Healthcare professional perspectives following implementation of an infection management care pathway for pediatric patients with cancer: a qualitative study.

PURPOSE: The Pediatric Oncology Group of Ontario (POGO) supported an effort to implement infection management care pathways based on clinical practice guidelines, to improve the consistency of infection management in pediatric cancer patients. The objective of this qualitative study was to describe the perspective of healthcare professionals (HCPs) following implementation. METHODS: Four tertiary pediatric oncology centers in Ontario, Canada, implemented the pathways. We randomly identified three HCPs per group (clinical pharmacists; nurse case managers, educators or practitioners and physician assistants; pediatric oncology fellows; or pediatric oncology staff physicians) per site and invited them to participate in a qualitative interview. One-on-one interviews were conducted remotely, followed by thematic analysis of interview transcripts. RESULTS: A total of 66 invitations were extended and 42 HCPs participated. Identified themes were: (1) implementation approach, (2) access and navigation, (3) engagement, (4) concerns, (5) workplace benefits, (6) reception, and (7) provincial harmonization. HCPs preferred in-person implementation strategies over e-mail communication. They identified teaching/educational utility and benefits to non-oncology departments and non-tertiary centers participating in shared care of patients. Other positive aspects related to evidence-based practice, safety, supporting oncology HCPs, and benefits to patients and families. Concerns included need to ensure users applied clinical judgement and loss of autonomy. Provincial harmonization of practice was viewed positively, although potential logistical and institutional cultural barriers were raised. CONCLUSIONS: Following infection management care pathway implementation, HCPs described educational utility and benefits to non-oncology departments, oncology HCPs, patients, and families. Our findings may facilitate future infection management care pathway provincial harmonization.

The impact of levofloxacin prophylaxis on empiric intravenous antibiotic use in pediatric hematopoietic stem cell transplant recipients.

Levofloxacin prophylaxis during periods of neutropenia in pediatric hematopoietic stem cell transplant (HSCT) may reduce the number of febrile episodes and use of empiric intravenous antibiotics (EIA); however, the literature is conflicting. This retrospective review compared EIA use before and after implementation of levofloxacin prophylaxis at a children's hospital. Levofloxacin prophylaxis was associated with reduced use of certain EIA; however, did not reduce the number of positive blood cultures or clinical deteriorations. Therefore, levofloxacin prophylaxis may have implications for the stewardship of broad-spectrum intravenous antibiotics used in pediatric HSCT.

Development of a Value Assessment Framework for Pediatric Health Technologies Using Multicriteria Decision Analysis: Expanding the Value Lens for Funding Decision Making.

OBJECTIVES: A health technology assessment (HTA) does not systematically account for the circumstances and needs of children and youth. To supplement HTA processes, we aimed to develop a child-tailored value assessment framework using a multicriteria decision analysis approach. METHODS: We constructed a multicriteria-decision-analysis-based model in multiple phases to create the Comprehensive Assessment of Technologies for Child Health (CATCH) framework. Using a modified Delphi process with stakeholders having broad disciplinary and geographic variation (N = 23), we refined previously generated criteria and developed rank-based weights. We established a criterion-pertinent scoring rubric for assessing incremental benefits of new drugs. Three clinicians independently assessed comprehension by pilotscoring 9 drugs. We then validated CATCH for 2 childhood cancer therapies through structured deliberation with an expert panel (N = 10), obtaining individual scores, consensus scores, and verbal feedback. Analyses included descriptive statistics, thematic analysis, exploratory disagreement indices, and sensitivity analysis. RESULTS: The modified Delphi process yielded 10 criteria, based on absolute importance/relevance and agreed importance (median disagreement indices = 0.34): Effectiveness, Child-specific Health-related Quality of Life, Disease Severity, Unmet Need, Therapeutic Safety, Equity, Family Impacts, Life-course Development, Rarity, and Fair Share of Life. Pilot scoring resulted in adjusted criteria definitions and more precise score-scaling guidelines. Validation panelists endorsed the framework's key modifiers of value. Modes of their individual prescores aligned closely with deliberative consensus scores. CONCLUSIONS: We iteratively developed a value assessment framework that captures dimensions of child-specific health and nonhealth gains. CATCH could improve the richness and relevance of HTA decision making for children in Canada and comparable health systems.

Palonosetron in pediatric patients: A single-center, retrospective evaluation of policy and clinical practice guideline discordance.

INTRODUCTION: Clinical practice guidelines (CPGs) recommending palonosetron for the prevention and management of chemotherapy-induced nausea and vomiting (CINV) were adapted for use at our institution. Palonosetron was restricted for use in patients experiencing breakthrough CINV and receiving highly emetogenic chemotherapy (HEC) or undergoing stem cell transplant conditioning and in patients with refractory CINV receiving HEC. Given the significant cost of palonosetron, we aimed to determine the proportion of chemotherapy blocks where palonosetron use was discordant with the institutional policy or source CPG. METHODS: A retrospective review of the health records of patients who received palonosetron between 1 July 2019 and 30 June 2020 was undertaken. Details of palonosetron use, antiemetic regimen and the date and time of each vomit during the acute and delayed phases were collected for each chemotherapy block where palonosetron was given. Discordance with the institutional policy and the source CPG was determined by assessing the indication for palonosetron and the dose. In the subset of chemotherapy blocks where information regarding vomiting episodes was available, the extent of acute phase chemotherapy-induced vomiting (CIV) control was reported. RESULTS: Four hundred thirty-eight chemotherapy blocks, representing 122 patients (mean age 9 years), receiving 595 palonosetron doses were included. Palonosetron use was discordant with institutional policy during most (72%; 314/438) of the chemotherapy blocks analyzed. However, palonosetron use was concordant with the source CPG during most chemotherapy blocks (74%; 326/438). Complete CIV control during the acute phase was observed in 66% (195/295) of chemotherapy blocks where palonosetron was given, irrespective of concomitant antiemetics administered. CONCLUSION: The majority of palonosetron use at our institution was discordant with institutional policy, but concordant with the source CPG. Our institutional policy has since been updated to be more aligned with the source CPG.

High-Performance and Recyclable Al-Air Coin Cells Based on Eco-friendly Chitosan Hydrogel Membranes.

Aluminum-air batteries are a promising power supply for electronics due to their low cost and high energy density. However, portable coin-type Al-air batteries operating under ambient air condition for small electronic appliances have rarely been reported. Herein, coin cell-type Al-air batteries using cost-effective and eco-friendly chitosan hydrogel membranes modified by SiO2, SnO2, and ZnO have been prepared and assembled. The Al-air coin cell employing chitosan hydrogel membrane containing 10 wt % SiO2 as a separator exhibits better discharge performance with a higher flat voltage plateau, longer discharge duration, and higher power density than the cells using a chitosan hydrogel membrane containing SnO2 or ZnO. Moreover, we also demonstrate that the presented Al-air coin cell can be recycled by a series of eco-friendly procedures using food-grade ingredients, resulting in recycled products that are environmentally safe and ready for reuse. The Al-air coin cell adopting a recycled cathode from a fully discharged Al-air coin cell using the above-mentioned procedure has shown comparable performance to cells assembled with a new cathode. With these merits of enhanced electrochemical performance and recyclability, this new Al-air coin cell with modified chitosan hydrogel membrane can find wide applications for powering portable and small-size electronics.

Concomitant Administration of High-dose Methotrexate and Low-dose Aspirin Without Any Delay in Methotrexate Clearance in a Patient With Osteosarcoma: A Case Report and Review of the Literature.

BACKGROUND: Methotrexate (MTX) is a commonly used agent in the treatment of oncology patients whose clearance depends on renal health maintaining glomerular filtration and tubular secretion. Thus concomitant use of other drugs that utilize the same mechanism of clearance are generally avoided as this may contribute to increased MTX-associated toxicity. OBSERVATION: Herein, we describe the use of low-dose aspirin with high-dose MTX in a patient with osteosarcoma. CONCLUSION: Concomitant aspirin use did not affect the clearance of high-dose MTX and the patient did not experience any MTX-related toxicity including mucositis or renal impairment.

Promising Dual-Doped Graphene Aerogel/SnS2 Nanocrystal Building High Performance Sodium Ion Batteries.

We report the effort in designing layered SnS2 nanocrystals decorated on nitrogen and sulfur dual-doped graphene aerogels (SnS2@N,S-GA) as anode material of SIBs. The optimized mass loading of SnS2 along with the addition of nitrogen and sulfur on the surface of GAs results in enhanced electrochemical performance of SnS2@N,S-GA composite. In particular, the introduction of nitrogen and sulfur heteroatoms could provide more active sites and good accessibility for Na ions. Moreover, the incorporation of the stable SnS2 crystal structure within the anode results in the superior discharge capacity of 527 mAh g-1 under a current density of 20 mA g-1 upon 50 cycles. It maintains 340 mAh g-1 even the current density is increased to 800 mA g-1. Aiming to further systematically study mechanism of composite with improved SIB performance, we construct the corresponding models based on experimental data and conduct first-principles calculations. The calculated results indicate the sulfur atoms doped in GAs show a strong bridging effect with the SnS2 nanocrystals, contributing to build robust architecture for electrode. Simultaneously, heteroatom dual doping of GAs shows the imperative function for improved electrical conductivity. Herein, first-principles calculations present a theoretical explanation for outstanding cycling properties of SnS2@N,S-GA composite.

Successful adaptation of fever and neutropenia clinical practice guideline in China

Background: To describe a process for adapting a supportive care clinical practice guideline (CPG) for use in a middle income country setting. Method: We reviewed different approaches for CPG adaptation and created a straight-forward approach for adapting supportive care guidelines for use in Shenzhen, China. The initial CPG to be adapted was for the empiric management of fever and neutropenia (FN) in children with cancer and hematopoietic stem cell transplantation recipients. Results: The steps to be used in adaptation were as follows: review of local guideline; understanding local clinical pathways and contexts through interviews; development of worksheets to facilitate adaptation decisions; deliberation of guideline recommendations in focus groups; and drafting of the adapted FN CPG. After several iterations, stakeholders agreed upon a final adapted guideline. Conclusions: We described an approach to adaptation of a supportive care CPG for the middle income country setting of Shenzhen, China. Although we believe this work has broad applicability, this approach requires rigorous evaluation, both in terms of methodology and the validity of the adapted guideline. Future work will evaluate implementation of the adapted CPG (AU)

Cyclosporine-induced pain syndrome in a child undergoing hematopoietic stem cell transplant.

OBJECTIVE: To report a case of calcineurin-induced pain syndrome (CIPS) in a child undergoing his second hematopoietic stem cell transplant (HSCT). CASE SUMMARY: A 6.1-year-old child received cyclosporine and methotrexate for acute graft-versus-host disease (aGVHD) prophylaxis after his first HSCT for acute myeloblastic leukemia. Amlodipine was given for the treatment of hypertension. Symptoms of CIPS were not observed. After the second HSCT at the age of 6.7 years, the child received cyclosporine (target trough whole blood cyclosporine concentration range 150-200 microg/L), starting on day -3, and mycophenolate mofetil for aGVHD prophylaxis. With the first cyclosporine dose, the patient complained of leg pain that was most severe during the cyclosporine infusion. Analgesic agents and a change from intravenous to oral administration of cyclosporine were ineffective in controlling the pain. Magnetic resonance imaging findings on day 10 showed periosteal soft tissue changes and mild bone marrow edema of the femora and tibiae. Tacrolimus was substituted for cyclosporine on day 20; on day 21 amlodipine was initiated to manage hypertension. Trough whole blood tacrolimus concentrations ranged from 1.7 to 6.2 microg/L. Pain was reduced in severity by day 29 and completely resolved once tacrolimus was discontinued on day 42. In this case, CIPS was considered to be probably associated with cyclosporine according to the Naranjo probability scale. DISCUSSION: CIPS is hypothesized to result from calcineurin-induced vascular changes that disturb bone perfusion and permeability, leading to intraosseous vasoconstriction and bone marrow edema. In our patient, symptoms were most acute during the infusion, when whole blood cyclosporine concentrations were likely to be the highest. Our patient's symptoms were resolved when tacrolimus was substituted for cyclosporine and amlodipine was initiated. CONCLUSIONS: Interventions aimed at reducing pain associated with CIPS may include the initiation of calcium-channel blocker therapy and conversion to an alternative calcineurin inhibitor.

Efficacy and safety of caspofungin for the empiric management of fever in neutropenic children.

This retrospective review evaluates the response to caspofungin when given to children with febrile neutropenia and describes adverse effects attributable to caspofungin, including risk of hepatotoxicity during concomitant therapy with cyclosporine. Sixty-seven courses of caspofungin administered to 56 patients (1-17 years) were surveyed; 53 (79%) courses resulted in an overall favorable response. Ten children (15% of courses) experienced an adverse drug-related event that was probably or possibly attributable to caspofungin. Rash and hypokalemia were the most commonly identified adverse effects. One of 19 children receiving caspofungin and cyclosporine concurrently developed hepatotoxicity possibly related to caspofungin.