Infection continues to be a major problem for children with acute myeloid leukemia (AML). Objectives were to identify factors associated with infection, sepsis, and infectious deaths in children with newly diagnosed AML.
We conducted a retrospective, population-based cohort study that included children = 18 years of age with de novo, non-M3 AML diagnosed between January 1995 and December 2004, treated at 15 Canadian centers. Patients were monitored for infection from initiation of AML treatment until recovery from the last cycle of chemotherapy, conditioning for hematopoietic stem cell transplantation, relapse, persistent disease, or death (whichever occurred first). Consistent trained research associates abstracted all information from each site.
341 patients were included. Median age was 7.1 years (interquartile range [IQR], 2.0-13.5) and 29 (8.5%) had Down syndrome. In sum, 26 (7.6%) experienced death as a first event. There were 1277 courses of chemotherapy administered in which sterile site microbiologically documented infection occurred in 313 courses (24.5%). Sepsis and infectious death occurred in 97 (7.6%) and 16 (1.3%) courses, respectively. The median days of corticosteroid administration was 2 per course (IQR, 0-6). In multiple regression analysis, duration of corticosteroid exposure was significantly associated with more microbiologically documented sterile site infection, bacteremia, fungal infection, and sepsis. The only factor significantly associated with infectious death was days of corticosteroid exposure (odds ratio, 1.05; 95% confidence interval, 1.02-1.08; P = .001).
In pediatric AML, infection, sepsis, and infectious death were associated with duration of corticosteroid exposure. Corticosteroids should be avoided when possible for this population.
A comprehensive evaluation of the psychometric properties of Care of My Child With Cancer (CMCC) was performed in a sample of 411 parents of children undergoing treatment of cancer at five Canadian pediatric oncology centers. Psychometric tests used to assess data quality, targeting, reliability, and construct validity demonstrated that the CMCC is a scientific sound measure. The CMCC will be helpful for assessing increasing parental responsibility for caregiving tasks associated with cancer care.
Unclassified inherited bone marrow failure syndromes are a heterogeneous group of genetic disorders that represent either new syndromes or atypical clinical courses of known inherited bone marrow failure syndromes. The relative prevalence of the unclassified inherited bone marrow failure syndromes and their characteristics and the clinical and economic challenges that they create have never been studied.
We analyzed cases of inherited bone marrow failure syndrome in the Canadian Inherited Marrow Failure Registry that were deemed unclassifiable at study entry.
From October 2001 to March 2006, 39 of the 162 patients enrolled in the Canadian Inherited Marrow Failure Registry were registered as having unclassified inherited bone marrow failure syndromes. These patients presented at a significantly older age (median: 9 months) than the patients with classified inherited bone marrow failure syndrome (median: 1 month) and had substantial variation in the clinical presentations. The hematologic phenotype, however, was similar to the classified inherited bone marrow failure syndromes and included single- or multiple-lineage cytopenia, severe aplastic anemia, myelodysplasia, and malignancy. Grouping patients according to the affected blood cell lineage(s) and to the presence of associated physical malformations was not always sufficient to characterize a condition, because affected members from several families fit into different phenotypic groups. Compared with the classified inherited bone marrow failure syndromes, the patients with unclassified inherited bone marrow failure syndromes had 3.2 more specific diagnostic tests at 4.5 times higher cost per evaluated patient to attempt to categorize their syndrome. At last follow-up, only 20% of the unclassified inherited bone marrow failure syndromes were ultimately diagnosed with a specific syndrome on the basis of the development of new clinical findings or positive genetic tests.
Unclassified inherited bone marrow failure syndromes are relatively common among the inherited bone marrow failure syndromes and present a major diagnostic and therapeutic dilemma.
The prevalence and severity of Clostridium difficile infection (CDI) has increased over time in adult patients, but little is known about CDI in pediatric cancer. The primary objectives were to describe the incidence and characteristics of CDI in children with de novo acute myeloid leukemia (AML). The secondary objective was to describe factors associated with CDI.
We performed a multicenter, retrospective cohort study of children with de novo AML and evaluated CDI. Recurrence, sepsis and infection-related death were examined. Factors associated with CDI were also evaluated.
Forty-three CDI occurred in 37 of 341 (10.9%) patients during 42 of 1277 (3.3%) courses of chemotherapy. There were 6 children with multiple episodes of CDI. Three infections were associated with sepsis, and no children died of CDI. Only 2 children had an associated enterocolitis. Both days of broad-spectrum antibiotics (odds ratio 1.03, 95% confidence interval: 1.01 to 1.06; P = 0.003) and at least 1 microbiologically documented sterile site infection (odds ratio 10.81, 95% confidence interval: 5.88 to 19.89; P
To compare the health-related quality of life (QOL) of parents of children who are undergoing treatment for cancer with that of Canadian population norms and to identify important parent and child predictors of parental QOL.
A total of 411 respondents of 513 eligible parents were recruited from five pediatric oncology centers in Canada between November 2004 and February 2007. Parents were asked to complete a questionnaire booklet that included a measure of adult QOL (SF-36), a measure of child health status (functional status IIR), and questions to assess health-promoting self-care actions (eg, sleep, diet, and exercise habits) and characteristics of the child with cancer (eg, relapse status, time since diagnosis, prognosis, treatment intensity).
Compared with population norms, parents of children with cancer reported poorer physical and psychosocial QOL in all psychosocial domains (effect sizes range, -0.71 to -1.58) and in most physical health domains (effect sizes range, -0.08 to -0.63). Parent characteristics associated with better parental QOL included better eating, exercise and sleep habits, younger age, and higher income. Child characteristics associated with better parental QOL included better child health status (functional status IIR scores), lower treatment intensity, and longer time since diagnosis.
Parents of children with cancer report poorer QOL compared with population norms. Interventions directed at parents should be included as part of the treatment plan for a child with cancer. Modifiable variables associated with poorer parental QOL, such as sleep quality and diet and exercise habits, indicate those parents most likely to experience poor QOL and may be potential areas for intervention.
It is currently unknown how the intensive and often prolonged treatment of childhood cancer impacts on the lives of single parents. Our aims were to determine whether single parents differ from parents from two-parent families in terms of caregiver demand (the time and effort involved in caregiving), and health-related quality of life (HRQL).
Forty single parents and 275 parents from two-parent families were recruited between November 2004 and February 2007 from five pediatric oncology centers in Canada. Parents were asked to complete a questionnaire booklet composed of items and scales to measure caregiver demand and HRQL (SF-36). The booklet also measured the following constructs: background and context factors, child factors, caregiving strain, intrapsychic factors, and coping factors.
Single parents did not differ from parents from two-parent families in caregiving demand and physical and psychosocial HRQL. Compared with Canadian population norms for the SF-36, both groups reported clinically important differences (i.e., worse health) in psychosocial HRQL (effect size = -2.00), while scores for physical HRQL were within one standard deviation of population norms.
Our findings suggest that the impact of caregiving on single parents, in terms of caregiving demand and HRQL is similar to that of parents from two-parent families.
This study aimed to gain a better understanding of the fertility preservation services provided by Canadian fertility clinics to women with cancer.
We invited a total of 76 fertility clinics across Canada to complete a mailed questionnaire related to the availability, accessibility, affordability, and utilization of fertility preservation services for oncology patients.
The total response rate was 59.2%: 72.4% for IVF clinics and 51.1% for fertility centres without on-site IVF. Not all the responding IVF centres accepted oncology referrals for women. Six clinics without on-site IVF accepted cancer patients for consultation. The medical consultation fees are covered by public health insurance in all provinces. The majority of respondents expedited the referrals to schedule an initial medical appointment within three days. Despite that, the referral volume reported by respondents was markedly low for all except two facilities. With over 4000 young women of reproductive age given a diagnosis of cancer each year in Canada, the findings suggest that cancer patients are severely under-served by fertility clinics.
There is a need to develop a stronger partnership between the fields of oncology and reproductive medicine to further improve access of patients with cancer to fertility preservation services. Development of evidence-based practice guidelines covering medical, clinical, psychosocial, ethical, and legal aspects geared to the Canadian health care system would help to avoid ambiguity relating to the roles and responsibilities in the provision of fertility preservation services. Such processes would ensure optimization of services so that all young cancer patients would receive the best care in protecting their fertility.
The impact of pandemic H1N1 influenza (pH1N1) virus in pediatric cancer is uncertain. The objectives of this study were to characterize the clinical course of pH1N1 and identify factors associated with severe outcomes.
We conducted a Canadian multicenter retrospective review of children with cancer and stem cell transplant (SCT) recipients who were diagnosed with laboratory-confirmed pH1N1 infection between May 1, 2009 and January 31, 2010.
We identified 100 (19 in wave 1 and 81 in wave 2) cases of pH1N1 infection. Median age was 8.7 years. 71% had a hematologic malignancy, and 20% received SCT. Median duration of fever and illness was 2 and 12.5 days, respectively. 51 (51.5%) were hospitalized for a median of 5 days, with no deaths and only 1 requiring admission to the intensive care unit. Radiologically confirmed pneumonia was diagnosed in 10 (10%). Interruption of chemotherapy or conditioning occurred in 43 patients. In multivariable analyses, age 5 days) correlated with shortened duration of viral shedding (P=0.041).
pH1N1 infection in pediatric cancer and SCT patients infrequently caused complications but commonly interrupted cancer treatment. Persistent shedding of virus after illness resolution was common. Further research is needed to verify this finding as it could have implications for treatment guidelines and infection control practices.
From the *Hematology/Oncology/Transplant Program, Alberta Children's Hospital, Calgary, Alberta; †Hematology/Oncology, Cancer Care Manitoba, Winnipeg, Manitoba; ‡Hematology/Oncology, Montreal Children's Hospital, Montréal, Quebec; §Pediatric Hematology/Oncology, British Columbia Children's Hospital, Vancouver, British Columbia; ¶Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario; ?Hematology/Oncology, Children's Hospital of Eastern Ontario, Ottawa, Ontario; **Pediatric Hematology/Oncology, Centre Hospitalier Universitaire de Quebec, Quebec, Quebec, ††Stollery Children's Hospital, University of Alberta Hospital, Edmonton, Alberta; ‡‡Hematology/Oncology, McMaster Children's Hospital at Hamilton Health Sciences, Hamilton, Ontario; §§Hematology/Oncology, Cancer Centre of Southeastern Ontario at Kingston, Kingston, Ontario; ¶¶Hematology/Oncology, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Quebec; ??Pediatrics, IWK Health Centre, Halifax, Nova Scotia; ***Hematology/Oncology, Janeway Child Health Centre, St. John's, Newfoundland; †††Hematology/Oncology, London Health Sciences, London, Ontario; ‡‡‡Hematology/Oncology, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebec; ¶§§§Population Genomics Program, Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton; and ¶¶¶¶Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada.
Viridans group streptococci (VGS) cause significant morbidity in children treated for acute myeloid leukemia (AML). Our goals were to determine the occurrence and impact of these infections in children treated for AML and to understand the factors that increase the risk of VGS infections and viridans streptococcal shock syndrome (VSSS) in this population.
We conducted a retrospective, population-based cohort study that included children =18 years of age with de novo AML treated at 15 Canadian centers. We evaluated factors related to VGS infection and VSSS.
Among 341 children with AML, VGS occurred in 78 (22.9%) children over the entire course of therapy and 16 had recurrent episodes. VGS infection occurred in 97 of 1277 courses of chemotherapy (7.6%). VSSS occurred in 19.6% of these episodes and included 11 patients who required intensive care services with 2 VGS infections resulting in death. In multiple regression analysis, factors independently related to VGS included treatment on a Medical Research Council-based protocol (odds ratio (OR) 2.87, 95% confidence interval (CI) 1.53-5.39; P = 0.001), cytarabine dose per gram/m² (OR 1.04, 95% CI 1.01-1.07; P = 0.002) and prolonged neutropenia (OR 1.58, 95% CI: 0.97-2.56; P = 0.06). None of the evaluated factors were predictive of VSSS.
VGS infections occur in 7.6% of chemotherapy courses and remain an important cause of morbidity and even mortality in children being treated for AML. Interventions to reduce VGS need to be identified.