Therapeutic plasma exchange for multiorgan dysfunction among critically ill pediatric patients with leukemia: A single-institutional experience.

INTRODUCTION: Therapeutic plasma exchange (TPE) has well-documented applications in the adult population, outlined by the American Society for Apheresis (ASFA) 2019 guidelines. Limited data exist regarding the use of TPE in critically ill pediatric patients; however, these reports rarely include patients with oncological diseases. METHODS: We highlight the use of TPE in the acute management of seven pediatric patients with leukemia treated at Children's Mercy Hospital ICU from 2015 to 2020, including TPE specifications, baseline and interval laboratory evaluation, and outcome measures. Analysis compared those who did (n = 4) and did not (n = 3) survive 30 days post-TPE. RESULTS: Multiorgan failure (MOF) prompted the initiation of TPE in 85.7% of patients, 57.1% of whom were also diagnosed with hemophagocytic lymphohistiocytosis (HLH). Baseline laboratory evaluations prior to initiation of TPE were similar between the two groups. With subsequent TPE treatments, C-reactive protein (CRP) and lactic acid decreased. CRP and lactic acid following the last TPE treatment were significantly higher for those deceased 30 days post-TPE (P = .023 and .031, respectively). No TPE-associated adverse events necessitated discontinuation of TPE treatment. Several surviving patients required chemotherapy dose reductions or alterations. CONCLUSION: Our cohort demonstrated MOF and HLH consistently as indications for TPE, currently ASFA category III indications (optimal role of apheresis is not yet established). Recognition of this treatment modality earlier in the clinical course for critically ill oncological patients may lead to the development of formal protocols that may result in earlier initiation of TPE and improved outcomes.

Standardization of Fertility Preservation Discussion Among Pediatric Oncology and Bone Marrow Transplant Patients: A Single Institution Experience.

Purpose: Infertility is an impactful late effect of cancer therapy. Options for fertility preservation exist, however, barriers remain. Within our division, we lacked a standard approach to discussing fertility preservation. Methods: During the time period of 2014-2020, a fertility preservation program was developed with program improvements implemented over time and provider comfort with fertility identified and addressed through educational intervention. To evaluate how our improvements affected frequency of documented reproductive health discussions, 474 pubertal pediatric patients with new oncological diagnoses were reviewed. Descriptive analysis of sociodemographic determinants was performed. Results: One hundred seventy-five patients met inclusion criteria. Racial/ethnic composition was similar in those receiving and not receiving a fertility consult. Although 19.3% of Caucasians pursued fertility preservation, none of the eight African Americans or five Hispanic females did. Division feedback identified a lack of knowledge regarding available fertility preservation options and diagnoses that should prompt this conversation as barriers to the consulting fertility preservation team. Pre- and posteducation assessments demonstrated increased comfort in discussing fertility preservation and knowledge regarding diagnoses at higher risk of infertility. Integration of a standardized fertility preservation process and addressing barriers identified led to a 33.6% increase in fertility discussions. Conclusion: The establishment of a fertility preservation process and team and division-wide education has led to improvement in rates of fertility discussion in pediatric and adolescent and young adult cancer patients. Similar to young adult data, our data suggest that some racial health disparities may exist in the utilization of fertility preservation in the pediatric oncology population.

Pain, Functional Scores, and Radiographic Severity of Illness Influence the Perception of Time Spent With the Physician by Patients Presenting for Initial Evaluation of Knee Osteoarthritis.

BACKGROUND: Patient satisfaction has become a significant factor in reimbursement schedules for physicians. A matter of debate is whether the patient's perception of time spent with the physician improves patient satisfaction. We sought to determine whether patient-physican time correlates with patient satisfaction and which factors are associated with patient perception of time. METHODS: A total of 73 patients who presented for an initial evaluation of knee osteoarthritis were evaluated by the same orthopedic surgeon at an outpatient clinic in New Orleans, LA. Each encounter was timed with a stopwatch. After the physician encounter, patients were asked to fill out a questionnaire assessing their perception of time spent with the physician, subjective pain, satisfaction with the visit, and understanding of the diagnosis and treatment plan. Patients were also asked to complete 4 functionality surveys. Radiographs of the patients' knees were taken and quantified using Kellgren-Lawrence and Ahlbäck grading scales. RESULTS: We noted no relationship between patient satisfaction and patients' perception of time spent with the physician. Patients perceived their time with the physician to be an average of 6.5 minutes more than the actual time. However, patients who reported higher subjective pain scores (>7 on a 10-point scale) misestimated their time with the physician by nearly 96%, while patients with lower subjective pain scores (<7 on a 10-point scale) misestimated their time with the physician by only 54% (P<0.007). We discovered similar findings in patients with worse Kellgren-Lawrence radiographic scores as well as worse Oxford Knee Scores and Knee injury and Osteoarthritis Outcome Scores. The actual time spent was not different among patients. CONCLUSION: Patients with greater subjective pain and worse functional status and patients with worse radiographic severity of knee osteoarthritis perceived greater time spent with the physician. However, no relationship between these variables and patient satisfaction scores was seen.