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Approved by the Cancer.Net Editorial Board , 10/2016

An infection occurs when the immune system does not quickly destroy harmful substances. Both cancer and cancer treatments weaken the immune system. This means that people with cancer are more likely to develop infections.

Treatment to relieve symptoms and side effects is an important part of cancer care. This approach is called supportive or palliative care . Talk with your health care team about any symptoms or changes in symptoms that you experience.

About the immune system

The immune system fights bacteria, viruses, and fungi that try to invade the body. The immune system includes these body parts:

A low level of white blood cells is called leukopenia. This condition increases the risk of developing dangerous infections. Neutropenia is a type of leukopenia. It means a low level of neutrophils. Neutrophils are the most common type of white bloods cells.

Signs and symptoms of an infection

Infections may start almost anywhere. Common infection sites:

Signs of infection:

Infections are treatable. However, they can be serious and potentially life-threatening. Talk with your doctor if you experience signs of an infection. Also, be sure to mention any changes in your symptoms.

Risk factors for developing an infection

The following factors can affect white blood cells and weaken the immune system:

Treating infections

Neutropenia, chemotherapy, or radiation therapy may place you at a higher risk of infection. In that case, you may receive preventive antibiotics or antifungal medications. This means the anti-infection medication is given before an infection starts.

In other cases, you may receive medication after developing an infection. If you develop neutropenia with a fever, you may need to stay in the hospital until the infection is gone.

If you have a high risk of developing neutropenia with a fever, your doctor may prescribe medications called white blood cell growth factors. These drugs help the body make more white blood cells. This reduces the risk of an infection. Learn more about with mastercard cheap sale 2015 new Shuz Touch Tan Boots MxbSWY

Tips for preventing infections

There are steps you can take to help prevent infections:

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The question at the center of this analysis is how states can support plan investment in social services that improve health outcomes and are cost-effective. In states with Medicaid managed care, this translates into a question of how to set Medicaid managed care capitation rates in such a way that plans are incentivized or required — and, even more importantly, have the resources — to address social issues that directly affect the health outcomes of their members.

The starting point for answering this question is the federal Medicaid managed care rules that require states to ensure that capitation rates are actuarially sound. This means that rates must be sufficient to cover the costs that plans incur to provide covered benefits to their enrollees, as well as related administrative and operational expenses. Notably, capitation rates must be based only on services covered under the state plan and services necessary to achieve mental health parity requirements. 3 In other words, states cannot directly build the cost of social support services not covered under the state plan into their capitation rates (Exhibit 3). 4

Exhibit 3

Value-Added and “In-Lieu-of” Services

Under the federal Medicaid managed care rules, plans may cover value-added services, which are services that are not covered under the state plan, but that a managed care plan chooses to spend capitation dollars on to improve quality of care and/or reduce costs. For example, a managed care plan might elect to provide supportive housing for a beneficiary with a mental illness who otherwise would cycle between hospital stays and homelessness. The cost of value-added services cannot be included in the capitation rates; it can, however, be included in the numerator of the medical loss ratio (MLR) if it is part of a quality initiative.

States and plans also may elect to cover “in-lieu-of” services, which substitute for services or settings covered in a state plan because they are a cost-effective alternative. For example, a state could allow plans to provide medically tailored meals as a substitute for a home visit by an aide in selected circumstances. The actual costs of providing the in-lieu-of service are included when setting capitation rates, and they also count in the numerator of the MLR. In-lieu-of services, however, can only be covered if the state determines the service or alternative setting is a medically appropriate and cost-effective substitute or setting for the state plan service; if beneficiaries are not required to use the in-lieu-of service; and if the in-lieu-of service is authorized and identified in the contract with Medicaid managed care plans.

42 CFR § 438.3(e)(1)(i). In some states, value-added services are required in the contract between a state and managed care plans even though value-added services are optional. In these instances, plans may offer to cover some value-added services when they bid to participate in a state’s managed care program, and then these services are enshrined in the contract. Even though the services are part of the contract, plans are not necessarily paid to provide them. By definition, value-added services are not covered benefits under a state plan, so the cost of providing them cannot be built into the capitation rate for managed care plans, leaving plans to pay for them out of profits. See 42 CFR § 438.3(e)(2).

The regulations also specify that rates should reflect reasonable nonbenefit expenses associated with providing the covered benefits and meeting mental health parity requirements. These nonbenefit expenses include administrative costs; taxes, licensing, and regulatory fees; contribution to reserves; profit or risk margin; the cost of capital; and other operational costs. As further discussed below, quality initiatives can be considered part of operational costs, potentially creating a vehicle for covering social interventions that are part of a plan’s quality initiatives.

These three examples show that randomized controlled trials of seriously ill patients with functional outcomes “truncated due to death” occur in diverse areas of medicine. When analyzing each of these trials, the investigators restricted their analysis of functional outcomes to survivors at the specified follow-up time point.

The multicenter Awakening and Breathing Controlled trial

The multicenter Awakening and Breathing Controlled (ABC) trial Metallic suede Touch brogues online cheap authentic visit new cheap price fxPeB1
randomized 336 patients with acute respiratory failure receiving mechanical ventilation in an intensive care unit to spontaneous awakening trials plus spontaneous breathing trials (intervention) versus usual care plus spontaneous breathing trials alone (control). The primary outcome was ventilator-free days (a commonly used composite outcome of mortality and duration of mechanical ventilation best place for sale E8 by MIISTA Sandals cheapest price kaFGA
) during the 28 day study period. Key long term secondary outcomes assessed among a single study site (roughly 200 randomized patients) included mortality, as well as cognitive, psychological, and physical function, at 12 month follow-up. Mortality at 12 month follow-up favored the intervention (41% 62%; P <0.01), and investigators compared the 12 month functional outcomes between treatment groups.

The CheckMate025 trial

The CheckMate025 trial randomized 821 patients previously treated for renal cell carcinoma to nivolumab versus everolimus. 9 The primary outcome was all cause survival to 30 months. A key secondary outcome included quality of life, which was assessed at baseline and then every four weeks to 104 weeks. The mortality results favored nivolumab versus everolimus (45% 52%; hazard ratio 0.73, P=0.002). The investigators compared the 104 week change from baseline in quality of life between treatment groups.


The PARADIGM-HF trial randomized 8442 patients with class II, III, or IV systolic heart failure to receive LCZ696 versus enalapril. 10 The primary outcome was a composite of death from cardiovascular causes or first admission to hospital for heart failure up to 42 month follow-up. Key secondary endpoints included all cause mortality by 42 months and functional outcomes. All cause mortality was lower for LCZ696 versus enalapril (17.0% 19.8%; hazard ratio 0.84, P<0.001), and the investigators compared a functional outcome, the change from baseline to eight month follow-up in the clinical summary score on the Kansas City Cardiomyopathy Questionnaire (KCCQ), between treatment groups.

The ABC trial randomized patients with acute respiratory failure receiving mechanical ventilation on an ICU to spontaneous awakening trials plus spontaneous breathing trials (intervention) versus usual care plus spontaneous breathing trials alone (control). The primary outcome was ventilator-free days (a commonly used composite outcome of mortality and duration of mechanical ventilation cheap sale in China Jil Sander Red Velvet MidCentury Kitty DOrsay Flats for sale sale online huge surprise sale online LsLESQj
) during the 28 day study period. For each patient, survival information, including the time of death and a binary indicator of surviving to 12 months, were recorded. For patients who survived to 12 months, several key secondary outcomes were measured, including cognition and a composite T score based on normative population data (mean=50 and SD=10, higher scores indicating better cognition). 7 Mortality at 12 month follow-up favored the intervention (41% v 62%; P<0.01), and among 12 month survivors, cognition was comparable between the intervention and control arms (41 v 42, respectively, P=0.66).

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Last Updated November 2017

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