Pain, depressive symptoms, and health-related quality of life among survivors of pediatric hematopoietic stem cell transplant

OBJECTIVE

Pediatric hematopoietic stem cell transplant (HCT) is an intensive medical procedure associated with significant late effects, of which pain is a prominent example. While pain is associated with increased depressive symptoms and health-related quality-of-life (HRQoL) impairments in other pediatric chronic illness populations, associations between these variables are not well understood in pediatric HCT. Clarifying these associations may inform clinical interventions to improve health outcomes following pediatric HCT. This study aimed to investigate the relations between pain intensity, depressive symptoms, and HRQoL in survivors of pediatric HCT.

METHOD

Fifty-one survivors of pediatric HCT (Mage  = 14.3 years, standard deviation [SD] = 4.3; 58.8% male; 80.4% White) completed self-report measures of pain intensity, depressive symptoms, and HRQoL. Demographic and disease information was collected via demographic forms and medical record review. Path analysis was used to examine hypothesized associations between pain intensity, depressive symptoms, and HRQoL.

RESULTS

Analyses revealed direct effects of pain intensity on depressive symptoms (estimate [Est.] = .23, p < .001) and HRQoL (Est. = -.2, p = .04), and direct effects of depressive symptoms on HRQoL (Est. = -.68, p < .001). Depressive symptoms also mediated the relationship between pain intensity and HRQoL (Est. = -.16, p = .006).

CONCLUSIONS

Greater pain intensity was associated directly with increased depressive symptoms and indirectly with HRQoL through depressive symptoms. Results of this study suggest that multitargeted cognitive behavioral interventions that address pain and depressive symptoms may improve HRQoL ratings in survivors of pediatric HCT.

Symptoms of Survivors of Pediatric Hematopoietic Stem Cell Transplant by Age, Sex, and Transplant Type

Purpose: The purpose of this study was to describe symptoms experienced by survivors of pediatric hematopoietic stem cell transplant (HSCT), and demographic and treatment-factors associated with ongoing symptomology. Methods: Fifty pediatric survivors completed a cross-sectional pilot study. Questionnaires were administered online via REDCap to assess symptoms experienced in the last week. Survivors also consented to a medical record chart review. Results: Survivors were on average 5.4 years post-HSCT (range 1.1 to 9 years), male (58%), and Caucasian (80%) who received an allogeneic HSCT (92%). The most commonly reported symptoms were difficulty concentrating (42.5%), pain (38%), worry (38%), nervousness (37.5%), and lack of energy/fatigue (34%). Survivors reported up to 14 symptoms, with 90% of the sample experiencing at least one symptom in the previous week. Average number of symptoms varied by age group between 2.1 (8-9 years) and 6.8 (18 and older). Age and female gender were associated with higher levels of fatigue. Conclusions: The majority of survivors experienced at least one symptom in the previous week. Neuropsychological symptoms and pain endure well into survivorship that can influence outcomes such as function and health-related quality of life (HRQOL). Research is needed on biological mechanisms of ongoing symptomology, effective interventions to prevent or mitigate symptoms, and the impact of symptoms on patient outcomes including daily functioning and HRQOL. Implications Survivors of pediatric HSCT continued to experience symptoms for up to nine years. Survivors should be frequently screened for symptoms, as symptoms may affect function, learning/employment outcomes, and HRQOL.

Token economy to improve adherence to activities of daily living

BACKGROUND

Participation in key activities of daily living (ADL), including daily bathing, physical activity, and oral hygiene, can decrease the risk of bloodstream infections, oral complications, and deconditioning in pediatric patients undergoing hematopoietic stem cell transplant (HSCT). However, many patients fail to perform ADL during their inpatient stay. To improve inpatient adherence to ADL, we tested a token economy to engage patients, families, and the clinical team in improving adherence to these important health behaviors during this critical time.

METHODS

We used a controlled before-after study design to test our hypothesis. All patients were prescribed three ADL. We used an "all or none" measurement for each component of the ADL 1-2-3 initiative to measure adherence. HSCT patients with poor ADL adherence (<20%) were eligible to receive the intervention, which consisted of rewarding patients through an ADL via a token economy.

RESULTS

Twenty-one patients participated in the study. ADL adherence for the 14 days prior to intervention in study subjects (n = 294 inpatient days) averaged 0.51 ADL per day (95% CI 0.45-0.57). In the 14 days postinitiation of the token economy intervention (n = 294 inpatient days), the average adherence was 2.5 ADL per day (95% CI 2.4-2.5; P = <0.001).

DISCUSSION

Positive reinforcement through a token economy system is associated with improved adherence to ADL in hospitalized pediatric patients who demonstrated poor ADL adherence at baseline. We believe this intervention can positively impact adherence to targeted health behaviors with the ability to correlate with improved health outcomes.

Health care provider-delivered adherence promotion interventions: a meta-analysis

BACKGROUND AND OBJECTIVE

Improving medical regimen adherence is essential for maximizing the therapeutic potential of treatments for pediatric chronic illness. Health care providers are uniquely positioned to deliver adherence promotion interventions. However, no studies have summarized the effectiveness of health care provider-delivered adherence interventions. The objective of this study was to describe the effectiveness of health care provider-delivered adherence promotion interventions in improving adherence among children who have chronic illness. Data sources include PubMed, PsycINFO, CINAHL, and Scopus. Studies were included if they were randomized-controlled trials of pediatric interventions aiming to increase adherence to the primary regimen for a chronic illness and at least 1 health care provider delivered the intervention.

RESULTS

A total of 35 randomized-controlled studies including 4616 children were included. Greater improvements in adherence were observed immediately after health care provider-delivered interventions (d = 0.49; 95% confidence interval, 0.32 to 0.66) than at longer-term follow-up (d = 0.32; 95% confidence interval, 0.10 to 0.54). Treatment effect sizes differed across the adherence behaviors measured. There was significant heterogeneity in treatment effects; however, no moderators of treatment effectiveness were identified. This meta-analysis focused on the published literature. In addition, the majority of studies involved children who had asthma and younger children.

CONCLUSIONS

Health care provider-delivered interventions for children who have chronic illness can be effective in improving adherence. Gains in adherence are highest immediately after intervention. Future interventions and studies should include multiple methods of assessing adherence, include active comparators, and address long-term maintenance of adherence gains.

Acute stress in parents of children newly diagnosed with cancer

OBJECTIVE

Acute Stress Disorder (ASD) and subclinical symptoms of acute stress (SAS) may be a useful framework for understanding the psychological reactions of mothers and fathers of children newly diagnosed with a pediatric malignancy.

PATIENTS AND METHODS

Mothers (N = 129) and fathers (N = 72) of 138 children newly diagnosed with cancer completed questionnaires assessing acute distress, anxiety, and family functioning. Demographic data were also gathered. Inclusion criteria were: a confirmed diagnosis of a pediatric malignancy in a child under the age of 18 years without prior chronic or life threatening illness and fluency in English or Spanish.

RESULTS

Descriptive statistics and multiple linear regressions were used to examine predictors of SAS. Fifty-one percent (N = 66) of mothers and 40% (N = 29) of fathers met DSM-IV diagnostic criteria for ASD. The majority of the sample reported experiencing at least one SAS. General anxiety, but not family functioning, was a strong predictor of SAS in both mothers and fathers even after controlling for demographic characteristics.

CONCLUSIONS

Immediately following their child's diagnosis of cancer, most mothers and fathers experience SAS, with a subsample meeting criteria for ASD. More anxious parents are at heightened risk of more intense reactions. The findings support the need for evidence-based psychosocial support at diagnosis and throughout treatment for families who are at risk for acute distress reactions.

Innate immune markers in mothers and fathers of children newly diagnosed with cancer

OBJECTIVE

The diagnosis of a life-threatening illness in a child is one of the most stressful events imaginable for parents and is associated with increased anxiety and distress. Despite associations between stress and immune function in animal and human models, the immune function in caregivers of children at the time of a child-related potentially traumatic event, like cancer, is not known.

METHODS

Nineteen parents (11 mothers, 8 fathers), representing six caregiver pairs, provided blood for natural killer (NK) cell count by flow cytometry and function assays [% NK whole blood, absolute NK whole blood, LU(20) (lytic unit) peripheral blood mononuclear cells, LU(20) NK cells] and completed self-report measures (acute stress) within 2 weeks of learning their child had cancer. The NK cell assay was also completed with a sample of healthy adults, the immune reference group.

RESULTS

There were similar levels of NK cell activity between caregivers and the immune reference group. Immune level and psychological outcomes were not associated. LU(20) peripheral blood mononuclear cells and LU(20) NK cells were each correlated at r = 0.83 between mothers and fathers in the same family.

CONCLUSIONS

Although based on a small sample, these preliminary results suggest that knowledge about stress responses in parents of children with life-threatening illness may be important and provide novel data regarding the shared impact of stress on immune function within caregiver dyads.

Comparison of single and biplane ejection fractions in patients with Ischaemic heart disease

Simultaneous biplane left ventriculography was performed in 59 patients with ischaemic heart disease. A comparison was made of the frontal (EFF), lateral (EFL), and biplane (EFB) ejection fractions. Discrepancies between the three measurements in the same patient were frequent observed. The patients were then grouped according to the presence or absence of signs of transmural myocardial infarction in the electrocardiogram or wall motion abnormalities, and the single and biplane EF data were again compared. There were 31 patients with previous transmural myocardial infarction and 37 patients with wall motion abnormalities, usually involving the anterior or inferior walls. The EFL of patients with transmural myocardial infarction or wall motion abnormalities commonly exceeded the EEF, because of frequent preservation of dorsal wall contraction visualized only in the lateral plane. Consequently, there was a significant difference between EFF or EFL and EFB for these patients. In contrast, there was close agreement EEF and EFL for patients without transmural myocardial infarction or wall motion abnormalities. It is concluded that differences frequently occur between single and biplane EF in patients with ischaemic heart disease, especially if transmural myocardial infarction or wall motion abnormalities are present. Hence, accurate assessment of left ventricular performance is greatly facilitated by simultaneous or sequential biplane ventriculography.