Browsing by Author "Hill, Rachel"
Now showing 1 - 5 of 5
- Results Per Page
- Sort Options
Item Exocrine pancreatic insufficiency following asparaginase-induced pancreatitis in pediatric acute lymphoblastic leukemia patients: A case report(2024-03-21) Thomas, Lindsey; Hill, RachelBackground: Asparaginase is an essential agent in the treatment of acute lymphoblastic leukemia (ALL) in pediatric patients. Despite its clinical benefits, patients are at risk for adverse effects including but not limited to asparaginase-associated pancreatitis (AAP). Exocrine pancreatic insufficiency (EPI) is a related condition that involves impaired secretion of digestive enzymes. Case presentations: A 14-year-old male with T cell lymphoblastic leukemia was tolerating chemotherapy well until day 21 of induction therapy when he was brought to the emergency room for generalized weakness and severe abdominal pain. Notably, his appetite had decreased in association with the abdominal pain. Due to his symptoms and recent PEG asparaginase administration, serum lipase was evaluated. Additionally, lipase was evaluated at 1371 U/L, so he was diagnosed with pancreatitis and initially made NPO. Weeks later, he had ongoing difficulties with weight gain and given that his abdominal pain and lipase had improved, the diet was liberalized to a regular diet. Difficulty with adequate intake and weight loss persisted, prompting evaluation of fecal elastase. The results showed a fecal elastase level of less than 10 (normal >/= 201 ug/g), indicating severe exocrine pancreatic insufficiency. The patient was started on pancreatic enzyme replacement therapy (PERT). Fecal elastase was repeated 4 months after EPI diagnosis. While the level had improved slightly (32 ug/g), it still indicated severe pancreatic insufficiency. Five months later, the fecal elastase was re-evaluated again, and it had improved to 131 ug/g, indicating moderate pancreatic insufficiency. The family was instructed to reduce PERT dosing by half with lower fat meals and snacks while monitoring for recurrence of malabsorption symptoms. The patient remained on the lower PERT dosing for three months until he began to have weight loss, abdominal pain, and intermittent loose stools. He was due for an updated fecal elastase level, which had reduced to 85 ug/g. Given the patient’s symptoms and low fecal elastase, PERT was increased to previous dosing using 24,000 UL/capsule. A 6-year-old female patient with preexisting obesity and recently diagnosed Pre-B acute lymphoblastic leukemia presented to the emergency room on day 12 of induction chemotherapy with complaints of severe abdominal pain, nausea, and vomiting. Her symptoms and recent PEG asparaginase administration, warranted serum lipase evaluation. She was diagnosed with pancreatitis due to her supporting symptoms and elevated lipase. Her nutritional intake improved, but the patient continued to experience diarrhea and abdominal pain, prompting evaluation of fecal elastase. Fecal elastase level was 22 ug/g, and PERT was started. Following a week on pancreatic enzyme replacement, the patient’s oral intake had increased. The patient had no complaints of oily stools despite not taking enzymes. She was able to trial off enzyme replacement therapy Conclusion: EPI is an important and often undiagnosed clinical condition with potential deleterious effects on the nutritional status of patients with pancreatitis. It is critical to evaluate for signs of malabsorption, such as oily stools, weight loss, abdominal pain, and bloating in patients with AAP.Item Nutrition Intervention in Pediatric Acute Lymphoblastic Leukemia Patients with Down Syndrome(2018-03-14) Hamby, Tyler; Hill, Rachel; Bricker, MadeleineAbstract: Purpose: Children and adolescents with Down Syndrome (DS) are more likely to become overweight or obese than those without DS. Additionally, children with DS develop acute lymphoblastic leukemia (ALL) at higher rates than the general population, and pediatric ALL treatment is associated with excessive weight gain. Despite DS-ALL patients’ increased risk for obesity and its complications, there remains a lack of research on preventing weight gain in this specific population. Our objective was to determine if a three-visit nutritional intervention in maintenance therapy was effective at reducing weight gain in DS-ALL patients. Methods: In a retrospective analysis, medical records of the intervention group were compared to historical controls on the same ALL treatment protocol. Anthropometrics were collected throughout intensive therapy and at every monthly visit during the 12 months of maintenance therapy. Results: Nine patients met the inclusion criteria: 5 males, 7 Caucasian and 2 Hispanic, and 5 on high risk protocols. The median age was 4.07 years (range, 1.60-14.26). Three and five patients had unhealthy BMIs at diagnosis and month 12 of maintenance, respectively. When comparing patients who had healthy BMIs at diagnosis, the intervention group had smaller increases in BMI than the control group. However, patients who had unhealthy BMIs at diagnosis had unhealthy BMIs at month 12 of maintenance therapy, regardless of intervention. Conclusions: These results provide evidence that DS patients do tend to gain weight during treatment for ALL, but the data were insufficient to determine whether the nutrition intervention was successful for this population. To our knowledge, this is the first study to investigate obesity prevention in DS-ALL patients. One approach for future studies is an inter-institutional collaboration to obtain a sample size large enough to draw conclusions using inferential statistics.Item Nutritional Complications Following PEG-Asparaginase Administration in Pediatric Patients with ALL(2022) Le, Christine; Hill, Rachel; Hamby, Tyler; Ray, AnishBackground: Acute lymphoblastic leukemia (ALL) is the most common childhood malignancy in the United States. Lymphoblastic lymphoma (LL) is less common than ALL in the pediatric population but is often treated with ALL protocols. Polyethylene glycol (PEG) L-asparaginase, a mainstay chemotherapeutic to treat pediatric ALL, can cause a myriad of nutritional complications, including acute pancreatitis, hyperglycemia, hypertriglyceridemia, and exocrine pancreatic insufficiency. However, these complications and the appropriate treatments for them have not been well described in the literature. Case Information: Two pediatric patients with ALL and one pediatric patient with LL, who all received PEG-Asparaginase, faced adverse events leading to nutritional complications. The first patient, a 17-year-old-male diagnosed with ALL, experienced blood clotting issues, acute pancreatitis, hyperglycemia, and exocrine pancreatic insufficiency (EPI). The patient was managed with insulin and a low fat diet; however, due to severe weight loss and loose, oily stools, a fecal elastase was ordered and confirmed EPI. Therefore, the patient was transitioned to enteral nutrition (EN) and treated with pancreatic enzyme replacement therapy. The second patient, a 6-year-old female diagnosed with LL and on ALL chemotherapy protocol, experienced acute pancreatitis, constipation, and vomiting. Based on new recommendations developed by the team in treating pediatric oncologic patients with acute pancreatitis and the patient's poor oral intake, she was managed with a proactive EN feeding protocol. This was well tolerated by the patient, and she did not experience any additional episodes of acute pancreatitis. The third patient, a 7-year-old female diagnosed with ALL, experienced hypertriglyceridemia (>5200 mg/dL). Further complications of hyponatremia (presumed to be partially pseudohyponatremia related to hypertriglyceridemia), weight loss, and excessive stooling warranted the need for EN. The patient was initially fed with a very low fat (and subsequently high in carbohydrate) formula but was later switched to a more balanced peptide-based formula with a high ratio of medium chain triglycerides and lower carbohydrate content. Conclusions: In this case series, three patients' courses were detailed following the nutritional difficulties they faced after PEG L-asparaginase administration. Although further studies are needed, this series sheds light on potential nutritional complications and interventions.Item Prevalence and Risk Factors for Malnutrition during Pediatric Acute Lymphoblastic Leukemia Induction Therapy(2018-03-14) Ali, Mir; Hill, Rachel; Hamby, Tyler; Johnson, Danielle; Ray, Anish MD; Boren, CharlesPurpose It is well documented that pediatric patients with acute lymphoblastic leukemia (ALL) often experience significant weight gain during induction therapy and later struggle with obesity. However, some patients experience unintended weight loss during induction therapy; since this issue is not well reported, it often goes unnoticed or undertreated. Although malnutrition is reported to be associated with decreased survival, increased risk of infection and loss of lean body mass, there remains a scarcity of in depth analysis of prevalence and risk factors that contribute to this problem. Our study attempts to address this critical yet unmet need. Our aim was to identify the clinical risk factors and outcomes associated with weight loss during induction therapy for pediatric ALL. Design/Method This was a retrospective chart review of patients between 2 and 20 years of age diagnosed with ALL at Cook Children’s Medical Center from 4/1/14 to 3/31/17. For each patient, we collected height, weight, age, body mass index (BMI) z-scores at diagnosis and end of induction therapy, risk stratification, and whether consolidation was delayed. Patients with a BMI z-score [greater than] 85th percentile at diagnosis were categorized as being overweight or obese. Using logistic regression analyses, we examined which variables predicted whether the patient had an increase or decrease in BMI z-score throughout induction. A critical alpha level of 0.05 indicated statistical significance. Results Ninety-six patients met our inclusion criteria. Of these, 40% experienced a decrease in BMI during induction therapy. Compared to patients whose BMI increased during induction, patients with a decrease in BMI were more likely to be overweight or obese at diagnosis (55% vs. 22%; p Conclusion This research highlights a risk not previously identified in the literature that may impact outcomes. Patients treated on high- or very-high-risk protocols, who are overweight or obese at diagnosis, and who are ≥10 years old at diagnosis should be monitored closely for weight loss during induction therapy. Patients who experience weight loss should receive prompt intervention. It is our hope that this information can be used for future prospective studies and help develop evidence-based guidelines.Item RETROSPECTIVE ANALYSIS OF A HYPERGLYCEMIA SCREENING PROTOCOL IN PEDIATRIC PATIENTS WITH ALL AND LLY(2023) Levitt, Mike; Siebert, Garland; Hamby, Tyler; Hill, Rachel; Mohamed, AshrafRETROSPECTIVE ANALYSIS OF A HYPERGLYCEMIA SCREENING PROTOCOL IN PEDIATRIC PATIENTS WITH ALL AND LLY Mike Levitt, MSa Garland Siebert, MSa Rachel Hill, RD, CSO, LD, CNSCb Tyler Hamby, PhDa,c Ashraf Mohamed, MDb aUniversity of North Texas Health Science Center, Texas College of Osteopathic Medicine bCook Children’s Health Care System, Department of Pediatric Hematology/Oncology cCook Children’s Health Care System, Department of Research Operations Background: Approximately 4-35% of pediatric patients undergoing treatment for acute lymphoblastic leukemia (ALL) and lymphoblastic lymphoma (LLy) develop drug-induced hyperglycemia. Hyperglycemia is associated with poor outcomes including increased infections, weight loss, diabetic ketoacidosis, and greater mortality. However, no guidelines for identifying drug-induced hyperglycemia currently exist and the time course of hyperglycemia development remains relatively uncharacterized past induction therapy. Objective: The present study aims to evaluate a hyperglycemia screening protocol (HSP) that was implemented to identify hyperglycemia more promptly and to further describe the time course of hyperglycemia during ALL and LLy therapy. Design/Methods: A retrospective medical records review of 154 patients diagnosed with ALL or LLy at Cook Children’s Medical Center between March 2018 and April 2022 was performed. The HSP included more frequent blood glucose monitoring, criteria for removal of dextrose from IV fluids, consultation with other providers (case management, patient educator, registered dietitian), and robust care coordination between the hematology-oncology and endocrinology teams. Predictors of hyperglycemia were examined with univariate Cox regression. Results: The HSP was ordered for 88 (57%) of the patients. Fifty-four (35%) patients developed hyperglycemia: 28 (52%) during induction therapy and 26 (48%) patients after induction therapy. Enrollment in the HSP increased the likelihood of a hyperglycemia diagnosis compared to those not enrolled (41% vs. 27%, HR=1.76, p<0.050). Age ³10 years was an independent predictor of hyperglycemia development (HR=3.72, p<0.0001). Patients who did not gain weight during the induction period were more likely to also have hyperglycemia (weight loss: HR=5.42, p=0.001; weight steady: HR=3.48, p=0.012). The development of pancreatitis was also associated with drug-induced hyperglycemia (HR=2.45, p=0.007). Blood glucose values were significantly more likely to be ³ 200 mg/dL during days 5-8 of induction therapy compared to days 1-4 (29% vs. 10%, OR=4.18, p<0.001). Compared to blood glucose measurements taken in the morning (10%), values were more likely to be ≥200 mg/dL when acquired overnight (20%, OR=4.42, p<0.001), in the afternoon (16%, OR=2.34, p=0.011), and in the evening (38%, OR=10.57, p<0.001). Conclusion: Implementation of the HSP helped detect hyperglycemia more frequently in enrolled patients compared to controls and readily identified individuals at the greatest risk of developing hyperglycemia. These findings highlight a population of patients that develop hyperglycemia past induction therapy and give guidance on the timing of continued blood glucose monitoring in at-risk patients.