Early hospital discharge of children with cancer treated for fever and neutropenia: identification and management of the low-risk patient.

1990 ◽  
Vol 8 (12) ◽  
pp. 1998-2004 ◽  
Author(s):  
C A Mullen ◽  
G R Buchanan
Keyword(s):  
Bone Marrow ◽  
Antibiotic Therapy ◽  
Neutropenic Patient ◽  
Early Discharge ◽  
Low Risk ◽  
Recurrent Fever ◽  
Monocyte Count ◽  
Advanced Malignancy ◽  
Serious Infection ◽  
Risk Patients

Children with leukemia and solid tumors are often hospitalized for empiric broad-spectrum antibiotic therapy because of fever during periods of chemotherapy-induced neutropenia. Conventional practice dictates that parenteral antibiotics be continued until the patient is afebrile and has recovered from neutropenia, ie, until the absolute neutrophil count (ANC) exceeds 500 cells per cubic millimeter. However, the practice in our center has been to discontinue parenteral antibiotic therapy and discharge many such patients before resolution of neutropenia. Since the feasibility and safety of this approach has not been studied, we reviewed the records of 114 consecutive hospitalizations for fever and neutropenia in 61 patients during a 13-month period. Seventy-seven children (68%) were discharged to their homes while still neutropenic after they had been afebrile for 1 to 2 days on parenteral antibiotics, had negative blood cultures, appeared well, and usually had some evidence of bone marrow recovery. Five patients (4.4%) developed recurrent fever and required rehospitalization within 7 days of discharge. Only three of the 77 patients (3.9%) who were sent home with neutropenia had recurrent fever. Each had a brief and uneventful second hospitalization. Two of the 37 children discharged with an ANC over 500 cells per cubic millimeter required rehospitalization. A declining ANC and advanced malignancy were risk factors in predicting recurrence of fever following discharge. A rising monocyte count was a predictor of imminent recovery from neutropenia. These results suggest that "early" discharge of an afebrile yet still neutropenic patient is safe when the patient is in remission, has no evidence of serious infection, appears clinically stable, and has indications of bone marrow recovery. The conventional approach of routinely continuing the hospitalization until resolution of neutropenia may be unnecessary in such low-risk patients.

scholarly journals Early Discharge in Low-Risk Patients Hospitalized for Acute Coronary Syndromes: Feasibility, Safety and Reasons for Prolonged Length of Stay

PLoS ONE ◽  
2016 ◽  
Vol 11 (8) ◽  
pp. e0161493 ◽  
Author(s):  
Marie-Eva Laurencet ◽  
François Girardin ◽  
Fabio Rigamonti ◽  
Anne Bevand ◽  
Philippe Meyer ◽  
...  
Keyword(s):  
Length Of Stay ◽  
Acute Coronary Syndromes ◽  
Early Discharge ◽  
Low Risk ◽  
Prolonged Length ◽  
Risk Patients ◽  
Coronary Syndromes

Impact of Risk Organ Involvement on Outcome in Langerhans Cell Histiocytosis (LCH)

Blood ◽  
2008 ◽  
Vol 112 (11) ◽  
pp. 4652-4652 ◽  
Author(s):  
Satyendra Katewa ◽  
Anupam Sachdeva ◽  
Veronique Dinand ◽  
Satya Prakash Yadav
Keyword(s):  
Bone Marrow ◽  
Lymph Node Involvement ◽  
Low Risk ◽  
Lung Involvement ◽  
Isolated Lung ◽  
Risk Patients ◽  
Node Involvement ◽  
Group A ◽  
Bony Involvement ◽  
Group B

Abstract Objectives: To compare the outcome in children with low risk vs. risk LCH and to evaluate the impact of individual risk organ on outcome. Material and Methods: Medical records of 52 patients were reviewed retrospectively (1992 to 2007). Patients were classified into 2 groups: A-low risk (bone, skin and lymph node involvement), B-risk patients (lungs, liver, spleen and bone marrow involvement). Group B further subdivided in B1-isolated lung involvement, B2-liver, bone marrow or both without lung, B3-lung involvement with liver and/or bone marrow. Patients were treated as per histiocytosis society protocols. Results: There were 31 Males and 21 Females. Mean age at presentation was 4.8 yrs (range 1 month to 15.5 yrs). There were 21 patients in Group A and 31 in Group B with 0 (0%) and 6 (19%) deaths respectively. Overall mortality was 6/52 (11.5%). In group A, 6 patients had skin and lymph node involvement, 6 had unifocal bony involvement and 9 multifocal. Out of these 15 (bony involvement) patients 4 had otitis media and 5 diabetes insipidus. There were 9 patients in Group B1, 18 in Group B2 and 4 in Group B3 with mortality of 0 (0%), 4 (22.2%) and 2 (50%) respectively. Comparison of mortality in risk patients vs. low risk patients approached statistical significance (19.4% vs. 0%, p=0.069). Mortality difference within the 3-subgroups of risk patients was not statistically significant (p=0.097). Conclusion: Outcome is worse if risk organs are involved. However, isolated lung involvement had trend towards better outcome.

Treatment of acute pulmonary embolism as outpatients or following early discharge

2008 ◽  
Vol 100 (05) ◽  
pp. 756-761 ◽  
Author(s):  
Muhammad Janjua ◽  
Aaref Badshah ◽  
Fadi Matta ◽  
Liviu G. Danescu ◽  
Abdo Y. Yaekoub ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Major Bleeding ◽  
Acute Pulmonary Embolism ◽  
Cost Effective ◽  
Early Discharge ◽  
Low Risk ◽  
Exclusion Criteria ◽  
Average Hospital ◽  
Risk Patients ◽  
Acute Pe

SummaryThe purpose of this systematic review is to test the hypothesis that carefully selected low-risk patients with acute pulmonary embolism (PE) can safely be treated entirely as outpatients or after early hospital discharge.Included articles were required to describe inclusion or exclusion criteria and outcome of patients treated for PE.Early hospital discharge was defined as an average hospital stay ≤3 days.Six investigations included patients with PE who were treated entirely as outpatients; two investigations included patients with PE who were treated after early discharge. All investigations included only low-risk patients or patients with small or medium sized PE. Outcome after 3-46 months in patients treated entirely as outpatients showed recurrent PE in 0% to 6.2% of patients, major bleeding in 0% to 2.8% with one death from an intracerebral bleed. Definite death from PE did not occur, but there was one possible death from PE. Outcome in three months in patients treated after early discharge showed no instances of recurrent PE. Major bleeding occurred in 0% to 3.7% of patients.There were no deaths from PE, but there was one death from bleeding. In conclusion, outpatient therapy of acute PE is probably safe in low-risk,carefully selected compliant patients who have access to outpatient care if necessary. Such outpatient treatment would be cost-effective.

Phase I clinical and laboratory evaluation of topotecan and cytarabine in patients with acute leukemia.

1997 ◽  
Vol 15 (1) ◽  
pp. 44-51 ◽  
Author(s):  
K Seiter ◽  
E J Feldman ◽  
H D Halicka ◽  
F Traganos ◽  
Z Darzynkiewicz ◽  
...  
Keyword(s):  
Bone Marrow ◽  
High Risk ◽  
Acute Leukemia ◽  
S Phase ◽  
Low Risk ◽  
Myelogenous Leukemia ◽  
Laboratory Evaluation ◽  
Apoptotic Cells ◽  
High Risk Patients ◽  
Risk Patients

PURPOSE To determine the maximal-tolerated dose (MTD) of topotecan with cytarabine in acute leukemia patients, and to evaluate leukemia cell apoptosis in these patients. PATIENTS AND METHODS Fifty-three patients with acute leukemia not responsive to standard therapy were treated at eight dose levels of topotecan (2.5 mg/m2/d to 7.75 mg/m2/d). Topotecan was given as a 30-minute infusion daily with cytarabine 1 g/m2/d, both for 5 days. Using a flow-cytometric technique, the percent apoptotic cells in blood and bone marrow samples was determined, and the cell cycle distribution of the leukemic cells studied. RESULTS Oropharyngeal mucositis was dose-limiting. The MTD of topotecan was 4.75 mg/m2/d for 5 days in high-risk patients and 7.0 mg/m2/d for 5 days in low-risk patients. The mean percent apoptotic cells in the peripheral blood reached a peak of 18.8%, a median of 48 hours following the first dose of topotecan. Patients with higher S-phase fractions, either before treatment or following cytarabine, were more likely to achieve bone marrow aplasia than those with lower S-phase fractions (P = .01 and P < .05, respectively). Clinical responses were seen in four of 39 patients with acute myelogenous leukemia (AML; of whom 32 had received prior high-dose cytarabine), three of six with acute lymphoblastic leukemia (ALL), and one of eight with chronic myelogenous leukemia in blast phase (CML-BP). CONCLUSION The recommended phase II dose of topotecan with intermediate-dose cytarabine is 4.75 mg/m2/d for high-risk patients and 7.0 mg/m2/d for low-risk patients. The percentage of cells in S phase was important in determining response to treatment.

Diagnosis and Treatment of Essential Thrombocythemia: Assessment of Current Clinical Practice.

Blood ◽  
2009 ◽  
Vol 114 (22) ◽  
pp. 1903-1903
Author(s):  
Vivian H Y Lee ◽  
Erica Peterson ◽  
Leslie Zypchen ◽  
Lynda M Foltz
Keyword(s):  
Bone Marrow ◽  
Clinical Practice ◽  
High Risk ◽  
Diagnostic Criteria ◽  
Bone Marrow Biopsy ◽  
Jak2 V617f ◽  
Low Risk ◽  
Cytoreductive Treatment ◽  
Risk Patients ◽  
History Of

Abstract Abstract 1903 Poster Board I-926 Introduction: The discovery of the JAK2 V617F gene mutation has significantly altered the clinical diagnostic approach to the myeloproliferative neoplasms, reflected in the revised 2008 WHO diagnostic criteria. Both the 2001 and 2008 diagnostic criteria for essential thrombocythemia (ET) require a bone marrow biopsy showing megakaryocytic proliferation to make a diagnosis of ET. Published expert opinion based on clinical studies suggests that ET patients > 60 years old or with history of thrombosis should be characterized as high risk and treated with hydroxyurea. It is unclear whether physicians in clinical practice utilize the WHO diagnostic criteria or follow expert treatment recommendations for ET. Methods: We conducted a retrospective chart review of all patients with a clinical diagnosis of ET made by a hematologist who were seen in clinic from 2006 to 2008 at two university teaching hospitals in Vancouver, Canada. Data collected included demographic information, thrombosis history, diagnostic tests performed and treatment administered. Testing for JAK2 V617F became locally available in 2006, so for assessment of diagnostic tests performed, patients were divided into cohorts of diagnosis pre-2006 and 2006–2008. Patients were characterized as high risk if > 60 y or history of thrombosis at the time of diagnosis. All other patients were considered low risk. Results: Diagnostic information was available for 116 patients diagnosed prior to the availability of testing for JAK2 V617F. 65% (75/116) of patients in this cohort had a bone marrow biopsy performed (table 1). 44 patients received a new diagnosis of ET from 2006–2008. Only 48% (21/44) patients in this cohort had a bone marrow biopsy performed, significantly less than in the historical cohort (p = 0.019). 41/44 had JAK2 V617F testing performed: 41% (17/41) were JAK2 V617F negative, 56% (23/41) positive and 1 equivocal. Bone marrow biopsy was performed in 59% (10/17) of JAK2 V617F negative patients and 39% (9/23) of JAK2 V617F positive patients (p = 0.055) (table 1). Bone marrow biopsy was also performed in 1 patient with equivocal JAK2 V617F testing and 1 patient not tested for JAK2 V617F. 170 patients diagnosed with ET were seen in follow up 2006–2008. 64% (109/170) were high risk due to age > 60 y or history of thrombosis. The remaining 36% (61/170) were considered low risk. Hydroxyurea was used preferentially over anagrelide for treatment of ET (table 2). Only 76% of high risk patients were receiving cytoreductive treatment. 23% of low risk patients received cytoreductive treatment. ASA was prescribed to 89% of high risk and 79% of low risk patients. Conclusion: Despite the requirement for a bone marrow biopsy to meet the WHO criteria for ET, hematologists performed a bone marrow biopsy in less than half of patients they diagnosed with ET since 2006. Hematologists performed bone marrow biopsy less frequently after JAK2 V617F testing became available, particularly in JAK2 V617F positive patients. A substantial portion of high risk patients (24%) were receiving no cytoreductive therapy, contrary to expert recommendation. Further study is required to understand the barriers to implementing treatment recommendations in clinical practice. This study highlights the challenges in translating published diagnostic criteria and treatment guidelines into changes in patient care. Disclosures: No relevant conflicts of interest to declare.

Efficacy and safety of an early discharge protocol in low-risk patients with upper gastrointestinal bleeding

1998 ◽  
Vol 105 (3) ◽  
pp. 176-181 ◽  
Author(s):  
Pablo Moreno ◽  
Eduardo Jaurrieta ◽  
Humberto Aranda ◽  
Juan Fabregat ◽  
Leandro Farran ◽  
...  
Keyword(s):  
Gastrointestinal Bleeding ◽  
Upper Gastrointestinal Bleeding ◽  
Early Discharge ◽  
Low Risk ◽  
Efficacy And Safety ◽  
Risk Patients ◽  
Discharge Protocol ◽  
Upper Gastrointestinal

Outpatient Oral Antibiotics for Febrile Neutropenic Cancer Patients Using a Score Predictive for Complications

2006 ◽  
Vol 24 (25) ◽  
pp. 4129-4134 ◽  
Author(s):  
Jean Klastersky ◽  
Marianne Paesmans ◽  
Aspasia Georgala ◽  
Frédérique Muanza ◽  
Barbara Plehiers ◽  
...  
Keyword(s):  
Significant Proportion ◽  
Early Discharge ◽  
Low Risk ◽  
Oral Antibiotics ◽  
Amoxicillin Clavulanate ◽  
Risk Patients ◽  
Discharged Patients ◽  
Neutropenic Patients ◽  
Neutropenic Episode ◽  
Observation Period

Purpose Since febrile neutropenic patients were recognized to constitute a heterogeneous population, several models have been developed for predicting the risk of serious medical complications. The Multinational Association for Supportive Care in Cancer score and its derived clinical prediction rules have been validated, but thus far there were no data about its use for simplifying therapy in predicted low-risk patients. Patients and Methods In a single institution, we followed all episodes of febrile neutropenia between January 1999 and November 2003. Those patients predicted at low risk for complications, who were not receiving antibacterials at fever onset and were eligible for treatment with oral antibiotics, were treated with ciprofloxacin and amoxicillin-clavulanate and were discharged if they were clinically stable or improving after an initial observation period. The primary end point of the study was the rate of resolution of the febrile neutropenic episode without complications, among these early discharged patients. Results Of 383 first febrile neutropenic episodes predicted at low risk of omplication, 178 patients (33 men and 145 women, mainly with solid tumors) were treated orally; they constituted the basis of our analysis. Seventy-nine patients (44%) were discharged early (with a median time to discharge of 26 hours); no complications occurred among them but three patients had to be readmitted, resulting in a success rate of 96% (95% CI, 92% to 100%). Conclusion Our study shows that oral therapy followed by early discharge was feasible in a small but significant proportion of patients selected by a strategy combining predicted low risk and medical and nonmedical criteria.

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