Presentation of childhood CNS tumours: a systematic review and meta-analysis

BACKGROUND

Suspicion of a CNS tumour is classically raised by symptoms of raised intracranial pressure, focal deficits (including seizures), or papilloedema. Development of guidelines is needed for the identification and referral of children who might have a CNS tumour. We did a systematic literature review and meta-analysis to identify the clinical presentation of childhood CNS tumours to provide evidence to support the development of guidelines to assist with the identification and referral for imaging of children who might have a central nervous system tumour.

METHODS

Medline, Embase, and PubMed were searched for cohort studies and case series in children, published between January, 1991, and August, 2005, detailing the symptoms and signs at diagnosis of a CNS tumour.

FINDINGS

74 papers (n=4171) met the inclusion criteria. 56 symptoms and signs at diagnosis were identified, ranked by frequency, and clustered according to age, anatomical criteria, and genetic criteria. The most frequent symptoms and signs at diagnosis were: headache (33%), nausea and vomiting (32%), abnormalities of gait and coordination (27%), and papilloedema (13%) for intracranial tumours; macrocephaly (41%), nausea and vomiting (30%), irritability (24%), and lethargy (21%) for children aged under 4 years with intracranial tumours; reduced visual acuity (41%), exophthalmia (16%), and optic atrophy (15%) for children with an intracranial tumour and neurofibromatosis; nausea and vomiting (75%), headache (67%), abnormal gait and coordination (60%), and papilloedema (34%) for posterior fossa tumours; unspecified symptoms and signs of raised intracranial pressure (47%), seizures (38%), and papilloedema (21%) for supratentorial tumours; headache (49%), abnormal eye movements (21%), squint (21%), and nausea and vomiting (19%) for central brain tumours; abnormal gait and coordination (78%), cranial nerve palsies (52%), pyramidal signs (33%), headache (23%), and squint (19%) for brainstem tumours; and back pain (67%), abnormalities of gait and coordination (42%), spinal deformity (39%), focal weakness (21%), and sphincter disturbance (20%) for spinal-cord tumours. Other features noted were weight loss, growth failure, and precocious puberty. Symptoms of raised intracranial pressure were absent in more than half of children with brain tumours. Other neurological features were heterogeneous and related to tumour location.

INTERPRETATION

Apart from raised intracranial pressure, motor and visual system abnormalities, weight loss, macrocephaly, growth failure, and precocious puberty also suggest presence of an intracranial tumour. Children with signs and symptoms that could result from a CNS tumour need a thorough visual and motor system examination and an assessment of growth and pubertal status. Occurrence of multiple symptoms and signs should alert clinicians to possible CNS tumours.

Pediatric sleep and epilepsy

Sleep disorders are common in childhood. The prevalence of childhood sleep disorders is higher in chronic neurologic disorders, specifically epilepsy. Sleep needs, requirements, and structure are different in children compared with adults. These variables are disrupted severely in patients with epilepsy. Electroencephalogram abnormalities, nocturnal seizures, and medications may contribute further to sleep problems and affect daytime functioning. These sleep disturbances may worsen seizure control and affect quality of life. This article offers an overview of the normal sleep patterns in children, describes the interaction of electroencephalogram, sleep, and commonly found sleep disorders, and reviews the current literature of the main sleep disturbances found in children with epilepsy.

Selective dorsal rhizotomies in the treatment of spasticity related to cerebral palsy

RATIONALE

Selective dorsal rhizotomy (SDR) is a surgical technique developed over the past decades to manage patients diagnosed with cerebral palsy suffering from spastic diplegia. It involves selectively lesioning sensory rootlets in an effort to maintain a balance between elimination of spasticity and preservation of function. Several recent long-term outcome studies have been published. In addition, shorter follow-up randomized controlled studies have compared the outcome of patients having undergone physiotherapy alone with those that received physiotherapy after selective dorsal rhizotomy.

MATERIALS AND METHODS

In this account, we will discuss the rationale and outcome after SDR. The outcome is addressed in terms of the gross motor function measurement scale (GMFM), degree of elimination of spasticity, strength enhancement, range of motion, fine motor skills, activity of daily living, spastic hip, necessity for postoperative orthopedic procedures, bladder and sphincteric function, and finally possible early or late complications associated with the procedure.

CONCLUSION

We conclude that SDR is a safe procedure, which offers durable and significant functional gains to properly selected children with spasticity related to cerebral palsy.

The use of actigraphy for assessment of the development of sleep/wake patterns in infants during the first 12 months of life

Maturation of sleep/wake patterns is one of the most important physiological developments during the first year of life. In this study, we aimed to compare the use of actigraphy and parental sleep diaries (SD) for recording the development of sleep/wake patterns longitudinally in term infants in their own home environments over the first 12 months of life. Twenty healthy term infants (7F/13M) were studied for 3 days each month in their own homes over the first 12 months of life. Sleep/wake patterns were recorded using both SD and actigraphy (AW) (AW64, Mini Mitter Co. Inc., Sunriver, OR, USA). The development of sleep and wake was analysed over 24 h, during the day (08:00-20:00 hours) and during the night (20:00-08:00 hours). A total of 186 studies had complete data sets for both analysis methods. Overall, there was no difference between methods of measurement for determination of the total percentage of sleep or wake over 24 h, or for the total percentage of sleep or wake during the day. However, at night, AW scored less time asleep (73.3 +/- 0.9%) and more time awake (26.7 +/- 0.9%) compared with the SD (80.7 +/- 1.04% and 19 +/- 1.0%, respectively, P < 0.001). Mean percentage sleep during the day decreased from 51% at 1 month to 28% at 12 months with the 1-month values being significantly higher than all other ages, while mean percentage sleep at night was only different between 1 month and 11 and 12 months. In conclusion actigraphy provides a useful tool for assessing the development infant sleep.

Decision-making for postpartum discharge of 4300 mothers and their healthy infants: the Life Around Newborn Discharge study

OBJECTIVES

Postpartum discharge of mothers and infants who are not medically or psychosocially ready may place the family at risk. Most studies of postpartum length of stay, however, do not reflect the necessary complexity of decision-making. With this study we aimed to characterize decision-making on the day of postpartum discharge from the perspective of multiple key informants and identify correlates of maternal and newborn unreadiness for discharge.

PATIENTS AND METHODS

This was a prospective observational cohort study of healthy term infants with mothers, pediatric providers, and obstetricians as key informants to assess the decision-making process regarding mother-infant dyad unreadiness for discharge. A mother-infant dyad was defined as unready for postpartum hospital discharge if > or = 1 of 3 informants perceived that either the mother or infant should stay longer at time of nursery discharge. Data were collected through self-administered questionnaires on the day of discharge.

RESULTS

Of 4300 mother-infant dyads, unreadiness was identified in 17% as determined by the mother (11%), pediatrician (5%), obstetrician (1%), and > or = 2 informants (< 1%). Significant correlates of unreadiness were as follows: black non-Hispanic maternal race/ethnicity, maternal history of chronic disease, primigravid status, inadequate prenatal care as determined by the Kotelchuck Adequacy of Prenatal Care Utilization Index, delivering during nonroutine hours, in-hospital neonatal problems, receiving a limited number of in-hospital classes, and intent to breastfeed.

CONCLUSIONS

Mothers, pediatricians, and obstetricians must make decisions about postpartum discharge jointly, because perceptions of unreadiness often differ. Sensitivity toward specific maternal vulnerabilities and an emphasis on perinatal education to insure individualized discharge plans may increase readiness and determine optimal timing for discharge and follow-up care.

Determination of toxaphene residues in fish foodstuff by GC-MS

A method for the determination of toxaphene residues in fish and fish-based baby foods has been developed. The cleanup of the fatty matrices was performed using an acid treatment on an Extrelut-NT3 and ENVI-Florisil SPE cartridges system, using light petroleum as eluent. Instrumental analysis was carried out by gaschromatography with mass spectrometry detector (GC/MS) in SIM mode. Recoveries from spiked samples were tested at 0.005 and 0.01 mg/kg per single congener and were in the range 82-104% while relative standard deviations (RSDs) were in the range 3.7-10.9%. Nineteen samples of both frozen fish food and fish-based baby foods representative of the Italian market were collected from local dealers and analysed.

A pharmacist's introduction to the effects of aging on patients with cerebral palsy

OBJECTIVE

To review the development of comorbidities in patients living with cerebral palsy (CP) and explore potential areas for intervention by consultant pharmacists.

DATA SOURCES

A MEDLINE search (1993 to present) was conducted to identify literature in the English language focusing on CP and aging. Based on the initial literature evaluation, an additional search was conducted to locate literature focusing on comorbidities in CP including, but not limited to, nutritional deficiencies, medication misadventures, osteoporosis, gastroesophageal reflux disease, and pain.

STUDY SELECTION AND DATA EXTRACTION

All studies evaluating coexisting medical conditions associated with CP as they relate to aging.

DATA SYNTHESIS

CP affects nearly 500,000 adults in the United States. Spastic CP is the most common form. Chronic medical conditions typically seen in the general older adult population may occur earlier in life for patients with CP.

CONCLUSION

Health care maintenance issues are often overlooked in adult patients with CP. Consultant pharmacists can be helpful resources and advocates for appropriate medication therapy, monitoring, and preventive services for these patients.

Attention-deficit/hyperactivity disorder or hyperactivity in preschool children

This article describes the evidence for the presentation of attention-deficit/hyperactivity disorder in young children and discusses the literature describing the manifestations of the condition, and assessment and treatment techniques.

Hope and spiritual well-being in adolescents with cancer

This study examines the relationships of hope and spiritual well-being (SWB)--and its dimensions, religious well-being (RWB) and existential well-being (EWB)--to time since diagnosis among adolescents with cancer. A descriptive cross-sectional design was used. The sample of 78 adolescents diagnosed with cancer was recruited from two pediatric oncology clinics. Adolescents in the first two time periods reported significantly higher levels of SWB, RWB, and EWB than those in subsequent time periods. Hope did not significantly vary over time. Hence, time since diagnosis may influence adolescents' levels of SWB and its dimensions during the cancer experience. Adolescents' use of SWB, RWB, and EWB as coping resources should be examined in longitudinal studies from diagnosis through survivorship.

Guidelines for molecular karyotyping in constitutional genetic diagnosis

Array-based whole genome investigation or molecular karyotyping enables the genome-wide detection of submicroscopic imbalances. Proof-of-principle experiments have demonstrated that molecular karyotyping outperforms conventional karyotyping with regard to detection of chromosomal imbalances. This article identifies areas for which the technology seems matured and areas that require more investigations. Molecular karyotyping should be part of the genetic diagnostic work-up of patients with developmental disorders. For the implementation of the technique for other constitutional indications and in prenatal diagnosis, more research is appropriate. Also, the article aims to provide best practice guidelines for the application of array comparative genomic hybridisation to ensure both technical and clinical quality criteria that will optimise and standardise results and reports in diagnostic laboratories. In short, both the specificity and the sensitivity of the arrays should be evaluated in every laboratory offering the diagnostic test. Internal and external quality control programmes are urgently needed to evaluate and standardise the test results between laboratories.

An intervention to increase the use of Asthma Action Plans in schools: a MASNRN study

School nurses, in collaboration with primary care providers (PCPs), can work to better manage asthma by using the Asthma Action Plan (AAP) with peak flow monitoring. The aim of this pilot study was to determine the effectiveness of an intervention to increase the number of AAPs in schools for students with asthma by having school nurses provide the students' peak flow measurements to their PCPs with a request for an AAP. The study found a significant increase in AAPs when school nurses provided PCPs with accurate peak flow data and requested an AAP from the PCP than when school nurses requested an AAP via the students' parents and did not provide peak flow data to the PCP. This study provided data on the importance of collaboration with PCPs in order to affect better care for children with asthma.

Can breastfeeding avert the appearance of growth pains during childhood?

Recurrent pains of the lower extremities (growth pains) constitute the most frequent cause of musculoskeletal pains in children. The disorder's pathophysiological mechanism remains unclear. Numerous researchers have tried to ascertain this by studying the anthropometrical characteristics of the children they examined, their family history and levels of physical activity, even their psychological background. To date though, no study has looked into whether breastfeeding may avert their appearance or limit their intensity and duration. Aiming to investigate the above theory, we conducted interviews with the mothers of 532 children, using a semiconstructed questionnaire. According to Petersen's criteria, 130 children presented growth pains during the last year. Specifically, 32.5% of non-breastfed children presented recurrent lower extremity pains, whereas such pains were identified in only 19.6% of breastfed children (p value = 0.001 < 0.005). The duration of breastfeeding also seems to play an important role. Indeed, amongst children breastfed for up to 40 days, the percentage of those presenting pain is 29.8%, whereas in those breastfed for more than 40 days, the respective percentage fell to 16.2% (p value = 0.001 < 0.005). These results show that there is a statistically significant dependence between the presentation of pains and whether the child had been breastfed or not, as well as the duration of breastfeeding during infancy. On the contrary, in children presenting growth pains, breastfeeding does not seem to affect the type or frequency of pain.

MMPs as therapeutic targets--still a viable option?

Matrix metalloproteinases (MMPs) appear to be ideal drug targets--they are disease-associated, extracellular enzymes with a dependence on zinc for activity. This apparently straightforward target, however, is much more complex than initially realized. Although disease associated, the roles for particular enzymes may be healing rather than harmful making broad-spectrum inhibition unwise; targeting the catalytic zinc with specificity is difficult, since other related proteases as well as non-related proteins can be affected by some chelating groups. While the failure of early-generation MMP inhibitors dampened enthusiasm for this type of drug, there has recently been a wealth of studies examining the basic biology of MMPs which will greatly inform new drug trials in this field.

Adolescent and young adult (AYA) oncology: the first A

Whereas adolescents with cancer as a group used to have a better prognosis than children with malignant disease, trends suggest that the overall survival of 15- to 19-year-olds is now worse than in younger patients. Also, the incidence of cancer is higher in 15- to 19-year age span than during the first 15 years of life. In 2006, the U.S. National Cancer Institute (NCI) and the Lance Armstrong Foundation conducted a Program Review Group (PRG) of the Adolescent and young Adult (AYA) problem. Recommendations covered awareness, prevention/cancer control/epidemiology/risk, biology, access, health insurance, clinical care models, clinical trials/research, special populations, psychosocial/behavioral factors, health-related quality of life, and long-term effects. This Commentary reviews each of the primary executive recommendations of the PRG report with respect to their adolescent oncology perspective and application. Primary implementation of the recommendations is responsibility of a new consortium of organizations devoted to assisting adolescents and young adults with cancer, the LiveStrong Young Adult Alliance, a program of the Lance Armstrong Foundation. Prior programs included the Children's Oncology Group AYA Committee and two disease-specific initiatives: the Intergroup Consortium Against Sarcoma and a clinical trial in young adults with acute lymphoblastic leukemia that will be conducted by Cancer and Leukemia Group B, the Southwest Oncology Group, and Eastern Cooperative Oncology Group. Preliminary evidence indicates that these efforts have already had measurable success.

Functional changes in children, adolescents, and young adults with cerebral palsy

Children with multiple handicaps, including cerebral palsy (CP), often lose or regress in their functional ability through adolescence and adulthood. The purpose of this study was to examine functional and psychological changes in children, adolescents and young adults with CP. A retrospective chart review and a prospective telephone interview of 30 patients (11-29 years, M = 16.8, S.D. = 4.9) was conducted. Seventy-three percent of the patients were male (n = 22) and 83% (n = 25) had spastic CP. According to the McNemar's test, four significant functional losses were found including crawling (p = 0.03), standing independently (p = 0.05), walking with or without assistance (p = 0.014), and eating by mouth (p = 0.01). Standing function loss was significantly related to walking function loss (p = 0.02). Sixty-three percent (n = 19) of the patients experienced anxiety and 10% (n = 3) reported depression. Results of this study indicate that a validated yearly assessment tool is needed to measure functional and emotional changes in children with CP rather than relying on parent recall. This data may also lead to a review of the current physical therapy national standards.

Neutrophils: the forgotten cell in JIA disease pathogenesis

Juvenile idiopathic arthritis (JIA) has long been assumed to be an autoimmune disease, triggered by aberrant recognition of "self" antigens by T-cells. However, systems biology approaches to this family of diseases have suggested complex interactions between innate and adaptive immunity that underlie JIA. In particular, new data suggest an important role for neutrophils in JIA pathogenesis. In this short review, we will discuss the new data that support a role for neutrophils in JIA, discuss regulatory functions that link neutrophils to adaptive immune responses, and discuss future areas of investigation. Above all else, we invite the reader to re-consider the use of the term "autoimmunity" as applied to the family of illnesses we collectively call JIA.

Use of videotaped interactions during pediatric well-child care: impact at 33 months on parenting and on child development

OBJECTIVE

We performed a randomized, controlled trial to assess the impact of the Video Interaction Project (VIP), a program based in pediatric primary care in which videotaped interactions are used by child development specialists to promote early child development.

METHOD

Ninety-nine Latino children (52 VIP, 47 controls) at risk of developmental delay based on poverty and low maternal education were assessed at age 33 months. VIP was associated with improved parenting practices including increased teaching behaviors.

RESULTS

VIP was associated with lower levels of parenting stress. VIP children were more likely to have normal cognitive development and less likely to have developmental delays.

CONCLUSION

This study provides evidence that a pediatric primary care-based intervention program can have an impact on the developmental trajectories of at-risk young preschool children.

Lemierre's syndrome associated with consumption coagulopathy and acute renal failure: a case report

Background:

Acute tonsillitis or pharyngitis may lead to suppurative thrombophlebitis of the internal jugular vein. This complication, also known as Lemierre's syndrome, remains, even nowadays, life threatening, due to dissemination of septic thromboemboli to various organs. Respiratory deficiency and renal impairment are often reported in patients suffering from Lemierre's syndrome.

Case report:

The unusual clinical manifestation of this case involves severe acute renal and respiratory deficiency in addition to microangiopathic consumption coagulopathy in a young patient treated with macrolides five days after the onset of acute tonsillitis.

Conclusion:

The usual causative pathogen, namelyFusobacterium necrophorum, shows a varying sensitivity to macrolides. As a result, the syndrome may present itself in a variety of clinical forms even in patients under treatment with macrolides. A high index of suspicion is therefore crucial for in time prevention of potentially life threatening complications.

Media Content and Externalizing Behaviors in Latino Toddlers

OBJECTIVE

There has been limited study of the association between media exposure and behavior in children younger than age 3 years. We sought to study this association in toddlers and determine whether the association varied depending on media content.

METHODS

We carried out a secondary analysis of a cohort of Latino mother-infant dyads followed from birth to 33 months. We assessed media exposure at 21 and 33 months with a 24-hour recall diary that included information about the duration and content of each program watched. Behavior was assessed at 33 months by the Child Behavior Checklist.

RESULTS

This analysis included 99 dyads. Results from multiple logistic regression analyses indicated associations of child behavior outcomes with 21-month total media exposure and both 21-month and 33-month exposure to noneducational young child media such as cartoons, after adjusting for maternal education, country of origin, and depressive symptoms, participation in a parenting program, and difficult child temperament. Media exposure has most consistent associations with aggressive behavior and externalizing problems.

CONCLUSIONS

Media exposure was associated with externalizing behavior in Latino toddlers, with the strongest association for media oriented toward young children but without educational content. This finding has importance for both parents of young children and pediatricians as they provide anticipatory guidance.

Attitudes about shared reading among at-risk mothers of newborn babies

OBJECTIVE

Attitudes about shared reading among at-risk mothers of newborn babies have not been the focus of previous study. Better understanding of factors associated with these attitudes would facilitate pediatricians' provision of anticipatory guidance. We sought to assess sociodemographic correlates of attitudes regarding and resources available for shared reading among multiethnic, low socioeconomic status (SES) mothers of newborns.

METHODS

This was a cross-sectional analysis of consecutive mother-infant dyads enrolled during the postpartum period onto an urban public hospital. Dependent variables were attitudes and resources related to shared reading with infants. Independent variables were family sociodemographics, reading difficulties, and social risks.

RESULTS

A total of 211 mother-newborn dyads were assessed; 23.7% reported not planning to look at books together until 12 months or later, 42.2% reported no baby books in the home, and 19.9% reported concerns about shared reading. In multiple logistic regression analyses, independent significant associations with not planning to share books together in infancy were lower maternal education, not speaking English, and firstborn. Independent significant associations of not having baby books were not speaking English, firstborn, and perceived difficulty reading in their native language.

CONCLUSIONS

Many at-risk mothers of newborn babies do not report plans to read in infancy and do not have appropriate books in the home. Consideration should be given to universal provision of early anticipatory guidance addressing shared reading, either during the postpartum period or during initial well-child care visits.

Imaging of sports injuries in children and adolescents

Sports injuries may be unique in childhood and adolescence due to the inherent weakness of the growing skeleton at specific sites, mainly the cartilaginous parts. Many injuries are predictable based on the known mechanism of injury encountered in certain sports. There are two distinct patterns of injury in sports; acute, and chronic or overuse. Imaging plays an important role in the diagnosis and management of these entities. Radiologists should be familiar with the advantages and limitations of the various imaging modalities when evaluating the injured young athlete. The present review focuses on the radiological findings and appropriate imaging approach in injuries that are typically or most commonly encountered in the skeletally immature athletes.

The Definition and Classification of Dry Eye Disease: Report of the Definition and Classification Subcommittee of the International Dry Eye Workshop (2007)

The aim of the DEWS Definition and Classification Subcommittee was to provide a contemporary definition of dry eye disease, supported within a comprehensive classification framework. A new definition of dry eye was developed to reflect current understanding of the disease, and the committee recommended a three-part classification system. The first part is etiopathogenic and illustrates the multiple causes of dry eye. The second is mechanistic and shows how each cause of dry eye may act through a common pathway. It is stressed that any form of dry eye can interact with and exacerbate other forms of dry eye, as part of a vicious circle. Finally, a scheme is presented, based on the severity of the dry eye disease, which is expected to provide a rational basis for therapy. These guidelines are not intended to override the clinical assessment and judgment of an expert clinician in individual cases, but they should prove helpful in the conduct of clinical practice and research.

Development of the Massachusetts School Nurse Research Network (MASNRN): A Practice-Based Research Network to Improve the Quality of School Nursing Practice

When school nurses embrace evidence-based practice (EBP), higher-quality care is provided to students, their families, and the larger community. Despite this, school nursing has been slow to embrace EBP. Practice-Based Research Networks (PBRNs), which capitalize on the combined strengths of clinicians and researchers to study clinical questions, are one approach to overcoming barriers towards advancing evidence-based practice (EBP) in school nursing. This article will briefly review EBP and PBRNs. The development of Massachusetts School Nurse Research Network (MASNRN), a PBRN designed to investigate health issues common across schools and to validate school nursing practice, will then be described. Details regarding MASNRN’s mission, governance, communications systems, staffing, and network maintenance and funding will be explicated. MASNRN can serve as a model for PBRN development within the broader school nursing community.

Drug use among juveniles in conflict with the law

OBJECTIVE

To study the pattern of drug use, reasons for initiation and the perception about the effects of using drugs, among juveniles in conflict with law.

METHODS

A qualitative study was conducted at Prayas Observation Home for boys, New Delhi. Eight key informant interviews were conducted to find the prevalence of prior drug use among boys. Five focus group discussions were conducted with 34 children using a topic outline guide.

RESULTS

The study showed that drug use was related to other criminal activities. Peer group and media were the most important influences for initiation of drug use. All kinds of drugs could easily be procured by children and there was a gradual progression from non-use to tobacco and alcohol use, to marijuana and ultimately to other drugs. Knowledge about medical and social mal-effects of consuming drugs did not seem to effect either the consumption of drugs or the desire to leave this habit.

CONCLUSION

Results of the study demonstrate an urgent need for taking stringent measures in order to curb drug use among adolescents.

Congenital nephrotic syndrome

When presented with an edematous infant who may be experiencing a severe infection, particularly an unusual one, it is important to include nephrotic syndrome in the differential diagnosis. Because drastic measures may be required to manage this illness, it is important to be able to recognize symptoms, compile needed diagnostic data, and commence appropriate treatment. A referred pediatric nephrologist can aid in diagnosis, direct management, and educate and support parents. The nephrologist is also instrumental in guiding ongoing care and preparing the infant for transplantation when it becomes necessary.

Using action research to change health-promoting practice

Action research was used as a method to develop an educational skills training program focusing on the health education aspect of nurses' health-promoting role. The program was based on the theoretical concepts of the Transtheoretical Model and Motivational Interviewing. Interviews were used to collect the data on a purposive sample of nurses working in an acute hospital ward. Three main themes were identified: using the skills, barriers to implementing the skills, and facilitators of implementing the skills. Most nurses were more aware of health education and health promotion and were able to incorporate the skills learnt and instigated a change in practice. There was evidence, however, that further training was required. This might focus more on helping nurses to use the skills with patients who are very resistant to change and to better recognize health-promoting opportunities. Ways of offering the training program to other health professionals also should be explored.

Acute lymphoblastic leukemia in children: correlation of musculoskeletal manifestations and immunophenotypes

PURPOSE

Studies on musculoskeletal manifestations (MSM) of childhood acute lymphoblastic leukemia (ALL) have yielded variable findings with regard to their clinical impact. We investigated the significance for differential diagnosis, treatment and outcome of musculoskeletal complaints as presenting symptoms of ALL, and their correlation with leukemia immunophenotypes, for which data is lacking.

METHODS

Data on 783 children in the national study for childhood ALL between 1984 and 2003 were reviewed retrospectively. Statistical analysis examined possible relationships between MSM at the time of diagnosis and demographic and clinical data, biological features of leukemia (peripheral blood counts, immunophenotype and main cytogenetic aberration), response to initial prednisone treatment, and outcome.

RESULTS

Of 765 children with data on orthopaedic complaints, 240 presented with MSM (31.4%). Among these children, B cell precursor (BCP) was much more common (209/576, 36.3%) than T cell ALL (25/176, 14.2%). Patients with MSM had lower white blood cell counts (WBC) (median of 9 vs. 20 x 10(9)/L, P < 0.001) and percentage of blast cells in the peripheral blood at diagnosis compared to those without (median of 27 vs. 53%, P < 0.001). Hepatomegaly and splenomegaly were less common in MSM group (67 vs. 53% <3 cm, P < 0.001, and 63 vs. 50% <3 cm, P < 0.001, respectively). Poor response to initial treatment with prednisone was recorded in 7.1% of patients with MSM versus 11.5% of those without (P = 0.086). The analysis revealed no independent effect of MSM on event-free survival (EFS), after correcting for differences in EFS related to immunophenotype or initial WBC.

CONCLUSIONS

MSM occur mostly in children with BCP ALL who present with less involvement of extramedullary organs, low peripheral blood blasts and white blood cells counts. These findings highlight the importance of including ALL in the differential diagnosis of MSM even in the presence of an apparently normal peripheral blood count. Our study also suggests that MSM are caused by leukemic cells with enhanced biological propensity to remain relatively confined within the intramedullary bone-marrow space.

Has blood pressure increased in children in response to the obesity epidemic?

The associations between elevated blood pressure and overweight, on one hand, and the increasing prevalence over time of pediatric overweight, on the other hand, suggest that the prevalence of elevated blood pressure could have increased in children over the last few decades. In this article we review the epidemiologic evidence available on the prevalence of elevated blood pressure in children and trends over time. On the basis of the few large population-based surveys available, the prevalence of elevated blood pressure is fairly high in several populations, whereas there is little direct evidence that blood pressure has increased during the past few decades despite the concomitant epidemic of pediatric overweight. However, a definite conclusion cannot be drawn yet because of the paucity of epidemiologic studies that have assessed blood pressure trends in the same populations and the lack of standardized methods used for the measurement of blood pressure and the definition of elevated blood pressure in children. Additional studies should examine if favorable secular trends in other determinants of blood pressure (eg, dietary factors, birth weight, etc) may have attenuated the apparently limited impact of the epidemic of overweight on blood pressure in children.

Motivational interviewing: improving patient education

Many health care conditions require behavior change by the patient or parent to improve health outcomes. Poor outcomes may be attributed to the lack of adherence to the behavior change recommendations. A shift from the authoritarian, expert providing advice to a more family-centered, collaborative model using motivational interviewing (MI) results in improved adherence. The principles of MI are exploring ambivalence, reflective listening, reinforcing positive behavior, and rolling with resistance. The process for MI is establishing relationships; setting an agenda; assessing importance, confidence, and readiness; exploring importance; and helping families select an action plan and building confidence in their ability to change.

Where do teenagers and young adults receive treatment for cancer?

BACKGROUND

Little is known about where teenagers and young adults receive their first cancer treatment.

METHOD

We extracted data on 2260 residents of southeast England diagnosed with a malignant neoplasm aged 10-24 between 1998 and 2002 from the Thames Cancer Registry database. We identified 11 cancer network areas of residence, and the hospital and network where each patient received their first chemotherapy treatment. We classified hospitals as those including paediatric oncology centres, cancer centres with a teenage cancer unit or adult cancer centres or units. We examined how many patients in each of the age groups 10-14, 15-19 and 20-24 travelled outside their network of residence for chemotherapy.

RESULTS

Overall 45% (1018) received chemotherapy. Three networks had paediatric oncology centres, and one also had a teenage cancer unit. Most 10-14-year-olds were referred from their network of residence to networks with these services. However, there was an increasing tendency for patients aged 15-19 and 20-24 to be treated within their network of residence and to be referred less commonly.

CONCLUSIONS

Many young people with cancer are not referred to services providing care tailored to the needs of their age group. The absence of any pattern to referral, despite the presence of a teenage cancer unit in the area, suggests a lack of coordinated referral practice within and between cancer networks.

Sleepless in America: inadequate sleep and relationships to health and well-being of our nation's children

OBJECTIVE

Our goal was to identify characteristics associated with inadequate sleep for a national random sample of elementary school-aged children (6-11 years) and adolescents (12-17 years).

METHODS

Data from 68418 participants in the 2003 National Survey of Children's Health were analyzed by using weighted bivariate and multivariate regression models. The dependent variable was report of not getting enough sleep for a child of his or her age >or=1 night of the past week. Independent variables included demographic characteristics, child health, school and other activities, and family life.

RESULTS

Parents of elementary school-aged children with inadequate sleep were more likely to report that their child was having problems at school or had a father with fair or poor health. Parents of adolescents with inadequate sleep were more likely to report that their child had an atopic condition, frequent or severe headaches, a parent with less-than-excellent emotional health, or experienced frequent parental anger. Inadequate sleep in both age groups was associated with parental report that their child usually or always displayed depressive symptomatology, family disagreements involved heated arguing, or parental concern that the child was not always safe at home, at school, or in their neighborhood.

CONCLUSIONS

Approximately 15 million American children are affected by inadequate sleep. Primary care providers should routinely identify and address inadequate sleep and its associated health, school, and family factors.

Dental caries

Dental caries, otherwise known as tooth decay, is one of the most prevalent chronic diseases of people worldwide; individuals are susceptible to this disease throughout their lifetime. Dental caries forms through a complex interaction over time between acid-producing bacteria and fermentable carbohydrate, and many host factors including teeth and saliva. The disease develops in both the crowns and roots of teeth, and it can arise in early childhood as an aggressive tooth decay that affects the primary teeth of infants and toddlers. Risk for caries includes physical, biological, environmental, behavioural, and lifestyle-related factors such as high numbers of cariogenic bacteria, inadequate salivary flow, insufficient fluoride exposure, poor oral hygiene, inappropriate methods of feeding infants, and poverty. The approach to primary prevention should be based on common risk factors. Secondary prevention and treatment should focus on management of the caries process over time for individual patients, with a minimally invasive, tissue-preserving approach.

Identification of overweight status is associated with higher rates of screening for comorbidities of overweight in pediatric primary care practice

OBJECTIVES

The goals were to determine whether primary care provider identification of children as overweight was associated with additional screening or referrals and whether the types and numbers of visits to primary care differed for overweight and nonoverweight children.

METHODS

Sequential parents/guardians at 13 diverse pediatric practices completed an in-office survey addressing health habits and demographic features. Medical records of each child from a sample of families were reviewed. Data were abstracted from the first visit and from all visits in the 14-month period before study enrollment. Analyses were limited to children > or = 2 years of age for whom BMI percentile could be calculated.

RESULTS

The analytic sample included 1216 children (mean age: 7.9 years; 51% male) from 777 families (parents were 43% white, 18% black, 34% Hispanic, and 5% other; 49% of families had a child receiving Medicaid/uninsured). Among overweight children (BMI of > or = 95th percentile; n = 248), 28% had been identified as such in the record. Screening or referral for evaluation of comorbidities was more likely among overweight children who were identified in the record (54%) than among overweight children who were not identified (17%). Among children at risk of overweight (BMI of 85th to 94th percentile; n = 186), 5% had been identified as such in the record and overall 15% were screened/referred. In logistic regression modeling, the children identified as overweight/at risk of overweight had 6 times greater odds of receiving any management for overweight.

CONCLUSIONS

Low rates of identification of overweight status and evaluation or referrals for comorbidities were found. Identification of overweight status was associated with a greatly increased rate of screening for comorbidities.

Advances in the diagnosis and treatment of osteoporosis

Although severely low bone density is relatively rare in the pediatric population, it can be a significant problem in many patients with chronic illness. As peak bone formation occurs during adolescence, it is crucial that pediatricians and other care providers for this patient population recognize the significance of attainment of adequate bone. Dietary intake of vitamin D and calcium should be optimized, and correction of underlying causes of poor bone density should occur whenever possible. Assessment of bone density is difficult, as each technology available has problems, and none of the technologies are well-associated with fracture risk in pediatric patients. Once diagnosis of severely low bone density is established, treatment options are limited and poorly studied. The benefits of bisphosphonate therapy appear to outweigh the risks in patients with low bone density and frequent fragility fractures, and it appears that most improvement with bisphosphonates occurs within the first 2 to 4 years. Evidence, however, is emerging that once off therapy, bone turnover remains decreased for at least several years. During that time, improvements in bone density are decreased. Many questions remain regarding duration of therapy with bisphosphonate therapy and the long-term effects on the children who receive this medication. Anabolic therapies may become important in the future, but there is currently extremely limited information regarding their use in pediatrics.

Fostering ecologic perspectives in child psychiatry

In this article, the authors seek to instill a readiness and enthusiasm for appreciating the many-faceted influences in the lives and struggles of developing children and their families. A framework for clinical investigation is proposed that draws from ecologic, ethnographic and attributional perspectives and therein augments and extends contemporary notions of culturally competent care. This framework can be used to help illuminate the culturally-relevant geography of the child's world such as: 1) health care and social welfare zones, 2) child activity zones, and 3) cultural and religious spheres of influence. Training tools and strategies are offered for building insightful, respectful and convivial co-investigator partnerships with patients and their families.

Weighing in on the issues of type 2 diabetes in children: a review

PURPOSE

The purpose of this review is to present the clinical issues, including risk, etiology, screening and identification, complications, management, and prevention of type 2 diabetes mellitus (T2DM) in children and to discuss the role of the pediatric physical therapist in effectively managing children with T2DM.

SUMMARY OF KEY POINTS

In studies done worldwide, T2DM is being diagnosed in children at rates much greater than that of type 1 diabetes. Sedentary lifestyle and the high prevalence of obesity are the primary problems, setting the stage for a lifetime of health complications for many of today's youth.

RECOMMENDATIONS

Health care providers must understand this disease to ensure proper management. A multidisciplinary approach is advocated for those children who are at risk for and diagnosed with T2DM to help prevent the disabling and often incapacitating complications associated with T2DM.

Acute myeloid leukemia: epidemiology and etiology

Acute myeloid leukemias (AMLs) are infrequent, yet highly malignant neoplasms responsible for a large number of cancer-related deaths. The incidence has been near stable over the last years. It continuously shows 2 peaks in occurrence in early childhood and later adulthood. With an incidence of 3.7 per 100,000 persons and an age-dependent mortality of 2.7 to nearly 18 per 100,000 persons, there is a rising awareness in the Western world of AML's special attributes resulting from an ever-aging population. To objectively describe epidemiologic data on this patient population, recent publications were evaluated to make transparent the current trends and facts. A review of the literature is presented, reflecting highlights of current research with respect to AML etiology. To estimate outcome and discuss informed treatment decisions with AML patients of different age groups and different biologic risk categories, it is mandatory to consider that the outcome results reported in clinical trials were until now heavily biased toward younger patients, whereas the overall dismal prognosis documented in population-based studies most likely reflects the exclusion of older patients from aggressive treatment. The etiology for most cases of AML is unclear, but a growing knowledge concerning leukemogenenic agents within chemotherapy regimens for other malignancies is already available. This includes specific associations of the most frequent balanced translocations in AML, including the "good-risk" abnormalities comprised by the core binding factor leukemias (i.e., AML with the translocation (8;21) and inversion of chromosome 16, and acute promyelocytic leukemia with the translocation (15;17)). In contrast to these genetic alterations, epigenetic lesions, e.g., promoter silencing by hypermethylation of the p15/INK4b and other genes, are increasingly recognized as important in the pathogenesis of AML.

Bone mineral density in children with sickle cell anemia

PURPOSE

We evaluated bone mineral density (BMD) and risk factors for poor bone mineralization in children with sickle cell anemia (SCA).

PATIENTS AND METHODS

Twenty-five children with severe manifestations of SCA (frequent hospitalizations, growth delay, or need for chronic red cell transfusions) were enrolled. Bone density was assessed at lumbar spine and proximal femur with dual-energy X-ray absorptiometry (DXA), and Z-scores were calculated by comparison with age, sex, and ethnicity-specific reference data.

RESULTS

The median age of the study population was 12.8 years (10.2-19.8 years). Calcium intake was inadequate in 60%, and serum 25-hydroxy vitamin D (25-OHD) level <50 nM in 74% of patients. Median Z-scores for lumbar spine (-2.3) and proximal femur (-1.7) were markedly reduced, and 64% (95% confidence interval, 43%-82%) of patients had low bone density. Z-scores were not related to age, growth delay, chronic transfusions, or ferritin level.

CONCLUSION

Our results suggest that children with severe manifestations of SCA have low BMD, and possess significant deficits in dietary calcium and circulating vitamin D.

Paroxysmal nonepileptic events of childhood

The paroxysmal nonepileptic events of childhood are a group of disorders, syndromes, and phenomena that mimic true epileptic seizures. Clinical experience and a clear description of the event in question will usually lead to a correct categorization. They span in age from neonate to young adult and are apt to be the most common diagnostic challenges clinicians face regularly. The key to diagnosis is a detailed history and careful observation. Despite the large number of discrete entities enumerated herein, common principles in clinical approach are successful and described. Each entity can pose a significant clinical challenge in identification, etiologic pathophysiology, genetics, and management. A simple division is offered here separating those episodes that are associated with an altered mental status or occurring during sleep and those without an altered mental status or occurring while awake.

Children, adolescents, and advertising

Advertising is a pervasive influence on children and adolescents. Young people view more than 40,000 ads per year on television alone and increasingly are being exposed to advertising on the Internet, in magazines, and in schools. This exposure may contribute significantly to childhood and adolescent obesity, poor nutrition, and cigarette and alcohol use. Media education has been shown to be effective in mitigating some of the negative effects of advertising on children and adolescents.

Family and home correlates of television viewing in 12-13 year old adolescents: the Nepean Study

BACKGROUND

Few young people meet television viewing guidelines.

PURPOSE

To determine the association between factors in the family and home environment and watching television, including videos and DVDs, in early adolescence.

METHODS

Cross-sectional, self-report survey of 343 adolescents aged 12-13 years (173 girls), and their parents (338 mothers, 293 fathers). Main measures were factors in the family and home environment potentially associated with adolescents spending >or= 2 hours per day in front of the television. Factors examined included family structure, opportunities to watch television/video/DVDs, perceptions of rules and regulations on television viewing, and television viewing practices.

RESULTS

Two-thirds of adolescents watched >or= 2 hours television per day. Factors in the family and home environment associated with adolescents watching television >or= 2 hours per day include adolescents who have siblings (Adjusted Odds Ratio [95%CI] AOR = 3.0 [1.2, 7.8]); access to pay television (AOR = 2.0 [1.1, 3.7]); ate snacks while watching television (AOR = 3.1 [1.8, 5.4]); co-viewed television with parents (AOR = 2.3 [1.3, 4.2]); and had mothers who watched >or= 2 hours television per day (AOR = 2.4 [1.3, 4.6]).

CONCLUSION

There are factors in the family and home environment that influence the volume of television viewed by 12-13 year olds. Television plays a central role in the family environment, potentially providing a means of recreation among families of young adolescents for little cost. Interventions which target family television viewing practices and those of parents, in particular, are more likely to be effective than interventions which directly target adolescent viewing times.

Cardiovascular disease risk in youth with diabetes mellitus

In the United States, cardiovascular disease is the leading cause of mortality in adults with diabetes over age 30 years. Studies in persons without diabetes have shown that atherosclerosis, a central factor in cardiovascular disease, begins in childhood and the presence of cardiovascular disease risk factors in youth lead to increased cardiovascular disease risk in adults. Therefore, youth with diabetes are at increased risk for developing cardiovascular disease as adults and there is a role for risk factor screening and addressing modifiable factors to lower cardiovascular disease risk starting in childhood. This paper reviews the literature on traditional cardiovascular disease risk factors in youth with diabetes including hyperglycemia, hypertension, dyslipidemia, smoking, obesity and family history of cardiovascular disease with an emphasis on type 1 diabetes as well as current American Diabetes Association guidelines for screening and treatment of modifiable risk factors. Current roles of inflammatory markers and measures of subclinical vascular changes such as arterial stiffness are also discussed.

Role of glutamine depletion in directing tissue-specific nutrient stress responses to L-asparaginase

L-asparaginase is important in the induction regimen for treating acute lymphoblastic leukemia. Cytotoxic complications are clinically significant problems lacking mechanistic insight. To reveal tissue-specific molecular responses to this drug, mice were administered asparaginase from either Escherichia coli (clinically used) or Wolinella succinogenes (novel, glutaminase-free form). Both enzymes abolished serum asparagine, but only the E. coli form reduced circulating glutamine. E. coli asparaginase reduced protein synthesis in liver and spleen but not pancreas via increased phosphorylation of the translation factor eIF2. In contrast, treatment with Wolinella caused no untoward changes in protein synthesis in any tissue examined. Treating mice deleted for the eIF2 kinase, GCN2, with the E. coli enzyme showed eIF2 phosphorylation to be GCN2-dependent, but only initially. Furthermore, although eIF2 phosphorylation was not increased in the pancreas or by Wolinella asparaginase, expression of the amino acid stress response genes, asparagine synthetase and CHOP/GADD153, increased as a result of both enzymes, even in tissues demonstrating no change in eIF2 phosphorylation. Finally, signaling downstream of the mammalian target of rapamycin kinase was repressed in liver and pancreas by E. coli but not Wolinella asparaginase. These data demonstrate that the nutrient stress response to asparaginase is tissue-specific and exacerbated by glutamine depletion. Importantly, increased expression of asparagine synthetase and CHOP does not require eIF2 phosphorylation, signifying alternate or auxiliary means of inducing gene expression under conditions of amino acid depletion in the whole animal.

Relationships of age and gender to hope and spiritual well-being among adolescents with cancer

The purpose of this study was to examine hope and spiritual well-being, with its 2 dimensions of religious well-being and existential well-being, as they relate to age and gender among adolescents with cancer. A cross-sectional design was guided by the conceptual framework, Adolescent Psychosocial Adaptation to the Cancer Experience. A total of 78 adolescents with a diagnosis of cancer were enrolled from 2 pediatric oncology clinics. Middle adolescents (15-17 years of age) reported higher religious well-being than late adolescents (18-20 years of age). Middle-adolescent boys were more hopeful than were early adolescent boys (13- 14 years of age). Also, girls were more hopeful and reported higher spiritual well-being than age the boys. Developmental phase and/or gender may influence adolescents' levels of hope, spiritual well-being, religious well-being, and existential well-being as they cope during the cancer experience. The nurse should consider developmental phase and gender when planning interventions to foster hope and spiritual well-being in adolescents' adaptations to the cancer experience.