Computed Tomography CT Radiographic Imaging
1.4.2.3 Magnetic Resonance Imaging MRI
MRI is advantageous over CT due to a lack of radiation exposure although at a much higher cost. MRI is also more affected by motion related to cardiorespiratory function increasing artifact incidence especially in the chest. Furthermore, given its increased imaging time, MRI usually requires sedation for pediatric patients, decreas- ing its convenience as a diagnostic tool. However, MRI remains the imaging of choice for assessing lesions in the liver, spleen, and central nervous system CNS brain and spine Sahani and Kalva 2004 ; Luna et al. 2006 .1.4.2.4 Positron Emission Tomography PET
PET is now used frequently alongside CT for the diagnosis of cancer, but experience using PET CT for FN is limited. A recent study from Australia compared diagnostic yields of PETCT and conventional imaging in 20 adult patients with FN of 5 days duration Guy et al. 2012 . By using conventional imaging, the authors found 14 infections sites, 13 of which were also confi rmed by PETCT; in addition, PETCT iden- tifi ed 9 more sites of infection 8 of which were subsequently confi rmed as true infection, sug- gesting that PETCT may be useful in the study of prolonged FN. However, more data are needed to support the use of this modality as fi rst-line imaging in pediatrics given its inherent expense and associated radiation exposure Xu et al. 2010 ; Haroon et al. 2012 .1.4.3 Biomarkers for Invasive
Fungal Infection IFI Early identifi cation of infection in FN, especially IFI, critically affects patient survival. Biomarkers for IFI have proven useful in the adult population as adjuncts to clinical fi ndings and imaging. Limited pediatric data suggest these biomarkers may also be used in children with similar sensi- tivities and specifi cities as defi ned in adults.1.4.3.1 Aspergillus Galactomannan GMN
GMN is a cell-wall component of growing hyphae and can be detected by assay from the serum, urine and bronchoalveolar BAL fl uid Klont et al. 2004 ; Pfeiffer et al. 2006 . The GMN assay has been shown effective in adult populations with hematologic malignancies and limited data in children suggest utility in pediatric oncology patients as well Sulahian et al. 2001 ; Pfeiffer et al. 2006 ; Steinbach et al. 2007 ; Castagnola et al. 2010 . A recent observational, prospective, multicenter study found the specifi city of urine and serum GMN assays were 80 and 95 , respectively. This study found that the false- positive rate was lower than previously described Fisher et al. 2012 . The GMN assay must be interpreted with cau- tion, particularly in the context of a single positive value, and should be utilized in conjunction with corroborative clinical and radiologic fi ndings. Serial repetition of the assay can be used as a sur- veillance marker either for potential IFI or disease response to antifungal therapy Groll et al. 2014 . The GMN assay may have false-positive results in patients receiving beta-lactam antimicrobials espe- cially piperacillintazobactam, although recent studies suggest the false-positive rate may not be as high as previously published Zandijk et al. 2008 ; Metan et al. 2010 ; Mikulska et al. 2012 .1.4.3.2 1,3-β-
D -glucan BDG Serum BDG, an important cell-wall component of most fungi including Pneumocystis jiroveci former carinii , has been measured in adult patients with IFI and hematologic malignancies Marty and Koo 2009 . Like GMN, studies using serum BDG in the pediatric population are lim- ited. In fact, few studies performed to date even establish a normal value for children, which may be higher than the 60 pgmL cutoff used in adult patients Smith et al. 2007 ; Mularoni et al. 2010 . In immunocompromised adult patients, serum BDG levels exceeding 500 pgmL have been used to diagnose P. jiroveci Del Bono et al. 2009 ; Koo et al. 2009 ; te Poele et al. 2009 . One pediatric study found serum BDG potentially useful for P. jiroveci diagnosis in three patients with hema- tologic malignancies, one with BAL fl uid confi r- mation Gonzalez et al. 2011 . The sensitivity of BAL for diagnosing P. jiroveci pneumonia is lower in non-HIV patients and in patients receiv- ing aerosolized pentamidine. Therefore, serum BDG may be a useful adjunctive, noninvasive diagnostic tool Levine et al. 1992 ; Azoulay and Schlemmer 2006 ; Jiancheng et al. 2009 . More pediatric studies are needed to defi ne serum BDG as a reliable indicator of IFI such as P. jiroveci . Serum BDG does not detect Cryptococcus or Zygomycetes spp. e.g., Mucor , Rhizopus , Absidia , which do not produce BDG. False posi- tives also occur in patients receiving antimicro- bial agents such as piperacillintazobactam in addition to hemodialysis with cellulose mem- branes, intravenous albumin and immunoglobulin Marty and Koo 2009 ; Karageorgopoulos et al. 2011 . Finally, the test may serve as a prognostic marker for invasive candidiasis when serial levels are measured, but data supporting this indication are limited Ginocchio et al. 2012 ; Glotzbecker et al. 2012 ; Jaijakul et al. 2012 .1.4.3.3 Polymerase Chain Reaction PCR
Molecular methodology such as PCR testing may improve the detection of IFI as well as bac- terial or viral organisms in children with FN Santolaya et al. 2011 ; Kourkoumpetis et al. 2012 . However, lack of standardization has limited its current use and more data are required to make fi rm recommendations.1.4.4 Viral Studies
Viral infections may cause prolonged fevers in neutropenic patients. Seasonal viral infections such as infl uenza AB and respiratory syncytial virus RSV in the winter and enterovirus in the summer must be considered Lindblom et al. 2010 ; Ozdemir et al. 2011 . In patients with mucositis, herpes simplex virus HSV should be considered. Viral PCR whole blood and plasma, cerebrospinal fl uid, stool is commercially available and enables faster identifi cation of viral etiologies at higher sensitivity and specifi city compared to viral culture. In addition, direct fl uorescent antibody DFA testing of cutaneous lesions may expedite diagnosis of herpetic skin infections i.e., HSV, varicella.1.4.5 Invasive Procedures:
Bronchoalveolar Lavage BAL and Tissue Biopsy Tissue is necessary for diagnosis when physi- cal examination or radiographic imaging is con- cerning for abscess formation or lesions of the skin, sinuses, or organ parenchyma but with- out corroborative microbiologic confi rmation. Microbiologic evaluations should include proper sample collection for assessing AFB and other bacterial and fungal pathogens. For IFI such as chronic disseminated candidiasis or invasive Aspergillus spp., hepatic or splenic biopsy may be required Masood and Sallah 2005 . In children with pulmonary lesions, BAL should be attempted fi rst as it has a low complica- tion rate and may yield an etiologic agent Pattishall et al. 1988 ; Jain et al. 2004 ; Efrati et al. 2007 . CT-guided lung biopsy or wedge resection may be necessary if BAL sampling is nondiagnostic in the patient with persistent fever and pulmonary nodules Wingard et al. 2012 . In addition to routine cultures, BAL samples should be analyzed by GMN assay Wingard et al. 2012 .Parts
» Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Introduction Supportive Care in Pediatric Oncology irantextbook.ir 93df
» History and Physical Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Defi ning the Risk for Serious
» Initial Laboratory Evaluation Diagnostic Evaluation
» Chest Radiography CXR A supine CXR may identify pleural effusions,
» Computed Tomography CT Radiographic Imaging
» Magnetic Resonance Imaging MRI
» Positron Emission Tomography PET
» Aspergillus Galactomannan GMN Biomarkers for Invasive
» 1,3-β- Biomarkers for Invasive
» Polymerase Chain Reaction PCR
» Viral Studies Diagnostic Evaluation
» Invasive Procedures: Diagnostic Evaluation
» Adult FN Guidelines Empiric Management
» Monotherapy Versus Combination Therapy
» Which Monotherapy to Choose A Cochrane review of antipseudomonal beta-
» Alterations in Initial Empiric FN Antibiotic Management
» Outpatient Management of FN Although there remains a lack of one uniform
» Choice of Empiric Antifungal Therapy
» Duration of Antimicrobial Empiric Management
» Endovascular Sources Empiric Management
» Adjunctive Treatment Empiric Management
» Emergence of Resistant Empiric Management
» Red Blood Cell Administration
» Granulocyte Transfusion Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Hemolytic Transfusion Risks of Blood Product
» Infection and Sepsis Risks of Blood Product
» Allergic Reactions Risks of Blood Product
» Febrile Nonhemolytic Risks of Blood Product
» Transfusion-Related Acute Risks of Blood Product
» Transfusion-Associated Risks of Blood Product
» Iron Overload Risks of Blood Product
» Laboratory Risk Factors Supportive Care in Pediatric Oncology irantextbook.ir 93df
» General Management Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Alkalinization Urinary alkalinization has been a long-standing
» Allopurinol Allopurinol inhibits xanthine oxidase, an enzyme
» Rasburicase Rasburicase, recombinant urate oxidase, converts
» Renal Interventions Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Pathophysiology Superior Vena Cava
» History and Physical Exam SVCSSMS should be suspected in a patient
» Imaging Studies The diagnosis of SVCSSMS is often made on
» Other Studies Tissue is required to make a defi nitive diagnosis
» Treatment Superior Vena Cava
» History and Physical Exam Small pericardial effusions are frequently asymp-
» Imaging and Other Studies The presence of a pericardial effusion can be
» History and Physical Exam Many patients with small pleural effusions are
» Imaging Studies When a pleural effusion is suspected, a chest
» History and Physical Exam Patients with pheochromocytoma typically have
» Laboratory Studies The diagnosis of pheochromocytoma is best made
» Imaging Studies Clinical Presentation
» Pulmonary Leukostasis Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Presentation Spinal Cord Compression
» Differential Diagnosis Spinal Cord Compression
» Imaging MRI of the spine can help narrow the differential
» Surgery Surgery in spinal cord compression can be uti-
» Radiation Therapy The advantages of external beam radiation ther-
» Outcomes Spinal Cord Compression
» Presentation Altered Mental Status
» Initial Management Altered Mental Status
» Metabolic The metabolic causes of AMS or seizure in pedi-
» Chemotherapy-Associated Neurotoxicity Differential Diagnosis
» Posterior Reversible Encephalopathy Syndrome
» Outcomes Altered Mental Status
» Initial Management Increased Intracranial
» Soft Tissue A large meta-analysis of published data suggests
» Cerebrospinal Fluid Hydrocephalus is an excess of CSF within the
» Hemorrhage and Thrombosis Differential Diagnosis
» Idiopathic Intracranial Hypertension Differential Diagnosis
» Presentation of Stroke Cerebrovascular Disease
» Differential Diagnosis Cerebrovascular Disease
» Etiology of Stroke in Pediatric
» Ischemic Stroke After an ischemic stroke is diagnosed, the patient
» Hemorrhagic Stroke Hematomas can expand over several hours from
» Acute Lymphoblastic Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Acute Myelogenous Leukemia Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Acute Promyelocytic Leukemia Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Chronic Myelogenous Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Management of Tumor Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Leukapheresis Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Hyperhydration Other Treatment Modalities
» Hydroxyurea Other Treatment Modalities
» Cranial Irradiation Other Treatment Modalities
» Pseudohyperkalemia Hyperleukocytosis has been noted to cause pseudo-
» Pseudohypoxemia Due to the rapid consumption of oxygen by leu-
» Pseudohypoglycemia Consumption of glucose by excess leukocytes
» Pseudothrombocytosis Leukemic blast lysis can lead to cell fragmenta-
» Transfusion Practice with Other Supportive Care
» Anesthetic Procedures Other Supportive Care
» Neutropenic Enterocolitis Gastrointestinal Infection
» Perirectal Abscess Gastrointestinal Infection
» Gastrointestinal Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Pancreatitis Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Bowel Obstruction Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Abdominal Compartment Supportive Care in Pediatric Oncology irantextbook.ir 93df
» ALL Risk Factors Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Other Malignancies Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Central Venous Catheters Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Diagnosis Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Nociceptive Pain Types of Pain
» Neuropathic Pain Types of Pain
» World Health Organization Pharmacologic Treatment
» Intermittent Opioid Use Pharmacologic Treatment
» Long-Acting Opioids Pharmacologic Treatment
» Breakthrough Dosing Pharmacologic Treatment
» Opioid Rotation Pharmacologic Treatment
» Patient-Controlled Analgesia Pharmacologic Treatment
» Constipation Side Effects of Opioids
» Nausea and Vomiting Nausea and vomiting are rare opioid side effects
» Pruritus Pruritus is a common side effect of opioid use
» Sedation Side Effects of Opioids
» Confusion and Agitation Renal and hepatic function should be checked
» Respiratory Depression When dosed appropriately, opioids rarely result
» Myoclonus Patients receiving very high doses of opioids for
» Urinary Retention Urinary retention can be caused by any opioid but
» Calcium Channel Blockers Neuropathic Pain
» Serotonin and Norepinephrine Neuropathic Pain
» Tricyclic Antidepressants Neuropathic Pain
» Interventional Techniques Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Vincristine-Related Peripheral Oncology-Specifi c Pain
» Osteonecrosis Oncology-Specifi c Pain
» Post-lumbar Puncture Oncology-Specifi c Pain
» Mucositis Pain Oncology-Specifi c Pain
» Pathophysiology of Emesis Chemotherapy-Induced
» Principles of Emesis Control in the Cancer Patient
» Emetogenicity of Chemotherapy Chemotherapy-Induced
» Dopamine Receptor Antagonists Classes of Antiemetics
» Corticosteroids Classes of Antiemetics
» Cannabinoids The plant Cannabis contains more than 60 differ-
» Other Antiemetic Agents Antihistamines
» Alternative Therapies Ginger Classes of Antiemetics
» Management of CINV Management of CINV Table
» Special Considerations Anticipatory Nausea and Vomiting
» Radiation-Induced Nausea Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Initiation The initiation stage occurs immediately following
» Primary Damage Response Pathophysiology of Oral Mucositis
» Signal Amplifi cation Pathophysiology of Oral Mucositis
» Ulceration Ulceration is the phase with the most clinical sig-
» Healing Pathophysiology of Oral Mucositis
» Clinical Course of Oral Mucositis
» Assessment Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Palifermin Prevention and Treatment
» Low-Level Laser Therapy Prevention and Treatment
» Glutamine Prevention and Treatment
» Cryotherapy Prevention and Treatment
» Oral Care Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Oral Infections Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Nutrition Assessment Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Dietary Counseling Nutrition Intervention
» Appetite Stimulants Nutrition Intervention
» Enteral Tube Feeding Nutrition Intervention
» Parenteral Nutrition Nutrition Intervention
» Nutrition and Survivorship Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Management of Neutropenia Hematologic Toxicity
» Management of Thrombocytopenia Hematologic Toxicity
» Management of Anemia Hematologic Toxicity
» Somnolence Syndrome Central Nervous System
» Lhermitte’s Sign Central Nervous System
» Skin Complications Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Oral Mucositis Head and Neck
» Ear Complications Head and Neck
» Laryngeal Complications Head and Neck
» Dysphagia and Esophagitis Gastrointestinal
» Nausea, Vomiting and Anorexia
» Pneumonitis Major Organ Infl ammation
» Pericarditis Major Organ Infl ammation
» Hepatitis Major Organ Infl ammation
» Nephropathy Major Organ Infl ammation
» Cystitis Major Organ Infl ammation
» Risk Stratifi cation Prevention of Bacterial
» Adult Data Antimicrobial Approaches
» Pediatric Data Data regarding the utility of bacterial prophylaxis
» Risks of Prophylaxis Prevention of Bacterial
» Guidelines and Current Usage of Antibacterial Prophylaxis
» Protocols for Line Placement and Care
» Antibiotic and Ethanol Locks
» Chlorhexidine Cleansing Chlorhexidine gluconate CHG is a bactericidal
» Future Directions Prevention of Bacterial
» Risk Stratifi cation Prevention of Fungal
» Approaches to Antifungal Prophylaxis
» Guideline Recommendations for Antifungal Prophylaxis
» Limitations of Current Options for Antifungal Prophylaxis
» Risks of Prophylaxis Prevention of Fungal
» Biomarkers Prevention of Fungal
» Future Directions Prevention of Fungal
» Risk Stratifi cation Prevention of Pneumocystis
» Approaches to PCP Prophylaxis
» Summary of the Recommendations
» Future Directions Prevention of Pneumocystis
» Postexposure Chemoprophylaxis Prevention of Viral Infections
» Suppressive Therapy Prevention of Viral Infections
» Future Directions Prevention of Viral Infections
» Hand Hygiene Infection Control Practices
» Mandatory Vaccination Infection Control Practices
» Hospital Isolation Practices Infection Control Practices
» Visitor Screening Policies Infection Control Practices
» Work Restriction Infection Control Practices
» Cytomegalovirus CMV Status of Transfused Blood
» Treatment of Myelosuppression with
» Prevention of Febrile Neutropenia, Delay
» Treatment of Febrile Neutropenia
» Treatment of Myelosuppression Clinical Usage of Myeloid Growth Factors
» Comparison of Granulocyte Colony-Stimulating Factor
» Optimal Dosing Adult guidelines recommend dosing of 5 mcgkg
» Route of Administration Optimal Administration of Colony-Stimulating Factors
» Optimal Timing Optimal Administration of Colony-Stimulating Factors
» Erythropoietin Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Interleukin-11 Platelet Growth Factors
» Thrombopoietin Receptor Agonists Platelet Growth Factors
» Immune Status Prior Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Immune Status During Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Immune Recovery After Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Immunization Practice Prior Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Diphtheria, Tetanus, and Acellular Pertussis
» Pneumococcal Conjugate Vaccine Recommendations
» Hemophilus Infl uenzae Type b
» Inactivated Infl uenza Vaccine Although in a Cochrane review Goossen et al.
» 2009 H1N1 Pandemic Vaccine Seven studies have reported on effi cacy of the
» Live Attenuated Infl uenza Vaccine
» Meningococcal Conjugate Vaccine Recommendations
» Varicella Zoster Virus Recommendations
» Recommendations Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Treatment of Hypogammaglobulinemia Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Vaccination of Household Contacts
» Peripherally Inserted Central Catheter
» External Tunneled Central Venous Catheter
» Implanted Port Types of Central Venous
» Catheter Insertion Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Exit Site Infection Infection
» Prevention of Infection Infection
» Drug Precipitate or Lipid Residue Occlusion Thrombotic Occlusion
» Evaluation of Catheter- Related Thrombosis
» Treatment of Catheter- Related Thrombosis
» Special Considerations During Anticoagulation Therapy
» Contraindications of Anticoagulant Therapy
» Skin Antisepsis Catheter Maintenance
» Central Venous Catheter Dressings
» Hub Care Catheter Maintenance
» Central Venous Catheter Flushing and Locking
» Chlorhexidine Bathing Chlorhexidine has been shown to be effective in
» Antiseptic Needleless Connectors and Antiseptic
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