Biomedical subjects

Shesh N Rai

Publications and source records attributed to Shesh N Rai.

At least 19 recordsLinked to original sources

PubMed2026

A Phase II Feasibility Study Combining Pembrolizumab and Metformin in Patients with Metastatic Head and Neck Cancer.

PURPOSE: Survival for recurrent/metastatic head and neck squamous cell carcinoma (R/M HNSCC) remains low with <20% immunotherapy response. Metformin increases tumor-infiltrating CD8+ T and natural killer (NK) cells, which harbor PD-1. In this phase II clinical trial (NCT04414540), we combined metformin and pembrolizumab to evaluate the overall response rate (ORR) in R/M HNSCC and assess NK-cell activity. PATIENTS AND METHODS: Eligible patients were randomized 1:1 into two arms: (i) metformin extended-release (ER) dose escalation to 2,000 mg over 14 days followed by combination with pembrolizumab 200 mg every 3 weeks or (ii) pembrolizumab 200 mg every 3 weeks followed by combination with metformin ER 2,000 mg daily. The primary endpoint was ORR per RECIST 1.1. Nineteen evaluable patients were planned to estimate the proportion of approximately 32% ORR. Safety was evaluated according to Common Terminology Criteria for Adverse Events v5.0. The distribution, activation, and cytotoxic function of NK cells were analyzed via flow cytometry. RESULTS: Twenty-one patients were enrolled; 76% were male, 52% were smokers, and the median age was 64 years. Ten patients had oropharyngeal tumors, of which nine were p16+. Eighteen patients were evaluable for response, including four complete and five partial responses for an ORR of 50% [95% confidence interval (29-71)]. Combination therapy was well tolerated with no unexpected adverse events (AE). Five grade 3 AEs occurred: nausea, diarrhea, fatigue, and weight loss. Metformin led to increased peripheral NK-cell maturation and cytotoxic ability. CONCLUSIONS: The combination of metformin and pembrolizumab was well tolerated with mild gastrointestinal AEs and promising activity, warranting further investigation in a randomized trial.

Humans↗

PubMed2007

Pleurodesis for effusions in pediatric oncology patients at end of life.

BACKGROUND: Pleurodesis for end-of-life care has been used in adults for decades, but little is known about the usefulness of this technique in improving the quality of care for pediatric patients. OBJECTIVE: To assess whether intractable pleural effusions in pediatric oncology patients at end of life could be sufficiently relieved by pleurodesis. MATERIAL AND METHODS: Eleven pleurodeses were performed with doxycycline in seven pediatric cancer patients (age 3-21 years) with intractable pleural effusions at the end of life. Five patients had unilateral pleurodeses and two had a unilateral followed by bilateral pleurodeses. RESULTS: Respiratory rates decreased in all seven patients (P = 0.016) and aeration improved significantly after chest tube placement (P = 0.033). The chest tubes were placed a median of 1 day before pleurodesis. Eight of nine chest tubes (89%) were removed before discharge at a median of 3 days after pleurodesis. Pain secondary to the pleurodesis lasted 1 day or less. Improvement in the respiratory rate remained after pleurodesis and chest tube removal (P = 0.031). Five of seven patients (70%) were able to leave the hospital to return home. The five patients discharged lived 10 to 49 days (median 19 days) after discharge. CONCLUSION: Pediatric oncology patients with intractable effusions at end of life can have respiratory benefit from pleurodeses and, as a result, are more likely to return home for terminal care.

Adolescent↗

PubMed2007

Assessing functional mobility in survivors of lower-extremity sarcoma: reliability and validity of a new assessment tool.

BACKGROUND: Reliability and validity of a new tool, Functional Mobility Assessment (FMA), were examined in patients with lower-extremity sarcoma. FMA requires the patients to physically perform the functional mobility measures, unlike patient self-report or clinician administered measures. PROCEDURE: A sample of 114 subjects participated, 20 healthy volunteers and 94 patients with lower-extremity sarcoma after amputation, limb-sparing, or rotationplasty surgery. Reliability of the FMA was examined by three raters testing 20 healthy volunteers and 23 subjects with lower-extremity sarcoma. Concurrent validity was examined using data from 94 subjects with lower-extremity sarcoma who completed the FMA, Musculoskeletal Tumor Society (MSTS), Short-Form 36 (SF-36v2), and Toronto Extremity Salvage Scale (TESS) scores. Construct validity was measured by the ability of the FMA to discriminate between subjects with and without functional mobility deficits. RESULTS: FMA demonstrated excellent reliability (ICC [2,1] >or=0.97). Moderate correlations were found between FMA and SF-36v2 (r = 0.60, P < 0.01), FMA and MSTS (r = 0.68, P < 0.01), and FMA and TESS (r = 0.62, P < 0.01). The patients with lower-extremity sarcoma scored lower on the FMA as compared to healthy controls (P < 0.01). CONCLUSION: The FMA is a reliable and valid functional outcome measure for patients with lower-extremity sarcoma. This study supports the ability of the FMA to discriminate between patients with varying functional abilities and supports the need to include measures of objective functional mobility in examination of patients with lower-extremity sarcoma.

Amputation, Surgical↗

PubMed2007

A comparative analysis of functional outcomes in adolescents and young adults with lower-extremity bone sarcoma.

BACKGROUND: Comparison of functional mobility and quality of life is performed in patients with lower-extremity bone sarcoma following either amputation, limb-sparing surgery, or rotationplasty with four different types of outcome measures: (1) an objective functional mobility measure that requires patients to physically perform specific tasks, functional mobility assessment (FMA); (2) a clinician administered tool, Musculoskeletal Tumor Society Scale (MSTS); (3) a patient questionnaire, Toronto Extremity Salvage Scale (TESS); and (4) a health-related quality of life (HRQL) measure, Short Form-36 version 2 (SF-36v.2). PROCEDURE: This is a prospective multi-site study including 91 patients with lower-extremity bone sarcoma following amputation, limb-sparing surgery, or rotationplasty. One of three physical therapists administered the quality of life measure (SF-36v.2) as well as a battery of functional measures (FMA, MSTS, and TESS). RESULTS: Differences between patients who had amputation, limb-sparing surgery, or rotationplasty were consistently demonstrated by the FMA. Patients with limb sparing femur surgery performed better than those patients with an above the knee amputation but similarly to a small number of rotationplasty patients. Several of the more conventional self-report measures were shown to not have the discriminative capabilities of the FMA in these cohorts. CONCLUSION: In adolescents with lower-extremity bone sarcoma, it may be advantageous to consider the use of a combination of outcome measures, including the FMA, for objective functional mobility assessment along with the TESS for a subjective measure of disability and the SF-36v.2 for a quality-of-life measure.

Adolescent↗

PubMed2006

Changes in bone mineral density in survivors of childhood acute lymphoblastic leukemia.

BACKGROUND: There is little information about factors modulating bone mineral density (BMD) in survivors of childhood acute lymphoblastic leukemia (ALL). PROCEDURE: We analyzed data from 57 survivors (26 male, 52 Caucasian) who underwent two serial quantitative computed tomography (QCT) studies of BMD. Using multiple linear regression, we evaluated the association of BMD change with demographic variables, treatment history, hormone therapy, exercise, and tobacco and alcohol use. RESULTS: The median age was 3.4 years (range, 0.9-17.4 years) at diagnosis of ALL; the median age at the first QCT (Study I) was 15.0 years (range, 10.6-31.0 years) and at the second QCT (Study II) was 18.2 years (range, 14.2-35.3 years). Mean height increased 4.7 cm and mean weight increased 8.8 kg between Studies I and II. While the mean BMD increased 9.33 mg/cc (P = 0.003), the BMD Z-score increased only slightly (0.21 SD, P = 0.035). Cortical bone density increased significantly (approximately 25.3 mg/cc; P = 0.001), but the ratio of trabecular to cortical BMD decreased significantly (P = 0.045). Factors independently associated with unfavorable BMD changes included older age at diagnosis (P = 0.001), female sex (P = 0.018), and nutritional supplementation (0.032). Alcohol (P = 0.009) was an unfavorable factor in a univariable analysis. CONCLUSIONS: Bone mineral accretion during adolescence is attenuated in childhood ALL survivors by a comparative deficit in trabecular versus cortical bone deposition. BMD is influenced favorably by exercise in early adolescence and unfavorably by the use of nutritional supplements and alcohol. These results provide new information about behavioral factors that affect bone accrual in survivors of childhood ALL and warrant definitive evaluation in a larger cohort.

Adolescent↗

PubMed2006

Relationships among range of motion, functional mobility, and quality of life in children and adolescents after limb-sparing surgery for lower-extremity sarcoma.

PURPOSE: The study was designed to examine relationships between range of motion (ROM), functional mobility, and quality of life (QL) in patients with lower-extremity sarcoma (LES) after limb-sparing surgery METHODS: Sixty-eight patients with LES (age, 10-26 years) participated. The patients performed hip flexion, hip extension, knee flexion, and knee extension, Timed Up and Down Stairs (TUDS), Timed Up and Go (TUG), nine-minute run-walk (9-min), and completed the QL measure, Short-Form-36 version two (SF-36v2). RESULTS: Significant correlations (p < 0.01) were found between hip extension and SF-36v2 physical component scale (PCS; r = 0.33), TUDS (r = -0.32), TUG (r = -0.33); hip flexion and TUDS (r = -0.31), TUG (r = -0.39), 9-min (r = 0.44); knee flexion and TUDS (r = -0.52), TUG (r = -0.40), 9-min (r = 0.37); SF-36v2 PCS and TUDS (r = -0.56), TUG (r = -0.51), 9-min (r = 0.60). CONCLUSION: ROM correlates with functional mobility and QL in patients with LES after limb-sparing surgery. ROM exercises are important component of a physical therapy program for children and adolescents with LES.

Adolescent↗

PubMed2006

Retention of survivors of acute lymphoblastic leukemia in a longitudinal study of bone mineral density.

Attrition in longitudinal studies of survivors of childhood cancer reduces these studies' statistical power, introduces bias and threatens internal and external validity. This study investigated the variables associated with dropout of survivors of acute lymphoblastic leukemia in a trial investigating the effect of vitamin D and calcium supplementation and nutritional counseling on bone mineral density (BMD). Twenty-five participants withdrew from the study. Common reasons given for withdrawing were intolerance of the study drug, family hardship and schedule conflicts. Few statistically and clinically significant differences identified participants who completed the study. Nurses need to be aware of the reasons that participants withdraw from clinical trials, as they are in a strategic position to encourage patients to participate in health promotion studies.

Adaptation, Psychological↗

PubMed2006

Use of diffusion weighted magnetic resonance imaging in predicting early postoperative outcome of new neurological deficits after brain tumor resection.

OBJECTIVE: To study risk factors for the development of postoperative neurological deficits after brain tumor resection and to define prognostic factors for recovery. METHODS: We prospectively studied 82 brain tumor patients undergoing tumor resection. Pre- and postoperative neurological examination, functional and performance status, cancer treatment, cardiovascular risk factors, seizure history, and blood pressure and oxygen saturation were recorded perioperatively. Postoperative magnetic resonance imaging scans were obtained within 72 hours of surgery, and the radiologist was blinded to the patient's status. Abnormalities on magnetic resonance diffusion weighted images were classified as new if they extended beyond the tumor cavity margins and were absent before surgery. RESULTS: Of the 80 assessable patients, 24 had a new or increased postoperative deficit by at least one point on the National Institutes of Health Stroke Scale. Presence of preoperative neurological deficits predicted development of postoperative deficits, whereas a new diffusion weighted imaging lesion after craniotomy predicted incomplete recovery of a new postoperative deficit. CONCLUSION: Postoperative diffusion magnetic resonance imaging is useful in predicting early functional recovery from new deficits after brain tumor surgery.

Brain Neoplasms↗

PubMed2006

MRI of knee osteonecrosis in children with leukemia and lymphoma: Part 2, clinical and imaging patterns.

OBJECTIVE: This aim of this study was to explore the relationship between MRI findings and clinical symptoms of knee osteonecrosis in children and to determine the significance of this relationship. Such information is important for early diagnosis of this frequent complication and for choosing an appropriate treatment strategy. MATERIALS AND METHODS: Osteonecrotic lesion size and location were determined in a retrospective analysis of MR images of the knee obtained in our institution during the past 10 years. Association between MRI findings and clinical symptoms expressed by the knee scores was tested for a subgroup of our patient population who had clinical evaluation of the knees in the orthopedic clinic within 6 weeks of their MRI studies. RESULTS: In 80% of patients, osteonecrosis was bilateral. Lesions were distributed as follows: femur and tibia, 66% of the knees; femur alone, 26%; and tibia alone, 8%. Clinical symptoms of knee osteonecrosis were associated with lesions involving the articular surface of the distal femur, large lesions, and involvement of any part of the tibia. MR images showed milder osteonecrosis in patients who were less than 10 years old at the time of primary diagnosis. CONCLUSION: Osteonecrosis affecting the knees of children treated for leukemia and lymphoma is mostly asymptomatic. Children who are 10 years old or older have signs of more advanced osteonecrosis. Clinical symptoms often lag MRI presentation and may develop late in the course of the disease. Routine MRI evaluation is recommended for timely diagnosis of treatment-induced osteonecrosis.

Adolescent↗

PubMed2006

MRI of knee osteonecrosis in children with leukemia and lymphoma: Part 1, observer agreement.

OBJECTIVE: The aim of this study was to determine whether a new MRI-based staging system for osteonecrosis of the knee in pediatric patients could be used with an acceptable level of intra- and interobserver agreement. MATERIALS AND METHODS: We conducted a retrospective analysis of MRI studies of the knee performed in a single institution between April 1994 and July 2003. Knee osteonecrosis was identified in 168 children with a primary diagnosis of hematologic malignancy. This substantial number prompted us to design a staging system for use with pediatric patients. To assess interobserver reliability of two primary observers in using the system, they reviewed and interpreted the same 36 imaging studies of randomly chosen patients. For the assessment of intraobserver reproducibility, each observer rereviewed 16 studies. A senior observer coded potential causes of disagreement between the primary observers. RESULTS: Interobserver agreement was substantial: the kappa value was 0.66 (95% confidence interval [CI], 0.58-0.75) in locations where the observers had to record only the presence or absence of a lesion, and the weighted kappa value was 0.65 (95% CI, 0.59-0.72) in locations where they had to classify the extent of involvement. The presence of marrow edema, punctate foci of altered signal, and mottled marrow changes was associated with a higher level of disagreement between the primary observers. CONCLUSION: Our proposed classification system, developed specifically for use with MRI, was used with substantial intra- and interobserver agreement. We think its use can contribute to a standardized approach to the interpretation of MRI findings in pediatric osteonecrosis of the knee.

Adolescent↗

PubMed2005

Patterns of treatment failure in pediatric and young adult patients with Hodgkin's disease: local disease control with combined-modality therapy.

PURPOSE: Refinement in managing pediatric Hodgkin's disease (HD) requires understanding of factors associated with local treatment failure. This study defines the cumulative incidence (CI) of local failure (LF) and prognostic factors for pediatric patients treated for HD with combined-modality therapy (CMT). PATIENTS AND METHODS: We enrolled 195 patients onto two prospective studies at St Jude Children's Research Hospital between 1990 and 2000. Patients received CMT with chemotherapy (vinblastine, doxorubicin, methotrexate, and prednisone [VAMP]; vinblastine, etoposide, prednisone, and doxorubicin; or VAMP/cyclophosphamide, vincristine, and procarbazine) and involved-field radiation therapy delivered to initial site(s) of disease on the basis of early response. Sites of disease involvement, treatment, and sites of failure were confirmed from the patients' medical record, imaging, and radiotherapy treatment records. We estimated the overall survival, event-free survival, and CI of LF. RESULTS: With a median follow-up of 7.6 years, the CI of LF was 10.9% and 11.6% at 5 and 10 years, respectively. Twenty-seven (14%) of 195 patients experienced recurrence of HD, and 22 (81%) of those experienced LF. Bulky mediastinal disease greater than one third transthoracic diameter predicted a higher incidence of LF, but did not predict failure in the mediastinum. Male sex, low initial hemoglobin, and bulky mediastinal disease were prognostic indicators of LF. Attenuation of radiation dose to 15 Gy based on response provides excellent infield control. CONCLUSION: CMT provides excellent local disease control in children and young adults with HD. LF remains a primary site of disease recurrence, with male sex, low initial hemoglobin, and bulky mediastinal disease predicting for LF.

Adolescent↗

PubMed2005

Predicting perceived vulnerability to tobacco-related health risks and future intentions to use tobacco among pediatric cancer survivors.

OBJECTIVE: To examine predictors of perceived vulnerability to tobacco-related health risks and future intentions to use tobacco among pre-adolescents and adolescents previously treated for cancer. METHODS: Written self-report measures of tobacco knowledge, perceived vulnerability, perceived positive value of tobacco use, past and present tobacco use, and intentions to use tobacco were completed by 103 cancer survivors, 10-18 years of age (51.5% males, 78.6% Caucasians). Patient reports of peer and parent tobacco use were also obtained. RESULTS: Perceived vulnerability was influenced by demographic variables, knowledge, and gender-related past tobacco use. Fifty-seven percent of non-smoking survivors reported some intention to use tobacco. Survivors who perceived some positive value associated with tobacco use and who used tobacco in the past reported greater intentions for future tobacco use. CONCLUSION: Modifiable cognitive-motivational variables directly associate with smoking-related outcomes among pediatric survivors of childhood cancer. PRACTICE IMPLICATIONS: Preventive tobacco interventions with this vulnerable cohort are warranted and should inform about tobacco-related health risks and attempt to modify misperceptions of the positive value associated with tobacco use.

Adolescent↗

PubMed2005

Adaptive style and symptoms of posttraumatic stress in children with cancer and their parents.

OBJECTIVE: To examine symptom levels of posttraumatic stress (PTS) in children with cancer and their parents as a function of patient and parent adaptive style. METHOD: Participants included 162 pediatric cancer patients and their parents. Patients completed self-report measures of PTS and adaptive style. Parents reported on their own adaptive style and PTS, as well as levels of PTS in their child. RESULTS: Adaptive style was a significant correlate of PTS. Children identified as low anxious (LA) or repressors (REP) obtained lower levels of PTS than did high anxious (HA) children, both by self-report and parent report. Parents identified as LA or REP self-reported lower levels of PTS than HA and also reported lower levels of PTS in their children. CONCLUSIONS: Patient and parent adaptive style are significant determinants of PTS in the pediatric oncology setting. These findings, in combination with the generally low levels of PTS in the pediatric oncology population, raise questions about the utility of the posttraumatic stress model for understanding the experiences of children with cancer, although such a model may be more applicable to parental response.

Adaptation, Psychological↗

PubMed2005

A comparison of tobacco-related risk factors between adolescents with and without cancer.

OBJECTIVE: To compare adolescents with and without cancer on current smoking status, intentions to smoke, and tobacco-related risk factors. METHODS: Ninety adolescents undergoing treatment for cancer (median time since diagnosis was 2.4 months) and a comparison sample of 279 adolescents without cancer, ages 12 to 18 years, completed questionnaires that asked about their smoking habits, intentions to smoke, and tobacco-related psychosocial risk factors. RESULTS: Approximately 2% of adolescents with cancer and 22% of adolescents without cancer reported current smoking. Compared to nonsmoking adolescents without cancer, nonsmoking adolescents with cancer were one third less likely to report intentions to smoke. No significant interactions were detected between group (having cancer or not) and each of the tobacco-specific and psychosocial variables tested in two separate multivariable models. Intentions to smoke were best predicted by variables most proximal to smoking. Adolescents who smoked in the past and who had lower tobacco knowledge and greater perceived instrumental value were more likely to report intentions to smoke. Adolescents who were less optimistic were also more likely to intend to smoke. CONCLUSIONS: Tobacco-related risk factors for intentions to smoke appeared to be similar among adolescents with and without cancer. Implications of these findings for tobacco control among adolescents with cancer are discussed.

Adolescent↗

PubMed2005

Symptoms of post-traumatic stress in children with cancer and their parents: effects of informant and time from diagnosis.

BACKGROUND: Post-traumatic stress disorder (PTSD) has been put forth as a model for understanding the adjustment of children with cancer and their parents, but findings in the literature regarding the prevalence of post-traumatic stress symptoms (PTSS) have been mixed. This study examined PTSS levels in both patients and parents as a function of time elapsed from diagnosis, and by use of parent versus child reports for assessing patient PTSS. PROCEDURE: Four groups of patients (total N = 162) differing in time elapsed since diagnosis were assessed with standardized measures of PTSS. Patients reported on their own symptoms, while parents reported on their symptoms as well as symptoms in their child. RESULTS: Significant differences between groups were observed on all patient PTSS measures. Recently diagnosed patients obtained higher PTSS scores than survivors more than 5 years from diagnosis. Likewise, parents of recently diagnosed patients self-reported significantly higher levels of PTSS than parents of long-term survivors. Parent-child correlations were high and no differences were observed between parent and patient report of patient PTSS. Comparison with historical control data suggests that levels of PTSS in patients are very low. CONCLUSION: Concordance between parent and child reports of child PTSS suggests that data may be obtained with reasonable confidence from either if only one informant is available. Higher levels of PTSS in patients who are recently diagnosed (and their parents) in comparison to long-term survivors, suggest that the symptoms reported reflect primarily a concurrent response to ongoing acute stressors, rather than a post-traumatic re-experiencing of past traumas. This, in combination with the low levels of patient PTSS raise questions regarding the utility of PTSD as a model for understanding patient and parent adjustment to childhood cancer.

Adolescent↗

PubMed2005

Adolescent survivors: a secondary analysis of a clinical trial targeting behavior change.

BACKGROUND: The late effects of radiation and chemotherapy increase childhood cancer survivors' risk of chronic health problems. Survivors' behavior is important in modifying this risk, yet adolescent and young adult survivors fail to engage in important health-promoting behaviors and frequently practice high-risk behaviors. This secondary analysis re-evaluated a multi-component behavior-change intervention that had previously demonstrated no impact in adolescent survivors of childhood cancer. PROCEDURE: The parent trial compared 132 adolescent survivors in the intervention arm with 135 in the standard-care arm at baseline and at 1 year for disease and treatment knowledge, perception of late effects risk, and the frequency of health-risk and health-protective behaviors (combined as a single summative measure). In contrast, the secondary analysis examined each of the 14 behaviors separately. Additionally, an analysis of covariance (ANCOVA) was conducted to examine the change in health behaviors while statistically controlling for age, gender, and the wide variation in baseline behaviors. RESULTS: Knowledge (P = 0.038), breast self-examination (BSE) (P < or = 0.0001) and testicular self-examination (P = 0.004) increased, as did perceptions about the need to change behavior (P = 0.004) and the effort needed to stay healthy (P < or = 0.0001). In the treatment group, junk food consumption decreased (P = 0.052) and smoking abstinence was maintained (P = 0.088). Significant interactions between gender and treatment group were demonstrated. CONCLUSIONS: Health-risk and health-protective behaviors cannot be effectively combined in a one-dimensional measure. Gender and age influence the impact of interventions targeting health behavior in survivors. Future trials should include observation of the patient-clinician encounter, more complex sampling methods, and pre-trial knowledge of the distribution of the study behaviors.

Adolescent↗

PubMed2005

Proxy assessment of quality of life in pediatric clinical trials: application of the Health Utilities Index 3.

BACKGROUND: With increased cure rates, pediatric oncology protocols increasingly seek to document the impact of treatment on patients' disease, symptoms, and functional capacity. PROCEDURE: Nurses as proxy respondents used the Health Utilities Index 3 (HUI3) to assess the health-related quality of life (HRQL) in twenty-five patients (age 6 years or older) enrolled on a frontline protocol for leukemia. HRQL observations (n = 70) were made at three different time points to coincide with high-dose methotrexate therapy. Additionally, the proxy respondents evaluated the ease of use of the instrument and the data quality. RESULTS: As patients' health status declined, the number of unassessable HRQL items increased. These missing data made scoring cumbersome and precluded calculation of the overall HRQL scores for nearly 50% of the patients. CONCLUSIONS: Use of the provider proxy-assessed HUI3 in pediatric cancer trials may result in a high proportion of missing data. Trials may benefit more from the use of HRQL measures that consider the acuity of the child's illness, domains specific and sensitive to both disease and treatment, and items that can be proxy-assessed independent of input from parent or patient. Evaluations that combine child self-reports with both parent and provider reports may ultimately provide the most reliable and comprehensive perspective on children's quality of life.

Adolescent↗

PubMed2005

Psychosocial predictors of distress in parents of children undergoing stem cell or bone marrow transplantation.

OBJECTIVE: To examine psychosocial predictors of distress (mood disturbance, perceived stress, caregiver burden) in parents of children undergoing stem cell or bone marrow transplantation (BMT). METHOD: Measures of prior illness experiences, premorbid child behavior problems, family environment, social support, and parental coping behavior were obtained from the resident parents of 151 children prior to the children's admission for BMT. Parents subsequently completed assessments of their mood disturbance, perceived stress, and caregiving burden on a weekly basis through week +6 post-BMT, and then monthly through month +6 post-BMT. RESULTS: Significant changes were observed in parental distress across the course of BMT. After correcting for demographic and medical factors, several significant predictors of parental distress trajectories were identified, including prior parent and patient illness-related distress, premorbid child internalizing behavior problems, the family relationship dimensions of the family environment, and parental avoidant coping behaviors. Multivariable models were developed using a hierarchical modeling approach. The best-fit model accounted for approximately 50% of the variance in parental global distress. CONCLUSIONS: Subgroups of parents at higher risk for increased distress during the acute phase of transplant have been identified. These findings can help target parents who may be in greater need of intervention aimed at reducing transplant-related distress.

Adaptation, Psychological↗