Children with cancer, fever, and treatment-induced neutropenia: risk factors associated with illness requiring the administration of critical care therapies.

OBJECTIVES: To identify clinical and laboratory characteristics of pediatric patients with cancer, fever, and treatment-induced neutropenia, available at existing at initial presentation, that are independently associated with the development of illnesses requiring administration of critical care therapies. METHODS: We retrospectively collected historical, clinical, and laboratory data on initial presentation for all pediatric (younger than 18 years) cancer patients admitted for fever and treatment-induced neutropenia at our institution over a 5-year period. The outcome variable was the need for administration of a critical care therapy within 24 hours of admission. A multivariable analysis was performed and internally validated using bootstrap analysis. RESULTS: We identified 303 events in 143 patients, of which 36 (11.9%) received a critical care therapy. Higher temperature at presentation and capillary filling time (CFT) of >3 seconds retained significance in the multivariable analysis and were validated by the bootstrap analysis. The positive and negative predictive values of the presence of either temperature of > or =39.5 degrees C or CFT of >3 seconds were 35% and 91%, respectively. CONCLUSIONS: Pediatric patients with cancer, fever, and treatment-induced neutropenia who present with higher fever or prolonged CFT are at increased risk of developing life-threatening illnesses requiring administration of critical care therapies, independent of hematologic factors, type of cancer, or other physiologic signs of sepsis.

Using telemedicine to provide pediatric subspecialty care to children with special health care needs in an underserved rural community.

OBJECTIVE: For children with special health care needs (CSHCN) that live in rural, medically underserved communities, obtaining subspecialty care is a challenge. Telemedicine is a means of improving access to these children by addressing rural physician shortages and geographic barriers. This article reports a medical-needs assessment of parents/guardians with CSHCN and the status of a telemedicine program for CSHCN as well as the results of parent/guardian and local provider satisfaction with the telemedicine program. DESIGN: We report the results of a pretelemedicine medical-needs survey conducted in March 1999 by using a convenience sample of CSHCN living in a rural, medically underserved community located 90 miles north of the University of California Davis Children's Hospital (Davis, CA). In April 1999, a telemedicine program was initiated to provide consultations to CSHCN and has continued since. We also report the parent/guardian's perceptions of the appropriateness and quality of telemedicine consultations and the local provider's satisfaction with telemedicine consultations completed from April 1999 to April 2002. RESULTS: The pretelemedicine medical-needs assessment demonstrated several barriers in access to subspecialty care including traveling >1 hour for appointments (86% of parents/guardians), missing work for appointments (96% of working parents/guardians), and frequently relying on emergency department services and/or self-regulation of their child's medications. From April 1999 to April 2002, 130 telemedicine consultations were completed on 55 CSHCN. Overall, satisfaction was very high. All the parents/guardians rated satisfaction with telemedicine care as either "excellent" or "very good," and all but 2 of the rural providers' surveys reported satisfaction with telemedicine as "excellent" or "very good." The frequency of telemedicine consultations has increased with time. CONCLUSIONS: Pediatric subspecialty telemedicine consultations can be provided to CSHCN living in a rural, medically underserved community with high satisfaction among local providers and parents/guardians. Telemedicine should be considered as a means of facilitating care to CSHCN that, relative to the customary delivery of health care, is more accessible, family-centered, and coordinated among patients and their health care providers.