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PubMedDate not supplied

Good communication in pediatric cancer care: a culturally-informed research agenda.

Communication affects people's factual understanding of the situations they are in. This in turn affects consent to be treated and adherence. Although a growing body of literature concerns cancer communication, it generally concerns adult patients; pediatric-specific knowledge is limited. Furthermore, most research focuses shortsightedly on physicians rather than providers who have more patient contact, favors studying the single visit instead of encompassing the cycle of cancer care, does not take the child into account, and ignores the importance of provider-provider communication. Moreover, cultural issues are only narrowly conceived. In exploring culture's role in pediatric cancer care communication, this article demonstrates that culture cannot be defined as just ethnicity or race. Professions also have cultures and resultant differences in communication patterns that can lead to communication failures. It also shows that there is a crucial need for more applied research as well as more qualitative research that can enrich our understanding of the complicated context-related factors facilitating or barring successful pediatric cancer communication.

Attitude of Health Personnel↗

PubMed2005

Cross-sectional study of bone mineral density in adult survivors of solid pediatric cancers.

To investigate the hypothesis that survivors of pediatric solid cancer have low bone mineral density, a cross-sectional study was done of subjects who had received treatment for pediatric solid tumors before 16 years of age and were less than 40 years old at follow-up. Excluded were subjects treated for acute lymphoblastic leukemia or those who had received cranial irradiation, total body radiation, or nonautologous bone marrow transplant. The study group consisted of 38 subjects, with the most common diagnoses being lymphoma (n = 17), sarcoma (n = 8), Wilms tumor (n = 5), and neuroblastoma (n = 4). Median age was 22 years (range 12-32). Time from diagnosis of underlying cancer averaged 12.6 years (range 5.5-20.3). Using criteria of osteopenia (Z-score < or = -1.0 and > -2.0) and osteoporosis (Z-score < or = -2.0) for any one or more areas including total body, lumbar spine, total hip, or femoral neck density, 13 of the 38 subjects (34%) had osteopenia or osteoporosis. A further six subjects (16%) had isolated upper extremity osteopenia or osteoporosis. Multivariate analysis showed a direct relationship between the number of chemotherapy drugs administered and the presence of osteopenia or osteoporosis in the lower extremities (P = 0.03). Young survivors of childhood solid tumors are at increased risk of developing premature osteopenia or osteoporosis, and screening evaluations and follow-up are warranted.

Absorptiometry, Photon↗

PubMed2005

Correlation between "malfunctioning events" and catheter-related infections in pediatric cancer patients bearing tunneled indwelling central venous catheter: results of a prospective observational study.

AIM OF THE STUDY: To evaluate the possible link between malfunctioning events and catheter related infections in indwelling central venous devices in children with cancer. PATIENTS AND METHODS: Prospective observation of 418 devices inserted in 2 Italian tertiary care pediatric cancer centers. The presence of a relationship was identified if a malfunctioning event was followed by a catheter related infection within 10 days, or vice versa. RESULTS: The 418 catheters were followed for a period of 107,012 days. Among the malfunctioning events 2 out of 141 (1%) were followed by a catheter related infection while among infectious episodes 3 out of 93 (3%) were followed by a malfunctioning event. CONCLUSIONS: Malfunctioning events followed by catheter related infections and catheter related infections followed by malfunctioning are both rare events in children with cancer.

Adolescent↗

PubMed1997

Guidelines for the pediatric cancer center and role of such centers in diagnosis and treatment. American Academy of Pediatrics Section Statement Section on Hematology/Oncology.

The intent of this statement is to delineate those personnel and facilities that are essential to provide state-of-the-art care for children and adolescents with cancer. This statement emphasizes the importance of a board-eligible or board-certified pediatric hematologist-oncologist and pediatric subspecialty consultants overseeing the care of all pediatric and adolescent cancer patients, and the need for facilities available only at a tertiary center as essential for the initial management and much of the follow-up for pediatric and adolescent cancer patients. In 1986, the Section on Oncology/Hematology of the American Academy of Pediatrics outlined the "Guidelines for the Pediatric Cancer Center and Role of Such Centers in Diagnosis and Treatment." Since that statement was published, significant changes in medical care reimbursement have prompted a review of the role of tertiary medical centers in the care of pediatric patients. The potential impact of these developments on the treatment of children with cancer led to a revision of the previous statement with the goal of delineating those elements that are necessary to ensure that current childhood cancer survival rates are not adversely impacted by requirements for care to be given at sites lacking essential personnel or equipment.

Child↗

PubMed1987

Cerebrospinal fluid and plasma pharmacokinetics of morphine infusions in pediatric cancer patients and rhesus monkeys.

The cerebrospinal fluid (CSF) and plasma pharmacokinetics of morphine administered as a continuous infusion were studied in pediatric cancer patients and in monkeys with implanted Ommaya reservoirs. In monkeys administered a constant infusion of 0.15 mg morphine sulfate/kg/h, morphine steady-state plasma and CSF concentrations were 84.4 +/- 20.0 ng/ml and 25.3 +/- 4.9 ng/ml, respectively, for a CSF:plasma ratio of 0.30 +/- 0.05. For comparison, the monkeys also received morphine as an intravenous bolus at a dose of 0.45 mg morphine sulfate/kg. The CSF:plasma area under the concentration-time curve (AUC) ratio was 0.40 +/- 0.07, similar to that seen with continuous infusion. Morphine pharmacokinetics were also studied in cancer patients administered long-term infusions of morphine sulfate over a wide dosage range (0.04-31 mg/kg/h). The steady-state plasma concentration of morphine was linearly related to the infusion rate although variability was noted. The average clearance value was 23 ml/min/kg which is at the upper end of the estimates reported for morphine clearance using bolus administration. No evidence for morphine accumulation using long-term administration was observed. A limited number of CSF samples obtained by lumbar puncture showed comparable CSF and plasma concentrations of unbound morphine assuming morphine is approximately 30% bound in human plasma.

Animals↗

PubMed1990

Anesthetic considerations in the pediatric cancer patient.

Cancer is second only to trauma as the leading cause of death in children 1-15 years of age. Pediatric cancer patients have unique physiologic, pharmacologic, and psychologic considerations that present a unique challenge to plan anesthesiologist. A thorough understanding of pediatric tumors, along with chemotherapeutics and their complications, is necessary to plan anesthetic management properly. Special attention is directed to the psychologic needs and preparation of both the patient and parents. Close cooperation and coordination among the pediatric oncologist, surgeon, and anesthesiologist are necessary for safe and expeditious operative care.

Adolescent↗

PubMedDate not supplied

Human herpesvirus-6 infection in children with cancer.

Pediatric cancer patients treated with multimodal therapy are at a great risk of opportunistic infections or reactivation of latent infections. Human herpesvirus-6 (HHV-6) can serve as an example of such infection, with high seroprevalence in population. In 66 children with cancer and in 45 healthy controls, age matched, the presence of DNA HHV-6 was examined in peripheral blood by the polymerase chain reaction method. HHV-6 serology was also performed. No difference has been found between patients at the time of cancer diagnosis and the group of healthy children in the presence of DNA HHV-6 in blood, 17.4 and 15.6%, respectively. During cytotoxic chemotherapy the presence of HHV-6 in peripheral blood raised to 37.1% in patients with fever. Other parameters and symptoms such as febrile neutropenia, lymphopenia, exanthem, hepatopathy, lymphadenopathy, enteritis, bone marrow aplasia, pneumonitis, and encephalitis were examined in both the HHV-6 positive and HHV-6 negative groups of pediatric cancer patients. Statistically significant differences (p < .05) were found in case of lymphopenia, exanthem, and hepatopathy. In 4 out of 66 patients (6.1%) severe HHV-6 infection has been found: in 3 patients during cytotoxic chemotherapy and in 1 at the time of cancer diagnosis. Reactivation of HHV-6 infection in pediatric cancer patients under treatment with cytotoxic chemotherapy is frequent and can lead to severe complications as described in patients after bone marrow or organ transplantation.

Adolescent↗

PubMedDate not supplied

Geographic studies of pediatric cancer near hazardous waste sites.

The incidence of pediatric (i.e., 0-17 y of age) cancers in North Carolina was studied for the years 1990-1993 in counties and ZIP-code areas that contained a National Priorities List hazardous-waste site. We analyzed the areas to determine if there was an excess incidence of cancer among the pediatric population. We used geographic information systems technology to address-match and map the cancer cases, along with county and National Priorities List hazardous waste-site location. No significantly elevated cancer incidence rates were found at the county level. Two ZIP-code areas had statistically significant elevations in cancer incidence (p < .05). Only 3 of the cancer cases we mapped resided within a 1.6-km (1 mi) buffer zone of a National Priorities List hazardous-waste site. These 3 cases were not in the ZIP-code areas that had increased incidence rates. The small numerators throughout the study led us to question the accuracy of the assessment of underlying rates. The general capabilities of the geographic information systems, as well as advantages and limitations of the system, are discussed. As an exploratory study, this study serves as a springboard into more in-depth environmental-health hypotheses and more-specific investigations of point sources of hazardous exposures.

Adolescent↗

PubMedDate not supplied

Trauma spectrum adaptation: somatic symptoms in long-term pediatric cancer survivors.

The authors assessed somatic symptoms and the degree of association among somatic symptoms, global adjustment, trauma symptoms, and personality characteristics in long-term pediatric cancer survivors. Forty cancer survivors completed self-report questionnaires and clinical interviews. Participants' level of somatic symptoms fell between nonclinic and psychiatric populations. Somatic symptom scores correlated with general adjustment in the negative direction and with posttraumatic stress disorder (PTSD) scores in the positive direction. The majority of participants met at least partial current PTSD criteria. Because these survivors demonstrate a repressive adaptive style but endorse somatic symptoms, the latter may represent a method for detecting trauma-related distress in this population.

Adaptation, Psychological↗

PubMed2002

Pediatric Cancer CareLink--supporting home management of childhood leukemia.

We conducted a descriptive evaluation of an Internet-based system designed to support home management of childhood leukemia (Pediatric Cancer CareLink). Twenty-five parents of children with ALL and thirty-four clinicians were interviewed to identify functional requirements and to demonstrate the system's potential to improve the experience and outcomes of children with acute lymphoblastic leukemia (ALL). Parental interviews focused on: medication and side effect management in the home; communication with the health care team; and the use of a computer for ALL home management. Results from these interviews provide strong evidence that parents of children with ALL are struggling to manage the complexity of their children's care in the home. Parents revealed an urgent need for tools that would help them to safely organize the medicines that their children receive while on ALL protocols. Forty percent of parents needed to know more about what to expect during their child's therapy and how to be prepared for it. Clinician interviews focused on the clinical impact and workflow issues associated with such a system. Decision support, prescription refill management, and educational and emotional support functions were considered key components. Clinicians were concerned that such a system would increase their already overburdened workload. Conversely, parents believed that access to such a system would eliminate unnecessary phone calls to the care team. Our findings show that parents would embrace collaborative Internet-based tools that would help with the home management of their child's leukemia.

Child↗

PubMed1997

Anticipatory nausea and vomiting in pediatric cancer patients: an analysis of conditioning and coping variables.

We examined the influence of cognitive factors and conditioning variables on anticipatory nausea and vomiting symptoms (ANV) in 32 pediatric cancer patients with postchemotherapy nausea and vomiting (PNV) who received ondansetron. The patients were compared with 18 patients without ANV (NANV). Age, gender, history of motion sickness, aggressiveness of the chemotherapy, PNV severity, number of chemotherapy treatments, number, type, and efficacy of self-reported coping strategies, and expectations of severity of postchemotherapy symptoms failed to differentiate the ANV and NANV groups. The amount of subjective distress associated with nausea and vomiting was significantly greater in the ANV group. Among patients in whom ANV developed, level of distress and expectations of severity of postchemotherapy symptoms were positively correlated with the severity of ANV and PNV symptoms. Therefore, greater distress might increase the likelihood of ANV conditioning. Once ANV is conditioned, cognitive factors might influence the severity of symptoms.

Adaptation, Psychological↗

PubMed1988

Ceftazidime with or without vancomycin vs. cephalothin, carbenicillin and gentamicin as the initial therapy of the febrile neutropenic pediatric cancer patient.

In a 28-month randomized trial we compared ceftazidime (CAZ), an extended spectrum cephalosporin, with cephalothin, carbenicillin and gentamicin (KCG) as empiric therapy for febrile neutropenic pediatric cancer patients. Because of the occurrence of ceftazidime-resistant Gram-positive primary infections, vancomycin was added to CAZ after the first year of study. Of 206 evaluable episodes 76 (37%) were documented infections including 20 bacteremias; 130 (63%) episodes were caused by fever of unknown origin. The number of complete responses to initial therapy in patients with documented infections did not differ among regimens: 26 of 43 (61%) for KCG, 9 of 16 (56%) for ceftazidime and 8 of 16 (50%) for CAZ + vancomycin (not significant). In patients with fever of unknown origin, response without modification of the initial regimen was 52 of 62 (84%) in the KCG arm, 32 of 40 (80%) on CAZ and 23 of 29 (80%) in patients treated with CAZ + vancomycin (not significant). Modifications of the regimen were similar among all three groups and were due primarily to the use of empiric antifungal or antiviral therapy and to empiric treatment of interstitial pneumonia. Hypokalemia occurred in 25 of 105 patients treated with KCG and in 4 of 101 treated with CAZ or CAZ + vancomycin (P less than 0.001). No differences between the efficacy of KCG, CAZ and CAZ + vancomycin as initial empiric therapy were demonstrated.

Agranulocytosis↗

PubMed1999

Outpatient treatment of fever and neutropenia for low risk pediatric cancer patients.

BACKGROUND: Fever and neutropenia (F&N) is a common complication of cancer chemotherapy. It is conveniently managed by hospitalization and empiric administration of parenteral antibiotics. This study attempted to determine whether pediatric cancer patients with F&N identified as low risk for morbidity and mortality by clinical criteria at the time of presentation could be treated safely as outpatients. METHODS: Seventy-three episodes of F&N in 41 patients were studied prospectively over 2 years. Eligibility criteria included age > or =2 years, reliable caretakers, and residence within 1 hour of the hospital. Exclusion criteria included hemodynamic instability, dehydration, severe mucositis, pneumonia, leukemia/lymphoma induction therapy, bone marrow transplantation, or other serious comorbidity. Patients were evaluated, received a single dose of intravenous ceftazidime, and were observed for 3-16 hours. They were randomized to receive either oral ciprofloxacin or intravenous ceftazidime as outpatients. Patients were seen daily until they had been afebrile for at least 48 hours and had a rising absolute phagocyte count of >500 cells/microL. RESULTS: Sixty-three of 73 episodes (86%) were successfully managed on an outpatient basis. For 31 of 33 episodes in the ceftazidime arm, the patients remained outpatients, compared with 32 of 40 in the ciprofloxacin arm; this difference was not statistically significant. On average, patients remained febrile for 2.7 days and were treated for 4.7 days. Seventy-seven percent of episodes required no modification of initial antibiotic therapy. Of the 10 patients who were hospitalized, 4 had prolonged fever and 3 had emesis. Protracted neutropenia was associated with the need for hospitalization. There were no deaths, intensive care unit transfers, or serious complications. CONCLUSIONS: Carefully selected low risk children with fever and neutropenia can be treated safely as outpatients. Close daily medical scrutiny is required.

Adolescent↗

PubMed1998

Evaluation of mutant frequencies at the hprt and the T-cell receptor loci in pediatric cancer patients before treatment.

Mutant frequencies (Mfs) at the two genetic loci, the hypoxanthine phosphoribosyl transferase (hprt) gene and the T-cell receptor (TCR) gene were evaluated in pediatric cancer patients before starting chemotherapy or radiotherapy. The study population consisted of 27 patients with various solid tumors (mean age +/- SD; 5.5 +/- 5.1 years, range; 0.2-14.5 years), 5 patients with acute leukemia (10.3 +/- 6.1, 1.3-17.0 years), and 26 healthy controls (11.6 +/- 4.0, 4.4-22.2 years). Although the age distributions were different, the mean Mf values of the hprt and the TCR loci were comparable among these three groups. On an individual basis taking the age factor into consideration, the hprt-Mfs of 3 patients with solid tumors, i.e., two patients with Hodgkin's disease and one patient with Askin tumor, were found to be well above the 95% confidence limit. There were no patients with a TCR-Mf exceeding the 95% confidence limit. These data suggest the possibility that some patients with solid tumors may be predisposed to mutational susceptibility before treatment. The assay of the hprt-Mf appears more sensitive than the TCR-Mf assay in distinguishing these patients.

Adolescent↗

PubMed1999

[Steroid pulse therapy and vital prognosis among pediatric cancer patients with sepsis].

The usefulness of glucocorticosteroid therapy in patients with sepsis has been controversial. We investigated the effect of steroid pulse therapy on the vital prognosis of pediatric patients with sepsis and followed the vital status up to one month after the use of pulse therapy. We reviewed the medical records of 89 pediatric cancer patients with sepsis treated at our hospital between 1988 and 1996. The risks of potential predictors were estimated by calculating crude and adjusted relative risk (RR). The total cumulative death was 33/89 (25%). All patients treated with steroid pulse therapy died (12/12). Patients with either interstitial pneumonia (IP), infection-associated hemophagocytic syndrome (IAHS) and graft-versus-host disease (GVHD) showed a significantly higher cumulative death (57% (12/21) vs 31% (21/68), p = 0.03). Increased risk of cumulative death was suggested for the older age group, inappropriate antimicrobial therapy, and the conditions requiring steroid pulse therapy (IP, IAHS, and GVHD), (crude RR were 1.6, 1.6, and 1.9, respectively). However, when adjusted for pulse therapy, these three factors no longer indicated risk elevation, (adjusted RR = 1.2, 1.2, and 0.3, respectively). On the other hand, steroid pulse therapy per se was independently associated with increased risk of cumulative death (crude RR = 3.6, adjusted RR = 10). Thus, the risk of the conditions requiring steroid pulse therapy (IP, IAHS, and GVHD) firstly observed could be regarded as an apparent association due to steroid pulse therapy.

Child↗

PubMed1990

Fungal infections in the pediatric cancer patient.

Chemotherapy, while undeniably effective in controlling or eradicating a variety of neoplasms, is also accompanied by a number of toxicities. Foremost among these is neutropenia, which places the pediatric cancer patient at risk for serious fungal infections. The fungal organisms most commonly responsible for infection in neutropenic children are Candida, Aspergillus, Mucor, and the Phycomycetes. Common sites of infection include the oral cavity, sinuses, lung, and bloodstream. Recently, candidal infection of the liver was recognized as a growing problem. Diagnosis of deep-seated fungal infections, such as pneumonia and hepatic candidiasis, is extremely difficult, often requiring open-lung or liver biopsy, which a patient's hematologic status may not permit. Because early treatment significantly improves prognosis, empirical antifungal therapy may be indicated in selected patients. Amphotericin B is currently the antifungal agent of choice against most fungal organisms. Antifungal efficacy studies based on animal models of disseminated candidal infection suggest that amphotericin B combined with 5-fluorocytosine (5-FC) is more effective than amphotericin B alone against most deep-seated Candida infections. The investigational drug, fluconazole, appears as effective as amphotericin B plus 5-FC in the prevention and early treatment of disseminated candidiasis, and clinical trials to assess this potentially important role for the new antifungal agent are now being initiated.

Adult↗

PubMed2002

A rapid interview protocol supporting patient-centered quality improvement: hearing the parent's voice in a pediatric cancer unit.

BACKGROUND: The Institute of Medicine's 2001 report on quality delimits six dimensions of optimal care: safety, effectiveness, efficiency, timeliness, patient centeredness, and equity. In fall 2001 parents of pediatric cancer patients were interviewed to determine how well they thought these dimensions were addressed with respect to medication administration. Immediate goals were to identify system weaknesses and devise strategies to prevent future errors. A higher-order goal was to develop and demonstrate a model protocol for rapid-cycle interview assessments. METHODS: Hematology/oncology directors worked with a research expert to develop a semistructured interview protocol. After training, which included directed reading, oral instruction, and role-playing, a convenience sample of 20 English- and Spanish-speaking parents of inpatients was recruited. Parents were asked to characterize current medication administration practices and to describe problems that they had experienced or witnessed. Rapid content analysis techniques were used to identify issues of importance to the parents. FINDINGS: Parents' medication concerns centered on their children's comfort. Parents called for communication improvements, standardization of all nursing procedures and techniques, and a guide or an outline providing a clear understanding of what to expect when and from whom. Viewing these concerns in relation to the Institute of Medicine's quality domains allowed the department to frame an improvement action plan aligned with organizational and national priorities. IMPLICATIONS: With good supervision and limited focused training, inexperienced staff can successfully administer semistructured qualitative interviews and help analyze findings for rapid cycle improvement purposes. The protocol can be adapted for use in organizations interested in rapid qualitative assessments of patient and parent preferences.

California↗

PubMed1999

Clinical hypnosis versus cognitive behavioral training for pain management with pediatric cancer patients undergoing bone marrow aspirations.

A randomized controlled trial was conducted to compare the efficacy of clinical hypnosis versus cognitive behavioral (CB) coping skills training in alleviating the pain and distress of 30 pediatric cancer patients (age 5 to 15 years) undergoing bone marrow aspirations. Patients were randomized to one of three groups: hypnosis, a package of CB coping skills, and no intervention. Patients who received either hypnosis or CB reported less pain and pain-related anxiety than did control patients and less pain and anxiety than at their own baseline. Hypnosis and CB were similarly effective in the relief of pain. Results also indicated that children reported more anxiety and exhibited more behavioral distress in the CB group than in the hypnosis group. It is concluded that hypnosis and CB coping skills are effective in preparing pediatric oncology patients for bone marrow aspiration.

Adaptation, Psychological↗