cultures of the blood and urine are pending While gram-negative organisms have historically been of primary concern, gram-positive bacteria have more recently become more threatening, particularly with the emergence of MRSA in some regions Antibiotic regimens need to broadly cover gram-positive and gram-negative bacteria (e.g., piperacillin/tazobactam and gentamicin) as well as MRSA when relevant Rarely seen as a complication of stem cell transplant, thrombotic thrombocytopenic purpura (TTP) can present with the classic pentad of fever, neurologic symptoms, hemolytic anemia, thrombocytopenia, and renal compromise ( Table 98.11 ) The disorder seems to be associated with immunosuppression with cyclosporine or FK506 in the posttransplant period In some patients, TTP may evolve into a more chronic picture with renal dysfunction and a clinical picture more consistent with HUS An experimental, promising new treatment for leukemia involves chimeric antigen receptor modified T cells (CART) See Complications of CAR-T Cell Therapy section above In this specialized therapy, a patient’s T cells are harvested and engineered to express a receptor that allows them to seek out and destroy leukemic blasts These cells are then reinfused into the patient in an inpatient setting Importantly for emergency clinicians, steroids are contraindicated for any patients being treated with CART therapy since steroids are lymphotoxic and likely to be detrimental to this type of therapy CARE OF PATIENTS WITH ADVANCED CANCER Pediatric palliative care has seen major changes in recent decades and these developments clearly impact care for children with cancer Children with incurable cancer may still receive treatment that may be life prolonging and options for managing symptoms related to advanced disease have expanded Also noteworthy is the increased decision-making role for the patient and family members in the setting of advanced disease Options for patients to receive care outside of the hospital, either in hospice or at home, have greatly evolved