol is widely administered in Raisa Gorbacheva Memorial Institute of Children Oncology Hematology and Transplantation, First Pavlov Saint Petersburg State Medical University ^
for purposes of pain control. Tramadol's metabolite - mono-0-desmethyltramadol demonstrates mechanisms of opioid and non-opioid actions and relatively prolonged elimination O
half-life. The role of tramadol administration in children is not completely established but there are data supporting tramadol as moderate pain reliever with high efficiency and safety cl
profile (WHO). The feasibility of tramadol administration by means of PCA also needs further investigation. ^
Aim. Evaluation of efficiency and safety of PCA with tramadol in children and adolescents with GI AM after HDCT with auto-HSCT.
Materials and methods. In the study 33 patients after HDCT with auto-HSCT were included. Median age was 9 (range 3-18). Indications for HDCT with auto-HSCT were neuroblastoma (n = 14), Ewing's sarcoma (n = 8), medulloblastoma (n = 7), Hodgkin's lymphoma (n = 2), ganglioneuroblastoma (n = 1), primitive neuroectodermal tumor (n = 1). All patients had GI AM grade 2-3. Duration of cytopenia varied from 7 to 20 days. Median length of pain reliever administration was 7 days (range 3-12). In order to analyze pain intensity Face Scale and Visual Analogue Scale (VAS) were used. Patient-controlled anelgesia was administered in all patients (loading dose 0.5 mg/kg, background infusion 0.25 mg/kg, bolus 0.25 mg/kg, lockout 15 minutes).
Results. Before the start of PCA median pain intensity (VAS score) was 7 (range 5-10). The median of pain score, patients could cope with was 4 (range 2-5). The median number of pain-associated night awakenings was 3 (range 1-5). The median VAS score after the start of pain relief therapy was 3 (range 0-4) and the most of children didn't wake up at night or woke up only once. Only in 2 patients (6 %) adequate level of analgesia couldn't be achieved and morphine was administered as a next drug in WHO pain relief ladder. Adverse effects of tramadol that were registered in the study included drowsiness in 6 patients during first two days (didn't require correction), nausea in 3 (9 %) patients (required antiemetic therapy), hearing hallucinations in 1 (3 %) patient with medulloblastoma (required withdrawal of tramadol and switch to morphine).
SIOP ASIA CONGRESS
Conclusion. PCA with tramadol is effective and safety pain reliever in children and adolescents with GI AM grade 2-3 after HDCT with auto-HSCT. Low incidence of night breakthrough pain episodes is associated with prolonged elimination half-life.
ABSTRACT NO.: OP-246
Spectrum of microbiological infections and resistance pattern in pediatric oncology patients: experience from a tertiary care center in North India
Vinod Gunasekaran, Nita Radhakrishnan, Veronique Dinand, Shiny Joy, Chand Wattal, Anupam Sachdeva
Sir Ganga Ram HospitaL, India
Key words: pediatric oncology, microbiological infections, antibiotic resistance
Introduction. In developing countries, infections pose the major challenge in curing pediatric malignancies. Data on spectrum of infections and resistance patterns in pediatric oncology from developing countries is sparse.
Aim. The aim of our study is to analyze the spectrum of microbiological infections and their resistance patterns among children receiving chemotherapy presenting with fever. Materials and methods. Pediatric oncology patients presenting with fever were enrolled (2007-2015). Results of the microbiological investigations were recorded. The spectrum of infections and their sensitivity pattern were analyzed.
Results. There were 1023 episodes of fever evaluated. 590 (57.6 %) episodes were febrile neutropenia. 225 (22 %) had microbiologically documented infections. Since 2012, around 90 % patients had central venous access devices. Gram positive, gram negative, fungal, viral, mycobacterial and parasitic infections accounted for 53 (23.5 %), 89 (39.5 %), 51 (22.6 %), 30 (13.3 %), 1 (0.4 %) and 1 (0.4 %) cases respectively. Spectrum of gram positive infections (n = 53) included coagulase negative Staphylococcus (65.7 %), Staphylococcus aureus (11.3 %), Enterococcus fecium (13.2 %), Enterococcus fecalis (3.7 %), Streptococcus pneumoniae (1.8 %) and other Streptococcal species (4.3 %). Gram negative infections (n = 89) included Klebsiella pneumoniae (29.2 %), Pseudomonas species (21.7 %), Escherichia coli (16.8 %), Acinetobacter species (8.9 %), Stenotrophomonas maltophilia (5.6 %), Proteus mirabilis (2 %), Salmonella species (2 %), Nocardia (1 %), Chryseobacterium (1 %), Elizabethkingia meningoseptica (1 %) and unidentified (in 11 %). Invasive aspergillosis was diagnosed in 34 cases (using galactomannan assay). Fungus isolated from body fluids (n = 17) included Candida albicans (5), Candida tropicalis (3), Candida parapsilosis (3), Candida glabrata (1), Candida haemulonii (1), Candidapelliculosa (1), Aspergilllus (1) and Trichosporon asahii (2). Documented viral infections included Cytomegalovirus (19), Dengue (6), Epstein-Barr virus (4) and Herpes simplex virus (1). One child had Cryptosporidiosis. With advancing years, incidence of gram positive infections decreased. Vancomycin resistance has not been observed among gram positives. Among Klebsiella and E.coli, extended spectrum beta lactamases were produced by 96 % and 81 % respectively, whereas carbapenemases were produced by 44 % and 31 % respectively.
Conclusion. Gram negative bacteria are the major isolates at our center. Gram positive isolates have shown reduction with time due to better nursing care of central lines. Multidrug resistant gram negative bacteria and aspergillus infections are emerging concerns.
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AABSTRACT NO.: PP-264
Successful emergency helicopter transfer for a boy of mediastinal lymphoblastic lymphoma complicated with reexpantion pulmonary edema and cardiac tamponade
Ritsuo Nishiuchi, Naoko Oura, Chiho Tokorodani, Kiyoshi Sasaki
Kochi Health Sciences Center
Key words: helicopter transfer, reexpantion pulmonary edema, cardiac tamponade
Introduction. Pleural and pericardial effusions are common oncologic emergencies, while reexpantion pulmonary edema (REPE) is a rare and potentially lethal complication for removal of pleural effusion.
0 Aim. Case repot.
01 Materials and methods. Case report.
^ Results. An eleven-year-old boy presented at a local hospital complaining of cough for the prior two weeks and appetite loss. A chest X-ray and computed tomography (CT) showed
findings of a large right pleural effusion and anterior mediastinal mass. Thoracentesis was performed resulting in the aspiration of 1900 ml. A few hours later, he started coughing, had dyspnea and pulse oximeter reading of 79 %. After removal of additional 700 ml effusion, his condition deteriorated and tracheal intubation was performed. The emergency helicopter transfer was requested at 17:30. He was picked up at 18:02 and arrived in our hospital at 18:53. Vital signs were: temperature of 38.0 °C pulse of 153/min, blood pressure of 145/93 mm Hg, respiratory rate of 40/min, a pulse oximeter reading of 82 % with 10 L/min oxygen. CT showed diffuse area of consolidation and ground-glass opacity in the right lung, suggestive of REPE. Echocardiography showed cardiac tamponade caused by pericardial effusion and compression by the tumor. Surgical drainage of pericardial effusion and biopsy of mediastinal mass with right anterolateral thoracotomy was performed from 3:32 to 7:11 on the 2nd day of admission. Simultaneously prednisolone was started for treatment of lymphoma. After surgery, his oxygen saturation and hemodynamics improved gradually. A diagnosis of T-cell lymphoblastic lymphoma (CD2+, CD3+, CD4+,CD 7+, CD8+, CD10+) was made based on histopathology of biopsy and flow cytometry results of pleural effusion. On the 4th day, his tracheal and pleural drainage, pericardial drainage tube were removed. On the 9th day, he started intensive chemotherapy according to JPLSG ALB-NHL03 protocol. He completed chemotherapy and remains disease free. Conclusion. Pediatric oncologists must recognize oncologic emergencies and treat them quickly with cooperation of emergency physicians and surgeons.
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ABSTRACT NO.: OP-288
Indicators of the Russian infrastructure of inpatient pediatric palliative care with malignancies
D.V. Nevzorova1, E.V. Polevichenko2, L.S. Kochetkova3
1Hospice № 1 named after V.V. Millionschikova, Moscow, Russia; 2Pirogov Russian National Research Medical University, Moscow, Russia; 3Research institution - Higher School of Economics, Moscow, Russia
Key words: children, pediatric palliative care, malignant diseases
Introduction. Intensive development of infrastructure of palliative medical care (PMC) for children in Russia is focused on the indicator value of the Government program of the Russian Federation "Healthcare development" - the availability of hospital beds for providing PMC (up to 2.08 per 100 thousand children by 2020). Nosological structure of patients who these beds are provided for during hospitalization considerably in different subjects of the Russian Federation and reflects healthcare quality indicators including compliance with clinical guidelines and pain management standards.
In 2013 998 children with malignant neoplasms (MN) under 18 years died in the Russian Federation. In order to plan and improve pediatric oncological care quality in regions it is necessary to evaluate the availability of stationary palliative medical care (PMC) for children with malignant neoplasms (MN). Aim. To evaluate the usage of bed capacity of PMC for children of the Russian Federation for incurable patients with MN in 2014-2015.
Materials and methods. A retrospective analysis of reported data provided by the governmental authorities in the field of health protection of the subjects of the Russian Federation. Results. As on October 1, 2015 PMC for incurable children in the RF was provided by 5 pediatric hospices, 29 inpatient departments of PMC for children and 20 mobile patronage teams of PMC for children.
Total bed capacity of PMC for children was 566 that ensured treatment of 2778 children over 9 months in 2015. Children with MN (n = 388) comprised 14.0 % of the total number of children who received care on palliative beds while the numerically prevalent nosological group during inpatient PMC consisted of children with neurologic pathology (n = 1755; 63.2 %). Similar figures in 2014 were the following: total number of patients who received treatment using beds of PMC for children was 2947, 382 (13.0 %) of which had MN. Incurable children with MN received care on palliative beds not in all subjects of the RF. Only 29 (34.1 %) of 85 subjects of the RF admitted these patients in order to provide stationary PMC. On average the inpatient PMC was provided to 13.4 of children with oncological diseases per 1 subject of 29 mentioned over 9 months. No significant changes were noted in comparison with the similar data of 2014 when in 23 subjects the inpatient PMC was provided to 382 children with MN (on average 16.6 children per 1 subject). Conclusion. In 2014-2015 in the RF children with oncological diseases comprised 12-13 % of all patients who received treatment using beds for stationary PMC that corresponds to the data from international medical statistics.
Not more than in one third of all subjects palliative beds were used for children with MN. No more than one third of the deceased children with MN received stationary PMC. Taking into account undeveloped network of ambulatory forms of palliative care for children and the absence of pediatric non-invasive forms of narcotic analgesics it is necessary to improve availability of the stationary PMC for children with oncological diseases in those regions of Russia where it was not established and was not used in 2014-2015.
ABSTRACT NO.: OP-300
Cytomegalovirus (CMV) viraemia and disease in children with haematological malignancies undergoing conventional chemotherapy: a study from a referral cancer centre in India
Anand Koratagere Chandrashekhar, Tushar Idhate, Gaurav Narula, Brijesh Arora, Shripad Banavali
Tata Memorial Hospital, Mumbai, India
Key words: CMV infection, children, non-transplant setting
Introduction. There is a paucity of data on Cytomegalovirus (CMV) infection in children with haematological malignancies in non-transplant settings, which is critical to plan timely therapy and reduce morbidity and mortality.
Aim. To study the clinic- biological features of CMV infection in children with hematological malignancies receiving myelo-suppressive chemotherapy in non- transplant setting. Materials and methods. Between January 2008 and November 2015, we screened all children with haemato-lymphoid malignancies having unexplained fever, prolonged cytopaenia, haemophagocytic lymphohistiocytosis (HLH) or clinical CMV disease, for CMV using RT-PCR technique. CMV-positive episodes were analysed for clinical features and response to treatment. Results. Seventy children had CMV infection. Of them, 61 (87 %) had CMV DNAemia and 9 (13 %) had CMV disease. The primary diagnoses were ALL (n = 59, 85 %), AML (n = 2), NHL (n=6), Hodgkin's lymphoma (HL, n = 2), and CML (n = 1). The median age was 12 years. For ALL patients, CMV DNAemia and disease occurred mostly during either consolidation (46 %) or maintenance (36 %) phase. The most common presenting feature of CMV infection was unexplained fever without focus (n = 68, 97 %). Of these, 37 (54.5 %) had no associated cytopaenias. All became afebrile at median ganciclovir duration of 3 days (range, 2-7 days). The rest (n = 31, 45.5 %) had unexplained fever with cytopaenia, and all recovered after a variable period of 3 to 28 days (median, 15 days). Two of them developed HLH and were treated with HLH protocol along with antiviral therapy. For patients with CMV viraemia, CMV titres became undetectable after a median period of 17 days (range 7-34 days). Five had relapse of CMV-viraemia: two had complete response and survived, while 3 died of primary malignancy during CMV therapy.
For the 9 with CMV disease, their primary diagnoses were ALL (n = 6), AML (n = 1), HL (n = 1), and Burkitts lymphoma (n = 1). Disease sites were chorio-retinitis (n = 2), pneumonitis (n = 3), gastrointestinal disease (n = 2) and encephalitis (n = 1). In addition, one patient had both GI infection and CMV encephalitis. After treatment with I.V. ganciclovir, 5 patients recovered fully, 2 died of CMV, one died of progressive primary disease and one was lost to follow up. Out of the 2 children with chorio-retinitis, one had permanent visual deficits while the other recovered normal vision.
Conclusion. CMV DNAemia and disease are prevalent in children with haematological malignancies on standard-dose therapy. ALL patients were more commonly affected, usually during the consolidation phase of ALL therapy. Most patients presented with unexplained fever with or without prolonged cytopaenias. Approximately 15 % can progress to HLH or CMV disease if not detected in time. Timely detection and therapy with ganciclovir is curative in most children.
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ABSTRACT NO.: OP-352
Disparities in the global landscape of palliative care clinical trials
Catherine Lam1, Scott Howard2
1St. Jude Childrens Research Hospital; 2University of Memphis
Key words: clinical trials, palliative care, global health, disparities
Introduction. Globally, palliative care is under-developed in many regions, as highlighted by the first World Health Organization (WHO) and Worldwide Palliative Care Alliance (WPCA) Global Atlas of Palliative Care at the End of Life (2014). Understanding the landscape of research across settings globally can identify key implementation gaps. Aim. We compared palliative care clinical trials across regions and income-settings relative to the expected patient needs as defined by the WHO/WPCA Atlas, and evaluated the current extent of inter-regional research.
Materials and methods. The WHO International Clinical Trials Registry Platform (ICTRP) was searched for palliative care trials (interventions, conditions, and/or key words), including data from 16 international sources across all six WHO regions (Americas (AMRO), African (AFRO), Eastern Mediterranean (EMRO), South East Asia (SEARO), and Western Pacific (WPRO)), last searched 1/29/2016. Data was extracted for trials pertaining to children (age 0-14 years) and adults. Primary outcome was proportion of trials conducted in countries per WHO region and World Bank income group (low-income [LIC], lower-middle-income [LMIC], upper-middle-income [UMIC], and high-income [HIC]). Comparative data was extracted from the WHO/WPCA Atlas. Secondary outcomes included the countries and regions represented per trial.
Results. Across 781 palliative trials registered, 58 countries were represented. Of the 746 adult trials, there were disparities in the proportion of trials from regions relative to patients in need, including under-representation in SEARO (5 % of trials vs 22 % of burden) and over-representation in EURO (44 % vs 22 %). There was under-representation in the proportion of trials including LMIC (5 % vs 29 %) or UMIC (7 % vs 41 %), and disproportionately more including HIC (90 % vs 22 %). No registered trial specified inclusion of a low-income country. Overall, although low- and middle-income countries account for more than 3/4 of the palliative care burden, they are represented by less than 1/8 of the trials, such that patients in HIC have access to 27 times more trials per patient in need compared to those outside HIC. The 35 (4 % of total) trials inclusive of pediatric needs appeared to correspond to WPCA's estimate of this age group reflecting 6 % of global needs. However, comparing proportion of trials to burden by region, there was under-representation in AFRO (0 % of trials vs 49 % of global burden), SEARO (0 % vs 24 %), and EMRO (3 % vs 12 %), with over-representation in other regions, notably AMRO (66 % vs 5 %). There was under-representation from LIC (0 % vs 35 %), LMIC (3 % vs 49 %), UMIC (6 % vs 14 %), and over-representation from HIC (94 % vs 2 %). Although low- and middle-income countries have 98 % of children with palliative care needs, they are represented by only 9 % of the trials, such that patients in HIC have access to 523 times more trials per patient in need. Across all trials, most (93 %) were single-country studies; of the 53 multi-country trials (involving up to 16 countries, 6 regions and 3 income groups), most involved countries within one region (60 %) and one income group (72 %). Only 3 pediatric studies (9 %) were multi-country trials.
Conclusion. Disparities in palliative care clinical trials include under-representation of trials relative to needs in South-East Asia and low- and middle-income countries for both adults and children. To address implementation gaps in these areas, further research investment and inter-regional collaborations are warranted.
ABSTRACT NO.: OP-363
Evaluation of chemotherapy-induced oral mucositis in pediatric oncology hospital
Sarah Mohamed Abdelsamie, Mohamed Abdelrahman, Doaa Abdelmegeed
^ Children's Cancer Hospital 57357, Egypt
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Key words: mucositis, pediatric oncology
Introduction. Oral mucositis (OM) is a common side effect experienced during chemotherapy course, and it can have a significant impact on the quality of life of patients. fC The incidence of oral mucositis in pediatric cancer patients was evaluated in 105 children with cancer, as well as associated risk factors, and patient adherence through interviewing
Ij patients/patient relatives and reviewing data from patients medical records.
cE Aim. To demonstrate the incidence of chemotherapy-induced oral mucositis (OM) in pediatric oncology hospital, identify patient populations at highest risk, evaluate level of patient
lu education concerning mucositis, evaluate patient awareness and adherence to OM prophylaxis counseling.
Materials and methods. 105 chemotherapy patients/patient relatives were interviewed to report any experience on oral mucositis since therapy started, and to mention the mouth care instructions they know. At the same time, the 105 patients' medical records (MR) were reviewed to gather demographics and related information. Results. Overall incidence of mucositis was 79 % (n = 83). A total of 79 % (n = 83) of patients developed OM at least once with a total no. of 163 OM events with 1.96 (=2) OM events developed per patient. Conflicts between patient answers and patient Medical Records documentation were faced (36 % of 105 patients) due to either inappropriate OM event Ô documentation (35 % of total 83 positive OM patients) or patient unawareness of the event (9 % of total 105 patients). Regarding gender; females were at greater risk of developing
OM than males with (85 %) developed OM compared to (79 %) within males. Greater child age was a risk for increased susceptibility to OM with 92 %, 81 %, 72 % within the studied ^ age ranges (0.2-6), (7-12), (13-19) years, respectively. Oncology Diagnosis and disease stage were important factors that within AML, NHL, OS, RMS, ALL patients, OM developed
in 100 %, 87 %, 78 %, 75 %, 72 % of each category, respectively with 100 % OM within relapsed patients compared to 77 % within first line therapy patients. Incidence of OM per patient differed among different protocol stages with 3.67, 1.8, 1.53, 1.41, 1.25, 1.17, 1,1 event per patient for pre/post operative chemotherapy, re-induction, first line induction, consolidation, second line therapy, continuation, intensification and re-intensification, respectively. Severity of OM was described in 70 % of total 163 OM events either from patient MR or patient interview answers while 30 % of the events could not be obtained neither from patient MR nor patient interview answers, with grades 1, 2, 3, 4 contributed to 21 %, 32 %, 12 %, 5 %, respectively. Again inappropriate documentation of OM event was faced that grades for 56 % OM events (of total 163 events) were not documented on patients MR. While 100 %, 74 % of grades 4, 3 events were appropriately documented, only 62 %, 51 % of grades 2, 1 were appropriately documented, respectively. Regarding prophylaxis medications usage, 89 % of 105 patients used prophylaxis (Chlorhexidine, Nystatin, Miconazole), but only 29 % exhibited adherence to appropriate use. Non-adherence was due to either unacceptable product taste or patient unawareness.
Conclusion. Increased patients susceptibility to chemotherapy-induced OM was observed. Patient gender, age, diagnosis, protocol stage and disease stage were contributing factors to OM. Level of event documentation and patient education was sub-optimal.
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ABSTRACT NO.: O-388
Percutaneous endoscopic gastroscopy in children with cancer and organic CNS disease
E.A. Dogadov, S.B. Bondarenko, P.V. Shumilov, S.V. Kulikov
Applied Research Center for Specialized Medical Care of Children named after V.F. Voyno-Yasenetsky, Russia
Key words: enteral feeding, gastrostomy, children's oncology, CNS tumors, palliative care
Introduction. Optimal nutritive status in children with CNS tumors is of particular importance. Nasogastric tube and standard surgical gastrostomy are conventional methods to provide longitudinal nutrition. Prolonged use of nasogastric tube negatively impacts patient's quality of life, impairs daily care and may lead to complications. Percutaneous gastrostomy may improve patient's quality of life.
Aim. Improvement of quality of life in children with cancer and organic CNS disease by choosing an optimal method of gastrostomy.
Materials and methods. From September 2012 to February 2016 eighty three endoscopy-assisted gastrostomies were performed in children aged 5 month to 17 years with CNS tumors and organic CNS disease. Pull method was used in 49 cases and Russell method in 34 cases. In 2 cases standard procedure was modified with laparoscopy due to left liver lobe enlargement and severe scoliosis affecting gastric topography.
Results. Pull method is less invasive and of 10-15 minute duration. There were no surgical complications, but intermittent leakage of gastric content around the tube complicating post-surgical care was observed in all patients. Percutaneous gastrostomy using Russell method provided a tight sealing between the tube, the stomach and abdominal wall preventing gastric content leakage and inflammation of the adjacent tissues. In 2 cases standard procedure was modified with laparoscopy due to left liver lobe enlargement and severe scoliosis affecting gastric topography. Gastrostomy in these patients was placed in non-typical areas. No complications were observed.
Conclusion. Both methods of percutaneous gastrostomy used in our study provided conditions for full enteral feeding but Russell method was associated with better sealing of the gastrostomy canal, facilitated care and better quality of life. In case of atypical topography of the stomach percutaneous gastrostomy should be supplemented by laparoscopy procedures.
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