Pediatric Oncology Group

Dengue infection should be considered in the differential diagnosis of febrile neutropenia in endemic areas, even in the absence of warning signs. A retrospective audit was done on medical records of patients (age 14y or younger) who were diagnosed with dengue fever from April 1, 2023 to March 31, 2024 in a tertiary care cancer center. Patients fulfilling the WHO 2009 criteria of dengue fever and confirmation with detection of either IgM or NS1 were included. Data regarding symptomatology, clinical course, laboratory values, and outcome were analyzed. Twenty-three patients were diagnosed with dengue. Primary malignancy was mainly B-ALL (n=16; 69%). Thirteen patients (56.6%) had criteria fulfilling dengue without warning signs, 5 (21.7%) had dengue with warning signs, and 5 (21.7%) had severe dengue. All patients were treated as inpatients with intravenous fluids and supportive care. Five patients (21.7%) with shock required IVF at 10mL/kg/h. Two patients (8%) had blood culture positivity and were managed based on the susceptibility pattern. Median delay in chemotherapy was 6 days. The mean duration of hospital stay was 7 days. Three patients (13%) had features of HLH. One patient succumbed to multiorgan failure (with HLH and MDR Klebsiella sepsis).

Point-of-care ultrasound (POCUS) plays a vital role in rapid diagnosis and management in emergency settings. We present a case of a 9-year-old male who presented after a high-speed motor vehicle collision with a negative focused assessment with sonography for trauma (FAST). However, the quality assurance (QA) review raised concerns for a splenic mass. Further imaging confirmed the finding, and the patient underwent elective splenectomy, revealing a rare benign littoral cell angioma. This case illustrates the importance of QA in identifying findings during POCUS exams, the limitations of POCUS compared with comprehensive imaging, and the value of a multidisciplinary approach to pediatric trauma care.

Hypertension is a significant morbidity among childhood cancer survivors (CCS). Ambulatory blood pressure monitoring (ABPM) allows for continuous 24-hour blood pressure assessment and provides valuable insights into abnormal nocturnal dipping (aND) and ambulatory arterial stiffness index (AASI). This study aimed to evaluate the prevalence of hypertension and prehypertension, as well as, the rates of aND, and AASI in CCS. Ambulatory blood pressure monitoring was performed in 49 patients who had completed cancer treatment at least 1 year prior. Among all patients, the prevalence of hypertension and prehypertension was 10% and 16%, respectively. The solid tumor group demonstrated a significantly higher prevalence of prehypertension, nephrotoxic drug exposure, and cumulative doses of endothelium-toxic agents compared with the hematologic malignancy group. However, no significant difference in hypertension prevalence was observed between the 2 groups. Notably, a diagnosis of Wilms tumor was significantly associated with prehypertension. According to ABPM findings, aND was observed in 61% of patients. The higher prevalence of prehypertension and aND in CCS compared with healthy children, along with the observed association between hypertension and AASI, highlights the importance of ABPM in the long-term cardiovascular monitoring of this population. The increased prevalence of prehypertension in patients with solid tumors may be attributed to the cumulative dosage of drugs used during treatment.

Impact of infection management care pathway implementation is uncertain in pediatric cancer. Objective was to determine whether fewer patients received clinical practice guideline (CPG)- and care pathway-inconsistent care after implementation of an adapted infection management care pathway compared to pre-implementation. We implemented adapted infection management care pathways based on CPGs for prophylaxis, and initial, ongoing, and prolonged fever and neutropenia (FN) management in three centers. We conducted a retrospective chart review, sampling patients with episodes of high- and low-risk FN, pre- and post-implementation of the care pathway. Up to five chemotherapy cycles per patient were adjudicated for antibacterial and antifungal prophylaxis care pathway inconsistency. Among these cycles, FN episodes were identified, and one was randomly chosen per patient. CPG- and care pathway-inconsistent actions were adjudicated. Three hundred seventy-five patients were assessed for eligibility, and 272 were included. For prophylaxis, 115 pre-implementation and 57 post-implementation high-risk cycles were evaluated. For FN, 82 pre-implementation and 42 post-implementation episodes were evaluated. Antifungal prophylaxis inconsistency decreased in the post-implementation period compared with the pre-implementation period (P = 0.023). However, there were no other significant differences in CPG- or care pathway-inconsistent actions by period. In both periods, CPG- and care pathway-inconsistent actions were common. Implementation of adapted care pathways for infection management was associated with fewer patients receiving care pathway-inconsistent antifungal prophylaxis. However, it did not reduce other CPG- or care pathway-inconsistent actions. Inconsistent actions for FN management were common in both periods. Targeted approaches are required to improve care pathway-consistent infection management in pediatric cancer patients.

Pyomyositis is a primary infection of the skeletal muscle, commonly occurring in tropical countries in children. Treatment is still controversial, with antibiotics plus drainage being the main option. Retrospective, unicentric study of pyomyositis in a tertiary care Pediatric Hospital, from January 2008 to December 2022. Predisposing factors, clinical, laboratory and radiological results, treatment and evolution were analyzed. Twenty-nine patients were identified, 75.9% male, median age of 8 years old (0.8;17). The most common predisposing factors were intense physical activity (37.9%), followed by trauma (31.0%). Pain (100.0%), functional impairment (82.8%) and fever (65.5%) were the most frequent symptoms. The most affected sites were the pelvis (51.6%) and the upper leg (22.6%). Magnetic resonance imaging had 100% sensitivity, whereas 40.7% of ultrasounds were inconclusive. Blood cultures were positive in 40.0% of cases and pus in 33.3%. Methicillin-sensitive Staphylococcus aureus was the most common isolated organism (36.0%). Most patients were treated with intravenous flucloxacillin plus clindamycin (55.2%) for a median of 14 days (7;30) and a median total duration of 29 days (14;72). Drainage was only performed in 20.7% of patients, of which 6/15 were in the suppurative phase. All patients improved without functional impairment at 6-month follow-up. Pyomyositis' symptoms can be nonspecific. Methicillin-sensitive Staphylococcus aureus was the most common isolated organism, and many patients can be treated conservatively, without drainage, even in the suppurative phase.

assessed the impact of the quality of initial and subsequent surgeries on the survival of patients with nonmetastatic and metastatic paratesticular rhabdomyosarcoma enrolled in the two Cooperative Weichteilsarkom Studiengruppe (CWS) trials (CWS-96, 2002P) and the Soft Tissue Sarcoma Registry (SoTiSaR).The quality of local surgical control has revealed unsatisfactory results, with a high prevalence of protocol violations during primary surgery (42%) and pretreatment re-excision (20%).

Rationale Chronic norovirus infection (CNI) is a significant cause of morbidity and mortality in immunocompromised patients. We sought to determine clinical and virologic features associated with CNI with an emphasis on IEI. Methods Norovirus-positive stool samples from 88 patients at the NIH Clinical Center from 2010 to 2023. Longitudinal clinical and virologic data were collected. Results Forty-eight patients had CNI; 23 had acute norovirus infection (ANI); 17 patients were unclassifiable. Eighty-three percent of CNI patients had an underlying diagnosis of IEI, including CID (N = 23), CVID (N = 11), and SCID (N = 6). The majority with ANI had hematologic disorders (48%); only 5 (21%) had CVID, CID, or SCID. Mortality in the CNI cohort was 38%. More than half of CNI patients had nutritional defects, including electrolyte abnormalities and hypovitaminosis; 20% required TPN. GII.4 was the predominant norovirus genotype among all patients, although diverse genotype I and II viruses were represented. Gastrointestinal coinfections during CNI infection were prevalent (50%); the most common being enteropathogenic E. coli (N = 12) and C. difficile (N = 12). Seventy-seven percent of CNI patients had chronic liver disease, including both cholestatic (N = 18) and hepatocellular (N = 14) patterns. Thirty-three percent (N = 16) of CNI patients had a diagnosis of nodular regenerative hyperplasia (NRH). Only 35% of patients with ANI had chronic liver disease. Twelve patients with CNI eventually cleared norovirus (median duration of 688 days versus 18 days for ANI). Eight patients cleared in the setting of definitive immune reconstitution, specifically HSCT or gene therapy. Three patients cleared in the setting of immunomodulatory therapy for concurrent IEI-related enteropathy treated with ustekinumab, abatacept, and/or JAK inhibitors. No patient cleared after traditional CNI therapies, including nitazoxanide, ribavirin, or immunoglobulin (PO or IV). Conclusions CNI patients were nutritionally compromised with high mortality and a high prevalence of liver disease. IEI with adaptive defects were disproportionately represented in CNI. Common CNI treatments were not effective. CNI consistently resolved with definitive immune reconstitution; some patients cleared infection with immunomodulatory therapy for enteropathy, suggesting a new treatment strategy to be explored in future studies. To our knowledge, this is the largest cohort of CNI with a focus on IEI analyzed to date. Figure 1. Category of underlying diagnosis. Figure 2. Norovirus genotypes represented across cohorts.

Pediatric cancer care services in high-income nations are mainly centralized in metropolitan cities. To allow treatments closer to home, patients across Ontario, Canada, a geographically large province, are offered decentralized care via satellite clinics; however, it is unclear whether the utilization of these pediatric oncology satellite clinics differs by area-level sociodemographic factors. To examine whether sociodemographic factors, such as area-level income and rurality, are independently associated with the odds of satellite clinic visit and the hazards of time to first visit among pediatric oncology patients receiving cancer treatment. This is a retrospective population-based cohort study of patients aged 0 to 17 years with cancer living in a satellite catchment area in Ontario, Canada (from 2015 to 2022, with follow-up through 2023). The Pediatric Oncology Group of Ontario Networked Information System cancer registry (containing age, sex, diagnosis type, and year information) was linked to satellite, OpenStreetMap, and postal-code databases to ascertain rural or urban dwelling, neighborhood-based income, and driving time saved. Age, sex, rural or urban dwelling, and neighborhood-level income quintiles. The primary outcomes were the odds of satellite clinic attendance within 1 year of diagnosis and the hazards of first clinic visit after starting systemic therapy, derived from multivariable logistic and Cox proportional hazards models, respectively. Among the 1280 eligible patients (median [IQR] age, 7.0 [3.0-13.0] years; 753 male [58.8%]), 844 (65.9%) visited a satellite clinic within 1 year of diagnosis with a median (IQR) of 39 (14-67) days to first visit. Driving time saved (>60 minutes) was the factor most associated with satellite use, followed by diagnostic type (with patients with central nervous system tumors least likely to visit). Rural (vs urban) patients had significantly lower odds of satellite visit within a year of diagnosis (odds ratio, 0.48; 95% CI, 0.31-0.74; P = .001) and lower instantaneous likelihood of visiting after start of treatment (hazard ratio, 0.65; 95% CI, 0.53-0.81; P < .001). Living in a lower-income (vs middle-income) area was also associated with significantly lower utilization (odds ratio, 0.53; 95% CI, 0.35-0.80; P = .009; hazard ratio, 0.73; 95% CI, 0.60-0.89; P = .002). This population-based study of pediatric oncology patients found that satellite clinics, despite being designed to reduce transportation and financial burdens, were disproportionately underutilized by patients living in rural and lower-income areas. Monitoring area-level social determinants of health can help inform interventions to improve timely and equitable access to childhood cancer care closer to home.