Prophylaxis and management of antineoplastic drug induced nausea and vomiting in children with cancer

AbstractAntineoplastic drug induced nausea and vomiting (AINV) is a major adverse event which deeply impacts the quality of life of children with cancer. It additionally causes distress to parents and negatively impacts compliance to therapy. A robust AINV prophylaxis regimen is essential to achieve complete control; and prevent anticipatory, breakthrough and refractory AINV. With a wide array of available anti-emetics, standard guidelines for their use are crucial to ensure uniform and optimum prophylaxis. Chemotherapeutic agents are classified as having high, moderate, low or minimal emetic risk based on their potential to cause emesis in the absence of prophylaxis. Three drug regimen with aprepitant, ondansetron/granisetron and dexamethasone is recommended for protocols with high emetic risk. Although approved in children ≥12 years, there is mounting evidence for the use of aprepitant in younger children too. In protocols with moderate and low emetic risk, combination of ondansetron/granisetron and dexamethasone; and single agent ondansetron/granisetron are recommended, respectively. Metoclopramide is an alternative when steroids are contraindicated. Olanzapine and lorazepam are useful drugs for breakthrough AINV and anticipatory AINV. Knowledge of pediatric dosage, salient adverse events, drug interactions as well as cost of drugs is essential to prescribe anti-emetics accurately and safely in resource constrained settings. Non pharmacological interventions such as hypnosis, acupressure and psychological interventions can benefit a sub-group of patients without significant risk of adverse events

A Comparative study of Drainage of Breast Abscesses by Conventional Incision and Drainage Vs Ultrasound Guided Needle Aspiration / Reaspiration in a Tertiary Health Care Centre

INTRODUCTION: Breast abscess continues to be a major cause of morbidity in developing countries. The treatment of breast abscess continues to be a challenge. Traditionally, treatment of breast abscess involved incision and drainage which is done under general anaesthesia following which the patient requires frequent dressing, will have unsightly scar formation and lactating mothers tend to avoid breast feeding after treatment. With this continuously tried method of incision and drainage, the recurrence rate is still high. Treatment of breast abscess has modified from invasive methods to less invasive procedures. The conventional method of incision and drainage (I and D), breaking loculi and insertion of a drain under general anesthesia has shifted to a minimally invasive approach of aspiration. The following study aims at establishing the necessity and the advantages of adopting a less invasive method of management of breast abscess which is also technically feasible. AIMS AND OBJECTIVES: To compare management of breast abscess by incision and drainage v/s USG guided needle aspiration/re-aspiration (under antibiotic coverage) with respect to 1. Residual abscess 2. Recurrence 3. Clinical outcome of patient basis functional and cosmetic criteria METHODS: 50 patients admitted with a diagnosis of breast abscess were included in the study for a period of 9 months. Diagnosis of breast abscess was confirmed by clinical examination and ultrasound findings. Written and informed consent was obtained and patients were alloted randomly into 2 groups 1. Group 1- Underwent incision and drainage 2. Group 2- Underwent ultrasound guided needle aspiration/re-aspiration of abscess cavity All patients were given appropriate antibiotic coverage primarily with injection Cloxacillin 500mg iv BD (ATD) and injection Metrogyl 500mg iv TDS. Each patient underwent appropriate management as per the group allotted. Ultrasound scan of the operated/drained breast was done on day 3 and 7 post operatively/post drainage to rule out residual abscess. Each patient was analysed on the basis of residual abscess, recovery time period, recurrence of abscess and resumption of functionality for lactating mothers. Both groups were compared based on multiple factors to assess the better method of management of breast abscess and the comparative charts and parameters have been documented and analysed. Each patient in the study was followed up 2 weeks after discharge to assess clinical improvement. RESULTS: A comparative study of drainage of breast abscess by conventional incision and drainage versus ultrasound guided needle aspiration/re-aspiration in a tertiary health care centre was done to compare management in terms of residual abscess, recurrence and clinical outcome of patient basis functional and cosmetic criteria. A total of fifty patients were studied prospectively for nine months. The following is a summary of the results: 1. 96% of patients in Group A (who underwent incision and drainage) had residual abscess, edema, collection whereas 44% of patients in group B (who underwent USG guided aspiration) completely normalized and recovered with no residual abscess/recurrence. 2. 25% of patients who underwent incision and drainage had residual abscess on POD 7 whereas only 12% had residual abscess on POD 7 3. 28% of patients who underwent incision and drainage had a recurrence of breast abscess after 2 weeks, whereas no patient who underwent USG guided aspiration had any recurrence after 2 weeks. 4. 91.67% of lactating mothers in the USG guided aspiration group, resumed breastfeeding after treatment whereas only 20% of lactating mothers who underwent incision and drainage, resumed breastfeeding. 5. Mean healing time in I and D group was 13.9 days whereas in USG guided aspiration group mean healing time was 5 days 6. 100% of patients who underwent incision and drainage had a scar whereas no patient who underwent USG guided aspiration of breast abscess had any scar CONCLUSION: The method of management of breast abscess must be decided based on different factors such as ease of technique, feasibility, acceptance, time for complete healing, cosmetic and functional outcome. As explicitly noted from the above results, USG guided aspiration/re-aspiration of breast abscess is the better, more feasible and more acceptable method of management of breast abscess. Based on the overall advantages of USG guided aspiration over incision and drainage, it is safe to conclude that USG guided aspiration is a safer and more effective method of treatment of breast abscess especially when initiated early and immediately after diagnosis

Vincristine induced cortical blindness: An alarming but reversible side effect

Vincristine is one of the commonest chemotherapeutic agents in the practice of pediatric oncology. Although peripheral neuropathy is a dose limiting adverse event, blindness secondary to vincristine is seldom reported. We describe a child with Wilms tumor who developed transient visual loss after administration of vincristine. The child underwent early surgery and vincristine was re-introduced at reduced doses and gradually escalated to full dose while closely monitoring for recurrence. Blindness is a distressing adverse event, and re-exposure to the offending agent involves a conscientious decision

Effect of socio-economic status & proximity of patient residence to hospital on survival in childhood acute lymphoblastic leukaemia

Background & objectives: Survival in paediatric acute lymphoblastic leukaemia (ALL) in lower/middle income countries continues to lag behind outcomes seen in high-income countries. Socio-economic factors and distance of their residence from the hospital may contribute to this disparity. This study was aimed at identifying the impact of these factors on outcome in childhood ALL. Methods: In this retrospective study, file review of children with ALL was performed. Patients were treated with the modified United Kingdom (UK) ALL-2003 protocol. Details of socio-economic/demographic factors were noted from a web-based patients' database. Modified Kuppuswamy scale was used to classify socio-economic status. Results: A total of 308 patients with a median age of five years (range: 1-13 yr) were studied. Patients belonging to upper, middle and lower SE strata numbered 85 (28%), 68 (22%) and 155 (50%). Nearly one-third of the patients were underweight. There was no treatment abandonment among children whose mothers were graduates. Neutropenic deaths during maintenance therapy were lower in mothers who had passed high school. In patients who survived induction therapy, the five year event-free survival (EFS) of upper SE stratum was significantly better 78.7±4.9 vs. 59±7.2 and 58.1±4.6 per cent in middle and lower strata (P =0.026). Five year overall survival was higher in the higher SE group; being 91.2±3.5, 78.3±5.6 and 78.8±3.9 per cent (P =0.055) in the three strata. Survival was unaffected by a distance of residence from treating centre or rural/urban residence. High-risk and undernourished children had a greater hazard of mortality [1.80 (P =0.015); 1.98 (P =0.027)]. Interpretation & conclusions: Our findings showed that higher socio-economic status contributed to superior EFS in children with ALL who achieved remission. Undernutrition increased the risk of mortality

Alopecia resembling an ‘undercut hairstyle’ in a child with acute lymphoblastic leukemia at presentation

Alopecia is unusual at presentation in children with cancer. Alopecia neoplastica has been described in adults with metastatic carcinoma and melanoma. Additionally, alopecia may accompany lymphoma as a paraneoplastic phenomenon. We describe a child with acute lymphoblastic leukemia, who presented with a distinct pattern of alopecia involving the scalp. The child had not received any chemotherapy prior. Keywords: Childhood leukemia, Dermatological manifestation, Hair loss, Malignant alopecia, Leukemic alopeci

Successful treatment of cytomegalovirus pneumonia in a child on maintenance chemotherapy for acute lymphoblastic leukemia without the use of intravenous immunoglobulin

Cytomegalovirus (CMV) infection is seldom suspected in children receiving chemotherapy for hematological malignancies. However, in populous countries such as India, incidence and subsequent re-activation during immunosuppression may be greater than anticipated. CMV disease can manifest in children with acute lymphoblastic leukemia with chorioretinitis, pneumonia, prolonged cytopenia, enterocolitis and fever unresponsive to antibiotics. We describe our experience in managing a child with acute lymphoblastic leukemia who presented during maintenance therapy with CMV pneumonia. She was successfully treated with ganciclovir alone. Although intravenous immunoglobulin is recommended as adjunctive therapy, its use may be restricted in resource limited settings