The Texas Children's Hospital Pediatric Advanced Warning Score as a predictor of clinical deterioration in hospitalized infants and children: a modification of the PEWS tool.

UNLABELLED: The purpose of this study was to examine the psychometric properties of the Texas Children's Hospital Pediatric Advanced Warning Score (PAWS) instrument as an indicator of clinical deterioration in infants and children. DESIGN AND METHODS: A retrospective chart review of 150 infants and children was performed. RESULTS: The overall Cronbach's alpha score was 0.75. The estimate of interrater reliability was 0.740. IMPLICATIONS: The Texas Children's Hospital Pediatric Advanced Warning Score instrument was found to be reliable and valid.

Phase II multicenter trial of a weekly paclitaxel and carboplatin regimen in patients with advanced breast cancer.

PURPOSE: To determine the activity of weekly paclitaxel plus carboplatin as first-line therapy in patients with advanced breast cancer (ABC) by assessing response rate, survival, and safety. PATIENTS AND METHODS: One hundred patients with ABC received paclitaxel 135 mg/m(2) (group 1, n = 20) and carboplatin area under the concentration-time curve (AUC) of 2. Paclitaxel was subsequently reduced to 100 mg/m(2) (group 2, n = 80) because of toxicity. The median age was 58.5 years, and most patients had an Eastern Cooperative Oncology Group performance status of

Phase II randomized trial of weekly paclitaxel with or without estramustine phosphate in progressive, metastatic, hormone-refractory prostate cancer.

This study was conducted to determine the similarity of response rates and safety produced by weekly paclitaxel with or without oral estramustine in patients with metastatic hormone-refractory prostate cancer. Between December 1998 and December 1999, 163 patients were randomized to receive 28-day cycles of paclitaxel 100 mg/m2 on days 2, 9, and 16 plus estramustine 280 mg orally 3 times a day on days 1-3, 8-10, and 15-17, or to receive paclitaxel 100 mg/m2 alone on days 1, 8, and 15. Objective response was defined as a > oe = 50% decrease in prostate-specific antigen (PSA) maintained for 4 weeks with stable or improved performance status. Response rates included 37 partial responses for paclitaxel/estramustine (47%) and 22 partial responses for paclitaxel (27%; P < 0.01). Median duration of response was 15.1 months for paclitaxel/estramustine and 15.5 months for paclitaxel; median survival was 16.1 months and 13.1 months, respectively (P = 0.049). Common toxicities for both treatments included neutropenia, gastrointestinal events, neuropathy, and asthenia. Thromboembolic events were more frequent in the paclitaxel/estramustine arm (no prophylactic anticoagulants). The rate of PSA decline for paclitaxel/estramustine was almost 2 times that of paclitaxel (47% vs. 27%), with acceptable toxicity. Multivariate analysis of prognostic factors affecting survival was not significant for treatment arm (P = 0.08). Although the incidence of thromboembolic events appeared to be increased in the paclitaxel/ estramustine arm, the addition of estramustine was responsible for a 20% increase in the rate of PSA decline. Neither treatment arm had significant impact on quality of life as measured by the Functional Assessment of Cancer Therapy-Prostate quality of life questionnaire. This study produced encouraging data; further studies of paclitaxel/ estramustine are recommended.

Lipid profiles of pediatric hematopoietic stem cell transplant survivors.

Cardiovascular disease (CVD) is the leading cause of death among adults in the United States. CVD pathology, including abnormal lipid levels, may begin in childhood. Hematopoietic stem cell transplant (HSCT) survivors have increased risk of abnormal lipid levels, but there is limited information in children post-HSCT. The study aimed to describe lipid levels and identify the factors associated with dyslipidemia in pediatric HSCT survivors during the first 3 years post-HSCT. This descriptive research study used a retrospective chart review to assess lipid profiles among 31 pediatric HSCT patients. Mean lipid levels were within normal limits but contained large ranges in values. There was no statistically significant change over time; however, there was an increased trend of total cholesterol and low-density lipoprotein levels and a decreased trend of high-density lipoprotein levels. The majority of patients had one abnormal lipid level at 1 and 2 years post-HSCT. Body mass index was the only factor significantly associated with dyslipidemia. An awareness of dyslipidemia among HSCT survivors may allow for early identification and treatment of abnormal lipid levels.

Children's coping strategies for chemotherapy-induced nausea and vomiting.

PURPOSE/OBJECTIVES: To identify anticipatory, acute, and delayed chemotherapy-induced nausea and vomiting (CINV) frequency and coping strategies used among pediatric patients with cancer. DESIGN: Prospective, cohort design. SETTING: A pediatric teaching hospital in the southern United States. SAMPLE: A convenience sample of 40 children aged 7-12 years scheduled to receive either moderately emetic chemotherapy or highly emetic chemotherapy for cancer treatment. METHODS: Children completed the Adapted Rhodes Index of Nausea and Vomiting for Pediatrics and the Kidcope-Younger Version. MAIN RESEARCH VARIABLES: CINV and coping strategies. FINDINGS: CINV occurred during the anticipatory, acute, and delayed times, with the highest frequency occurring during the delayed time. The most frequently used coping strategies were distraction and wishful thinking, whereas the most effective strategies were social support and distraction. No statistically significant differences were observed in the frequency or efficacy of coping strategies over time. CONCLUSIONS: CINV occurs throughout chemotherapy treatment. The most efficacious coping strategies included active and passive coping, with active coping strategies being more effective. IMPLICATIONS FOR NURSING: Nurses should recognize that CINV occurs at all points of chemotherapy treatment. Nurses can assist children in developing active coping strategies to manage their CINV.

Nausea and vomiting perspectives among children receiving moderate to highly emetogenic chemotherapy treatment.

BACKGROUND: Chemotherapy-induced nausea and vomiting (CINV) are common adverse effects, but occurrences among pediatric oncology patients are not well documented. OBJECTIVE: The primary aim was to describe anticipatory, acute, and delayed CINV among children with cancer from the child's, caregiver's, and nurse's perspective. A secondary aim evaluates the correlation of CINV among the child's, caregiver's, and nurse's perspectives. METHODS: CINV perspectives were evaluated before, during, and after a single course of highly or moderately emetogenic chemotherapy. CINV were evaluated among 40 pediatric cancer patients using the Adapted Rhodes Index of Nausea and Vomiting for Pediatrics, among their caregivers using the Adapted Rhodes Index of Nausea and Vomiting for Parents, and among their nurses using the National Cancer Institute Nausea and Vomiting Grading Criteria. RESULTS: CINV were reported by the patient, caregiver, and nurse at all times, with the most frequent reports occurring in the delayed period. Patient's mean total nausea and vomiting scores increased significantly over time. Patient reports of anticipatory, acute, and delayed CINV correlated with caregiver and nurse reports except for anticipatory nausea between the nurse and patient. CONCLUSIONS: CINV occurred throughout the chemotherapy course, with delayed CINV occurring most frequently and with greater severity and distress. Caregiver CINV reports correlated closely with patient reports. IMPLICATIONS FOR PRACTICE: Nurses need to be aware of the frequency, severity, and distress of CINV throughout the chemotherapy regimen. CINV can occur before and after chemotherapy treatment and should be assessed so that appropriate interventions can be implemented.

Sickness behavior clustering in children with cancer.

Despite knowing that pediatric cancer patients experience multiple concurrent symptoms, most research focuses on individual symptoms. This study is a secondary data analysis from previous research evaluating symptom clusters and carnitine plasma levels in 67 children and adolescents aged between 7 and 18 years, before and after receiving ifosfamide, doxorubicin, or cisplatin chemotherapy. In preparation for cluster analysis, fatigue, nausea and vomiting, depression, and performance status symptoms were rated in categories of none, mild, moderate, or severe. A conceptual approach was used to evaluate the identification of unique patterns of symptoms that cluster as well as what subgroup members of pediatric oncology patients assemble together. Comparison of symptoms is made with the recent literature on sickness behavior symptoms. The hierarchical agglomerative cluster analysis was used to identify and classify variables into groups based on similarities they possess. This cluster analysis increases awareness of sickness behavior symptoms, patterns, interaction, and synergy. Increasing knowledge of the complex symptom experiences of pediatric oncology patients provides the scientific basis for new directions in symptom intervention.

Interface pressure comparison of healthy premature infants with various neonatal bed surfaces.

PURPOSE: The aim of this study was to determine interface pressure between the occiput of healthy premature infants and 5 different bed surfaces used in special care nurseries. SUBJECTS: Thirteen healthy premature infants comprised the convenience sample enrolled 1 to 3 weeks prior to discharge. DESIGN: A quasi-experimental design was used with the dependent variable being the interface pressures obtained under the occiput and the independent variables as the bed surfaces. METHODS: Order of bed surfaces was randomized and standardization of the infant positioning and measuring procedure maintained. Measurements were made between the infant's occiput and the bed surface and interface pressures recorded in millimeters of mercury. The 5 bed surfaces were standard crib mattress with or without foam, gel donut, gel mattress, and water pillow. MEASURES: Interface pressure measurements were obtained using the Mini-Texas Interface Pressure Evaluator (Mini-TIPE, Tee-Kay Applied Technology, Inc, Stafford, Texas). RESULTS: A 1-way blocked analysis of variance was conducted to evaluate the relationship between the mattress surfaces and the interface pressure measurements. A significant difference in the mean of the interface pressures among the 5 mattress bed surfaces was determined, F(4,46) = 33.267, P < .001, with the lowest being the foam overlay. The standard crib mattress had the highest interface pressure that exceeded 100 mm Hg. Post hoc comparisons showed a significant difference between the standard crib mattress with and without foam and the other surfaces. CONCLUSIONS: Interface pressure is an important consideration when choosing a support surface for premature infants susceptible to tissue compromise and head molding. Variations in interface pressures between neonatal bed surfaces are apparent. Comparison studies of interface pressures using these and other neonatal bed surfaces will be valuable in determining appropriate products for both premature and neonatal populations with lengthy intensive care stays.

Longitudinal evaluation of fine motor skills in children with leukemia.

BACKGROUND: Improved survival for children with acute lymphocytic leukemia (ALL) has allowed investigators to focus on the adverse or side effects of treatment and to develop interventions that promote cure while decreasing the long-term effects of therapy. Although much attention has been given to the significant neurocognitive sequelae that can occur after ALL therapy, limited investigation is found addressing fine motor function in these children and motor function that may contribute to neurocognitive deficits in ALL survivors. METHODS: Fine motor and sensory-perceptual performances were examined in 82 children with ALL within 6-months of diagnosis and annually for 2 years (year 1 and year 2, respectively) during therapy. RESULTS: Purdue Pegboard assessments indicated significant slowing of fine motor speed and dexterity for the dominant hand, nondominant hand, and both hands simultaneously for children in this study. Mean Visual-Motor Integration (VMI) scores for children with low-risk and high-risk ALL decreased from the first evaluation to year 1 and again at year 2. Mean VMI scores for children with standard risk ALL increased from the first evaluation to year 1 and then decreased at year 2. Significant positive correlations were found between the Purdue and the VMI at both year 1 and year 2, suggesting that the Pegboard performance consistently predicts the later decline in visual-motor integration. Significant correlations were found between the Purdue Pegboard at baseline and the Performance IQ during year 1, though less consistently during year 2. A similar pattern was also observed between the baseline Pegboard performance and performance on the Coding and Symbol Search subtests during year 1 and year 2. CONCLUSIONS: In this study, children with ALL experienced significant and persistent visual-motor problems throughout therapy. These problems continued during the first and second years of treatment. These basic processing skills are necessary to the development of higher-level cognitive abilities, including nonverbal intelligence and academic achievement, particularly in arithmetic and written language.

Practice patterns of SGO members for stage IIIA endometrial cancer.

OBJECTIVE: The purpose of surgical staging is to better determine prognosis and treatment. The International Federation of Gynecology and Obstetrics (FIGO) stage IIIA endometrial cancer is a heterogenous disease, and adjuvant therapy is not well-defined. The aim of this study was to survey the Society of Gynecologic Oncologists (SGO) members and fellows about their approach to the treatment of patients with stage IIIA endometrial cancer. METHODS: All 850 members of the SGO were mailed surveys that asked how they would manage various case scenarios of stage IIIA endometrial cancer. Data were collected using an Internet survey database. Frequency distributions were determined, and nonparametric tests were performed. RESULTS: Fifty-three percent of SGO members and fellows responded. For the treatment of stage IIIA disease with malignant cytology only, adjuvant therapy was recommended 46%, 62%, and 98% of the time for women with grades 1, 2, and UPSC, respectively. Sixty-six percent of respondents would not remove malignant cytology from the current staging criteria. Ninety-nine percent of respondents recommended adjuvant therapy for patients with adnexal or serosal involvement. Eighty-six percent indicated that a hysteroscopy for diagnosis would not alter their treatment recommendations. CONCLUSIONS: While most gynecologic oncologists in our survey recommend adjuvant therapy for stage IIIA endometrial carcinoma, our results showed that patients with malignant cytology only would receive different treatments than patients with adenxal or serosal involvement. Histology and grade of the tumor are predictors of therapy recommendations over malignant cytology. Most respondents agreed that patients with malignant cytology should remain in stage IIIA.

A phase II evaluation of weekly paclitaxel plus carboplatin in advanced urothelial cancer.

This Phase II trial was designed to evaluate the overall objective response rate, complete response rate, efficacy, and safety of weekly paclitaxel (Taxol) and carboplatin (Paraplatin) in the treatment of advanced urothelial carcinoma. Thirty-three patients with measurable, unresectable, stage III-IV carcinoma of the urothelium were enrolled. Paclitaxel (135 mg/m2) and carboplatin (AUC=2) were given by intravenous (IV) infusion weekly x 6 followed by two weeks rest. Patients were premedicated with oral dexamethasone, diphenhydramine, and cimetadine (or equivalent). Patient characteristics included an Eastern Cooperative Oncology Group Performance Status (ECOG PS) 0 (36%), one (36%), two (28%); median age 70 years (37-83); 29 (88%) male, four (12%) female; 16 (48%) patients had prior chemotherapy [eight postoperative (adjuvant), five neoadjuvant, three for metastatic disease] and eight (24%) had prior radiation therapy. Eight patients (24%) achieved objective responses, three complete responses (CR) and five partial responses (PR); one patient was not evaluable (patient died prior to first dose). The median duration of response was 13 months (range, 2-29). Nine patients (27%) had stable disease (SD) and 15 patients (45%) had progressive disease (PD). Median time to progression was 3.6 months (range, < 1-29) and median survival was 10.3 months (range, < 1-33). Grade 3 and 4 toxicities included: asthenia (46%), neutropenia (36%), leukopenia (15%), thromboembolism (12%), diarrhea (9%), nausea and vomiting (9%), hyperglycemia (7%), and neuropathy (6%). Two patients died of sepsis, one death was treatment-related. Weekly paclitaxel plus carboplatin shows promising activity; however in the current study, efficacy may have been limited by the toxicities associated with this dose-intensive regimen in an elderly, pretreated patient population with poor performance status. This regimen warrants further study, perhaps as a three out of four week regimen or at reduced doses.

Laparoscopic training and practice in gynecologic oncology among Society of Gynecologic Oncologists members and fellows-in-training.

OBJECTIVE: To determine the proportion of Society of Gynecologic Oncologists (SGO) members performing laparoscopic procedures and to determine SGO members' and fellows' opinions regarding indications for and the adequacy of training in laparoscopy. METHODS: Surveys were mailed to SGO members and fellows-in-training in December 2002. Anonymous responses were collected by mail or through a Web site. The survey was mailed twice and was estimated to take 5 min to complete. The data were analyzed using frequency distributions and nonparametric tests. RESULTS: Three hundred thirty-six SGO members (45%) and fifty-seven fellows (49%) responded. Among SGO members, 272 (84%) currently performed laparoscopic surgeries. Reasons cited for performing laparoscopy were decreased length of hospital stay (74%), improved patient quality of life (57%), patient preference (48%), improved cosmesis (46%), and better visualization (18%). Among those who did not perform laparoscopy, 50% cited increased operating time as their main reason. When asked to indicate the laparoscopic procedure most commonly performed in their practice, 69% reported diagnosis of an adnexal mass; 11%, prophylactic bilateral salpingo-oophorectomies; and 10%, laparoscopically assisted vaginal hysterectomy and lymph node staging for uterine cancer. Only 3% of SGO respondents performed more than 50% of their procedures laparoscopically, and all respondents reported converting from laparoscopy to laparotomy less than 25% of the time. Most respondents had limited laparoscopic training during their fellowships: 39% received none, and 46% received limited (less than five procedures per month) training. Nevertheless, 78% of SGO respondents rated their laparoscopic skills as either very good or good. Among fellows, only 25% believed they were receiving very good or good laparoscopic training. Eighty percent of SGO respondents believe that at least six procedures per month were necessary for adequate training, yet only 33% of fellows performed that many procedures. CONCLUSIONS: Most SGO respondents used laparoscopy for selective indications, and most developed their laparoscopic skills after their fellowship training. SGO respondents believed laparoscopic instruction is an important part of training, but most fellows perceived their laparoscopic training as inadequate.