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van Hulst AM, Verwaaijen EJ, van den Berg SAA, van Litsenburg RRL, Grootenhuis MA, Fiocco M, Neggers SJCMM, van den Heuvel-Eibrink MM, van den Akker ELT. Leptin Increase During Dexamethasone and Its Association With Hunger and Fat in Pediatric Acute Lymphoblastic Leukemia. J Clin Endocrinol Metab 2024; 109:631-640. [PMID: 37878899 PMCID: PMC10876409 DOI: 10.1210/clinem/dgad621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 10/13/2023] [Accepted: 10/17/2023] [Indexed: 10/27/2023]
Abstract
CONTEXT During treatment, children with acute lymphoblastic leukemia (ALL) receive high doses dexamethasone, which induce acute side effects. OBJECTIVE To determine the influence of a 5-day dexamethasone course on changes in leptin, fat mass, BMI, hunger, sleep, and fatigue and to explore associations between these changes. METHODS Pediatric ALL patients were included during maintenance treatment. Data were collected before (T1) and after (T2) a 5-day dexamethasone course (6 mg/m2/day). At both time points, BMI, fat mass (bioelectrical impedance analysis), and leptin were assessed, as well as parent-reported questionnaires regarding hunger, fatigue, and sleep problems. Changes between T1 and T2 were assessed using paired tests. Correlation coefficients were calculated to assess associations between these changes (Delta scores: T2-T1). Univariable regression models were estimated to study associations between covariates and elevated leptin. RESULTS We included 105 children, with median age 5.4 years (range, 3.0-18.8). Leptin and fat mass, as well as hunger scores, fatigue, and sleep deteriorated after 5 days of dexamethasone (P < .001), in contrast to BMI (P = .12). No correlations between delta leptin and delta fat mass, BMI, hunger, fatigue, or sleep were found. Elevated leptin on T1 was associated with older age (odds ratio [OR] 1.51; 95% CI, 1.28-1.77), higher fat mass (OR 1.19; 95% CI, 1.07-1.33), and earlier maintenance week (OR 0.96; 95% CI, 0.92-0.99). CONCLUSION Five days of high-dose dexamethasone treatment led to direct and significant changes in leptin, hunger scores, and fat mass. Since children with ALL are at increased risk for metabolic adverse events, understanding underlying mechanisms is important, and a dexamethasone-induced state of acute leptin resistance might play a role.
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Affiliation(s)
| | - Emma J Verwaaijen
- Pediatric Oncology, Princess Máxima Center, 3584 CS Utrecht, The Netherlands
| | - Sjoerd A A van den Berg
- Department of Internal Medicine, Division of Endocrinology, Erasmus Medical Center, 3015 GD Rotterdam, The Netherlands
| | | | | | - Marta Fiocco
- Pediatric Oncology, Princess Máxima Center, 3584 CS Utrecht, The Netherlands
- Leiden University Mathematical Institute, 2333 CA Leiden, The Netherlands
- Department of Biomedical Data Science, Medical Statistics, Leiden University Medical Centre, 2333 ZA Leiden, The Netherlands
| | - Sebastian J C M M Neggers
- Pediatric Oncology, Princess Máxima Center, 3584 CS Utrecht, The Netherlands
- Department of Internal Medicine, Division of Endocrinology, Erasmus Medical Center, 3015 GD Rotterdam, The Netherlands
| | - Marry M van den Heuvel-Eibrink
- Pediatric Oncology, Princess Máxima Center, 3584 CS Utrecht, The Netherlands
- Child Health, UMCU-Wilhelmina Children's Hospital, 3584 EA Utrecht, The Netherlands
| | - Erica L T van den Akker
- Department of Pediatric Endocrinology, Erasmus MC- Sophia Children's Hospital, 3015 CN Rotterdam, The Netherlands
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Verwaaijen EJ, van Hulst AM, Hartman A, Pieters R, Fiocco M, Pluijm SMF, van Litsenburg RRL, Grootenhuis MA, van den Akker ELT, van den Heuvel‐Eibrink MM. Physical frailty deteriorates after a 5-day dexamethasone course in children with acute lymphoblastic leukemia, results of a national prospective study. Cancer Med 2023; 12:22304-22315. [PMID: 38069550 PMCID: PMC10757098 DOI: 10.1002/cam4.6779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 11/08/2023] [Accepted: 11/21/2023] [Indexed: 12/31/2023] Open
Abstract
BACKGROUND Dexamethasone is important in the treatment for pediatric acute lymphoblastic leukemia (ALL) but induces muscle atrophy with negative consequences for muscle mass, muscle strength, and functional abilities. The aim of this study was to establish the effect of a dexamethasone course on sarcopenia and physical frailty in children with ALL, and to explore prognostic factors. METHODS Patients with ALL aged 3-18 years were included during maintenance therapy. Patients had a sarcopenia/frailty assessment on the first day of (T1) and on the day after (T2) a 5-day dexamethasone course. Sarcopenia was defined as low muscle strength in combination with low muscle mass. Prefrailty and frailty were defined as having two or ≥three of the following components, respectively: low muscle mass, low muscle strength, fatigue, slow walking speed, and low physical activity. Chi-squared and paired t-tests were used to assess differences between T1 and T2. Logistic regression models were estimated to explore patient- and therapy-related prognostic factors for frailty on T2. RESULTS We included 105 patients, 61% were boys. Median age was 5.3 years (range: 3-18.8). At T1, sarcopenia, prefrailty, and frailty were observed in respectively 2.8%, 23.5%, and 4.2% of patients. At T2, the amount of patients with frailty had increased to 17.7% (p = 0.002), whereas the number of patients with sarcopenia and prefrailty remained similar. Higher ASMM (odds ratio [OR]: 0.49, 95% CI: 0.28-0.83), stronger handgrip strength (OR: 0.41, 95% CI: 0.22-0.77) and more physical activity minutes per day (OR: 0.98, 95% CI: 0.96-0.99) decreased the risk of frailty at T2. Slower walking performance (OR: 2, 95% CI: 1.2-3.39) increased the risk. Fatigue levels at T1 were not associated with frailty at T2. CONCLUSION Physical frailty increased strikingly after a 5-days dexamethasone course in children with ALL. Children with poor physical state at start of the dexamethasone course were more likely to be frail after the course.
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Affiliation(s)
| | | | - Annelies Hartman
- Department of Pediatric PhysiotherapyErasmus Medical Center‐Sophia Children's HospitalRotterdamThe Netherlands
| | - Rob Pieters
- Princess Máxima Center for Pediatric OncologyUtrechtThe Netherlands
| | - Marta Fiocco
- Princess Máxima Center for Pediatric OncologyUtrechtThe Netherlands
- Mathematical Institute Leiden UniversityLeidenThe Netherlands
- Department of Biomedical Data Science, Section Medical StatisticsLeiden University Medical CenterLeidenThe Netherlands
| | | | | | | | - Erica L. T. van den Akker
- Department of Pediatrics, Division Pediatric Endocrinology, Obesity Center CGGErasmus Medical Center‐Sophia Children's HospitalRotterdamThe Netherlands
| | - Marry M. van den Heuvel‐Eibrink
- Princess Máxima Center for Pediatric OncologyUtrechtThe Netherlands
- Division of Child HealthWilhelmina Children's HospitalUtrechtThe Netherlands
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Verwaaijen EJ, van Hulst AM, Molinger J, Hartman A, Pieters R, Grootenhuis MA, van den Akker EL, van den Heuvel‐Eibrink MM. The utility of a portable muscle ultrasound in the assessment of muscle alterations in children with acute lymphoblastic leukaemia. J Cachexia Sarcopenia Muscle 2023; 14:2216-2225. [PMID: 37562959 PMCID: PMC10570095 DOI: 10.1002/jcsm.13305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 06/18/2023] [Accepted: 07/11/2023] [Indexed: 08/12/2023] Open
Abstract
BACKGROUND During treatment for acute lymphoblastic leukaemia (ALL), children are prone to musculoskeletal deterioration. However, non-invasive tools to measure muscle mass and intramuscular alterations are limited. In this study we explored the feasibility of muscle ultrasound in children with ALL. Additionally, we analysed whether automated ultrasound outcomes of muscle size and intramuscular fat infiltration (IMAT) were associated with appendicular skeletal muscle mass (ASMM), muscle strength and physical performance. METHODS Children with ALL, aged 3-18 years were included during maintenance therapy. Bilateral images of the rectus femoris muscle were captured using a portable linear array transducer connected to a tablet. Subsequently, an automated image annotation software (MuscleSound) was used to estimate cross-sectional area, muscle thickness and IMAT. Feasibility was assessed using acceptance (percentage of children approached who were enrolled), practicality (percentage of children that completed the ultrasound measurement after enrolment) and implementation (percentage of children that had sufficient imaging to be processed and analysed by the software). Assessments of ASMM by bioimpedance analysis, muscle strength using handheld dynamometry and timed physical performance tests were administered at the same visit. Multivariable linear models were estimated to study the associations between muscle ultrasound outcomes and ASMM, strength and physical performance, adjusted for sex, age, body mass index and ALL treatment week. RESULTS Muscle ultrasound was performed in 60 out of 73 invited patients (76.9%), of which 37 were boys (61.7%), and median age was 6.1 years (range: 3-18.8 years). The acceptance was 98.7%, practicality 77.9% and implementation was 100%. Patients who refused the examination (n = 13) were younger (median: 3.6, range: 3-11.2 years) compared with the 60 examined children (P = 0.0009). In multivariable models, cross-sectional area was associated with ASMM (β = 0.49 Z-score, 95% confidence interval [CI]:0.3,2.4), knee-extension strength (β = 16.9 Newton [N], 95% CI: 4.8, 28.9), walking performance (β = -0.46 s, 95% CI: -0.75, -0.18) and rising from the floor (β = -1.07 s, 95% CI: -1.71, -0.42). Muscle thickness was associated with ASMM (β = 0.14 Z-score, 95% CI: 0.04, 0.24), knee-extension strength (β = 4.73 N, 95% CI: 0.99, 8.47), walking performance (β = -0.13 s, 95% CI: -0.22, -0.04) and rising from the floor (β = -0.28 s, 95% CI: -0.48, -0.08). IMAT was associated with knee-extension strength (β = -6.84 N, 95% CI: -12.26, -1.41), walking performance (β = 0.2 s, 95% CI: 0.08, 0.32) and rising from the floor (β = 0.54 s, 95% CI: 0.27, 0.8). None of the muscle ultrasound outcomes was associated with handgrip strength. CONCLUSIONS Portable muscle ultrasound appears a feasible and useful tool to measure muscle size and intramuscular alterations in children with ALL. Validation studies using magnetic resonance imaging (gold standard) are necessary to confirm accuracy in paediatric populations.
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Affiliation(s)
| | | | - Jeroen Molinger
- Department of Anesthesiology, Division of Critical Care, HumanDuke University School of MedicineDurhamNCUSA
- Department of Intensive Care AdultsErasmus Medical CenterRotterdamThe Netherlands
| | - Annelies Hartman
- Department of Pediatric PhysiotherapyErasmus Medical Center‐Sophia Children's HospitalRotterdamThe Netherlands
| | - Rob Pieters
- Princess Máxima Center for Pediatric OncologyUtrechtThe Netherlands
| | | | - Erica L.T. van den Akker
- Department of EndocrinologyErasmus Medical Center‐Sophia Children's HospitalRotterdamThe Netherlands
| | - Marry M. van den Heuvel‐Eibrink
- Princess Máxima Center for Pediatric OncologyUtrechtThe Netherlands
- Division of Child HealthWilhelmina Children's HospitalUtrechtThe Netherlands
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van Hulst AM, van den Akker ELT, Verwaaijen EJ, Fiocco M, Rensen N, van Litsenburg RRL, Pluijm SMF, Zwaan CM, van Santen HM, Pieters R, Evers AWM, Grootenhuis MA, van den Heuvel-Eibrink MM. Hydrocortisone to reduce dexamethasone-induced neurobehavioral side-effects in children with acute lymphoblastic leukaemia-results of a double-blind, randomised controlled trial with cross-over design. Eur J Cancer 2023; 187:124-133. [PMID: 37149961 DOI: 10.1016/j.ejca.2023.03.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 03/29/2023] [Indexed: 05/09/2023]
Abstract
BACKGROUND Dexamethasone is a cornerstone of paediatric acute lymphoblastic leukaemia (ALL) treatment, although it can induce serious side-effects. Our previous study suggests that children who suffer most from neurobehavioural side-effects might benefit from physiological hydrocortisone in addition to dexamethasone treatment. This study aimed to validate this finding. METHODS Our phase three, double-blind, randomised controlled trial with cross-over design included ALL patients (3-18 years) during medium-risk maintenance therapy in a national tertiary hospital between 17th May 2018 and 5th August 2020. A baseline measurement before and after a 5-day dexamethasone course was performed, whereafter 52 patients with clinically relevant neurobehavioural problems were randomised to receive an intervention during four subsequent dexamethasone courses. The intervention consisted of two courses hydrocortisone (physiological dose 10 mg/m2/d in circadian rhythm), followed by two courses placebo, or vice versa. Neurobehavioural problems were assessed before and after each course using the parent-reported Strengths and Difficulties Questionnaire (SDQ) as primary end-point. Secondary end-points were sleep problems, health-related quality of life (HRQoL), hunger feeling, and parental stress, measured with questionnaires and actigraphy. A generalised mixed model was estimated to study the intervention effect. RESULTS The median age was 5.5 years (range 3.0-18.8) and 61.5% were boys. The SDQ filled in by 51 primary caregivers showed no difference between hydrocortisone and placebo in reducing dexamethasone-induced neurobehavioral problems (estimated effect -2.05 (95% confidence interval (CI) -6.00-1.90). Also, no benefit from hydrocortisone compared to placebo was found for reducing sleep problems, hunger, parental stress or improving HRQoL. CONCLUSIONS Hydrocortisone, when compared to placebo, had no additional effect in reducing clinically relevant dexamethasone-induced neurobehavioural problems. Therefore, hydrocortisone is not advised as standard of care for children with ALL who experience dexamethasone-induced neurobehavioural problems. TRIAL REGISTRATION Netherlands Trial Register NTR6695/NL6507 (https://trialsearch.who.int/) and EudraCT 2017-002738-22 (https://eudract.ema.europa.eu/).
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Affiliation(s)
- Annelienke M van Hulst
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS Utrecht, the Netherlands.
| | | | - Emma J Verwaaijen
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS Utrecht, the Netherlands
| | - Marta Fiocco
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS Utrecht, the Netherlands; Mathematical Institute, Leiden University, Rapenburg 70, 2311 EZ Leiden, the Netherlands; Department of Biomedical Data Science, section Medical Statistics, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA Leiden, the Netherlands
| | - Niki Rensen
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS Utrecht, the Netherlands
| | | | - Saskia M F Pluijm
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS Utrecht, the Netherlands
| | - C Michel Zwaan
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS Utrecht, the Netherlands
| | - Hanneke M van Santen
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS Utrecht, the Netherlands; Wilhelmina Children's Hospital, Lundlaan 6, 3584 EA Utrecht, the Netherlands
| | - Rob Pieters
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS Utrecht, the Netherlands
| | - Andrea W M Evers
- Institute of Psychology, Rapenburg 70, 2311 EZ Leiden, the Netherlands
| | - Martha A Grootenhuis
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS Utrecht, the Netherlands
| | - Marry M van den Heuvel-Eibrink
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS Utrecht, the Netherlands; Wilhelmina Children's Hospital, Lundlaan 6, 3584 EA Utrecht, the Netherlands
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5
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van Hulst AM, Grootenhuis MA, Verwaaijen EJ, van Litsenburg RR, Li L, van Zelst BD, Broer L, Pluijm SM, Pieters R, Fiocco M, van den Akker EL, van den Heuvel-Eibrink MM. Unraveling Dexamethasone-Induced Neurobehavioral and Sleep Problems in Children With ALL: Which Determinants Are Important? JCO Precis Oncol 2023; 7:e2200678. [PMID: 37343203 PMCID: PMC10309531 DOI: 10.1200/po.22.00678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 04/14/2023] [Accepted: 04/24/2023] [Indexed: 06/23/2023] Open
Abstract
PURPOSE Dexamethasone, the preferred corticosteroid in most treatment protocols for pediatric acute lymphoblastic leukemia (ALL), can induce undesirable side effects. Neurobehavioral and sleep problems are frequently reported, but the interpatient variability is high. We therefore aimed to identify determinants for parent-reported dexamethasone-induced neurobehavioral and sleep problems in pediatric ALL. METHODS Our prospective study included patients with medium-risk ALL and their parents during maintenance treatment. Patients were assessed before and after one 5-day dexamethasone course. Primary end points were parent-reported dexamethasone-induced neurobehavioral and sleep problems, measured with the Strengths and Difficulties Questionnaire and Sleep Disturbance Scale for Children, respectively. Analyzed determinants included patient and parent demographics, disease and treatment characteristics, parenting stress (Parenting Stress Index and Distress Thermometer for Parents), dexamethasone pharmacokinetics, and genetic variation (candidate single-nucleotide polymorphisms rs41423247 and rs4918). Statistically significant determinants identified in univariable logistic regression analyses were incorporated in a multivariable model. RESULTS We included 105 patients: median age was 5.4 years (range, 3.0-18.8) and 61% were boys. Clinically relevant dexamethasone-induced neurobehavioral and sleep problems were reported by parents in 70 (67%) and 61 (59%) patients, respectively. In our multivariable regression models, we identified parenting stress as a significant determinant for parent-reported neurobehavioral (odds ratio [OR], 1.16; 95% CI, 1.07 to 1.26) and sleep problems (OR, 1.06; 95% CI, 1.02 to 1.10). Furthermore, parents who experienced more stress before start of a dexamethasone course reported more sleep problems in their child (OR, 1.16; 95% CI, 1.02 to 1.32). CONCLUSION We identified parenting stress, and not dexamethasone pharmacokinetics, genetic variation, patient/parent demographics, or disease/treatment characteristics, as a significant determinant for parent-reported dexamethasone-induced neurobehavioral and sleep problems. Parenting stress may be a modifiable target to reduce these problems.
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Affiliation(s)
| | | | | | | | - Letao Li
- Department of Hospital Pharmacy, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Bertrand D. van Zelst
- Division of Endocrinology, Department of Internal Medicine, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Linda Broer
- Department of Internal Medicine, Erasmus Medical Center, Rotterdam, the Netherlands
| | | | - Rob Pieters
- Pediatric Oncology, Princess Máxima Center, Utrecht, the Netherlands
| | - Marta Fiocco
- Pediatric Oncology, Princess Máxima Center, Utrecht, the Netherlands
- Mathematical Institute, Leiden University, Leiden, the Netherlands
- Department of Biomedical Data Science, Medical Statistics, Leiden University Medical Centre, Leiden, the Netherlands
| | - Erica L.T. van den Akker
- Department of Pediatric Endocrinology, Erasmus MC- Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Marry M. van den Heuvel-Eibrink
- Pediatric Oncology, Princess Máxima Center, Utrecht, the Netherlands
- Child Health, UMCU-Wilhelmina Children's Hospital, Utrecht, the Netherlands
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Verwaaijen EJ, van der Torre P, Vormoor J, Pieters R, Fiocco M, Hartman A, van den Heuvel-Eibrink MM. Novel Adaption of the SARC-F Score to Classify Pediatric Hemato-Oncology Patients with Functional Sarcopenia. Cancers (Basel) 2023; 15:cancers15010320. [PMID: 36612316 PMCID: PMC9818846 DOI: 10.3390/cancers15010320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 12/23/2022] [Accepted: 12/27/2022] [Indexed: 01/05/2023] Open
Abstract
Sarcopenia in pediatric hemato-oncology patients is undesirable because of the consequences it may have for treatment continuation and outcome, physical abilities and participation in daily life. An easy-to-use screening tool for sarcopenia will facilitate the identification of children at risk who need interventions to prevent serious physical deterioration. In the elderly, the use of the SARC-F score as a case-finding tool for sarcopenia is recommended. The aim of this cross-sectional study was to investigate the accuracy of the pediatric SARC-F (PED-SARC-F) for identifying sarcopenia in pediatric hemato-oncology patients, including the determination of a cut-off point for clinical use. Patients 3−20 years of age, under active treatment or within 12 months after treatment cessation were eligible. Patients had a physiotherapy assessment including a PED-SARC-F (0−10) and measurements of muscle strength (handheld dynamometry), physical performance (various tests) and/or muscle mass (bio-impedance analysis), as part of the standard of care. Spearman’s correlation coefficient (rs) between the PED-SARC-F and physiotherapy outcomes were calculated. Structural sarcopenia was defined as low appendicular skeletal muscle mass (ASMM) in combination with low muscle strength and/or low physical performance. Functional sarcopenia indicated low muscle strength combined with low physical performance. Multiple logistic regression models were estimated to study the associations between the PED-SARC-F and structural/functional sarcopenia. To evaluate which cut-off point provides the most accurate classification, the area under the receiver operating characteristic curve (AUCs), sensitivity and specificity per point were calculated. In total, 215 assessments were included, 62% were performed in boys and the median age was 12.9 years (interquartile range: 8.5−15.8). The PED-SARC-F scores correlated moderately with the measurements of muscle strength (rs = −0.37 to −0.47, p < 0.001) and physical performance (rs = −0.45 to −0.66, p < 0.001), and weakly with ASMM (rs = −0.27, p < 0.001). The PED-SARC-F had an AUC of 0.90 (95% confidence interval (CI) = 0.84−0.95) for functional sarcopenia and 0.79 (95% CI = 0.68−0.90) for structural sarcopenia. A cut-off point of ≥5 had the highest specificity of 96% and a sensitivity of 74%. In conclusion, we adapted the SARC-F to a pediatric version, confirmed its excellent diagnostic accuracy for identifying functional sarcopenia and defined a clinically useful cut-off point in pediatric hemato-oncology patients.
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Affiliation(s)
- Emma J. Verwaaijen
- Princess Máxima Center for Pediatric Oncology, 3584CS Utrecht, The Netherlands
- Correspondence: ; Tel.: +31-650006739
| | | | - Josef Vormoor
- Princess Máxima Center for Pediatric Oncology, 3584CS Utrecht, The Netherlands
- Wolfson Childhood Cancer Research Centre, Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne NE1 7RU, UK
- Utrecht Cancer Center, University Medical Center Utrecht, 3584CX Utrecht, The Netherlands
| | - Rob Pieters
- Princess Máxima Center for Pediatric Oncology, 3584CS Utrecht, The Netherlands
| | - Marta Fiocco
- Princess Máxima Center for Pediatric Oncology, 3584CS Utrecht, The Netherlands
- Mathematical Institute, Leiden University, 2333CA Leiden, The Netherlands
- Department of Biomedical Data Science, Section Medical Statistics, Leiden University Medical Center, 2333ZA Leiden, The Netherlands
| | - Annelies Hartman
- Department of Pediatric Physiotherapy, Erasmus Medical Center-Sophia Children’s Hospital, 3015CN Rotterdam, The Netherlands
| | - Marry M. van den Heuvel-Eibrink
- Princess Máxima Center for Pediatric Oncology, 3584CS Utrecht, The Netherlands
- Division of Child Health, Wilhelmina Children’s Hospital, 3584EA Utrecht, The Netherlands
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7
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Oudmaijer CAJ, van den Boogaard WMC, Komninos DSJ, Verwaaijen EJ, van Santen HM, Lilien MR, Hoeijmakers JHJ, Wijnen MHW, van den Heuvel-Eibrink MM, Vermeij WP. Fasting Intervention for Children With Unilateral Renal Tumors to Reduce Toxicity. Front Pediatr 2022; 10:828615. [PMID: 35155309 PMCID: PMC8829466 DOI: 10.3389/fped.2022.828615] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 01/05/2022] [Indexed: 11/18/2022] Open
Abstract
Childhood renal tumors account for around 6% of all childhood cancers and 90% of these cases are Wilms tumor. In Europe, the SIOP-RTSG approach is considered standard of care and has resulted in five-year survival rates of over 90%. Efforts to decrease toxicity are now being pursued. Short-term fasting (STF), a short but strong reduction in calorie-intake, is associated with improved fitness, enhanced coping with acute physical stress and a lower risk of age-associated diseases. STF temporarily reduces growth to boost resilience, maintenance, and defense-mechanisms, by which toxic side-effects of (oxidative) damage and inflammation are largely prevented. Renal surgery for Wilms tumor carries a risk of acute kidney injury (AKI) and pediatric patients that had an episode of AKI are at increased risk for developing chronic renal disease. STF could mitigate surgery-induced stress and could further improve outcomes. We aim to investigate the effect of STF on renal function recovery after renal tumor surgery by conducting a single-center, prospective, randomized, non-blinded, intervention study. Children diagnosed with a unilateral renal tumor and opting for curative treatment are eligible for inclusion. The main study objective is to investigate the potential decrease in occurrence of AKI due to STF. Secondary objectives include renal function recovery, child's wellbeing, physical functioning, and feasibility of and adherence to STF in children with cancer.
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Affiliation(s)
- Christiaan A J Oudmaijer
- Princess Máxima Center for Pediatric Oncology, Utrecht, Netherlands.,Oncode Institute, Utrecht, Netherlands
| | | | - Daphne S J Komninos
- Princess Máxima Center for Pediatric Oncology, Utrecht, Netherlands.,Oncode Institute, Utrecht, Netherlands
| | | | - Hanneke M van Santen
- Princess Máxima Center for Pediatric Oncology, Utrecht, Netherlands.,Department of Pediatric Endocrinology, University Medical Center Utrecht, Wilhelmina Childrens Hospital, Utrecht, Netherlands
| | - Marc R Lilien
- Department of Pediatric Nephrology, University Medical Center Utrecht, Wilhelmina Childrens Hospital, Utrecht, Netherlands
| | - Jan H J Hoeijmakers
- Princess Máxima Center for Pediatric Oncology, Utrecht, Netherlands.,Oncode Institute, Utrecht, Netherlands.,Department of Molecular Genetics, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, Netherlands.,Institute for Genome Stability in Aging and Disease, Cologne Excellence Cluster for Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, Cologne, Germany
| | - Marc H W Wijnen
- Princess Máxima Center for Pediatric Oncology, Utrecht, Netherlands
| | | | - Wilbert P Vermeij
- Princess Máxima Center for Pediatric Oncology, Utrecht, Netherlands.,Oncode Institute, Utrecht, Netherlands
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Verwaaijen EJ, Ma J, de Groot-Kruseman HA, Pieters R, van der Sluis IM, van Atteveld JE, Halton J, Fernandez CV, Hartman A, de Jonge R, Lequin MH, Te Winkel ML, Alos N, Atkinson SA, Barr R, Grant RM, Hay J, Huber AM, Ho J, Jaremko J, Koujok K, Lang B, Matzinger MA, Shenouda N, Rauch F, Rodd C, van den Heuvel-Eibrink MM, Pluijm SMF, Ward LM. A Validated Risk Prediction Model for Bone Fragility in Children With Acute Lymphoblastic Leukemia. J Bone Miner Res 2021; 36:2290-2299. [PMID: 34610647 DOI: 10.1002/jbmr.4442] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 08/30/2021] [Accepted: 09/13/2021] [Indexed: 11/06/2022]
Abstract
Although bone fragility may already be present at diagnosis of pediatric acute lymphoblastic leukemia (ALL), routine performance of dual-energy X-ray absorptiometry (DXA) in every child is not universally feasible. The aim of this study was to develop and validate a risk prediction model for low lumbar spine bone mineral density (LS BMD Z-score ≤ -2.0) at diagnosis, as an important indicator for fracture risk and further treatment-related BMD aggravation. Children with ALL (4-18 years), treated according to the Dutch Childhood Oncology Group protocol (DCOG-ALL9; model development; n = 249) and children from the Canadian Steroid-Associated Osteoporosis in the Pediatric Population cohort (STOPP; validation; n = 99) were included in this study. Multivariable logistic regression analyses were used to develop the prediction model and to confirm the association of low LS BMD at diagnosis with symptomatic fractures during and shortly after cessation of ALL treatment. The area under the receiver operating characteristic curve (AUC) was used to assess model performance. The prediction model for low LS BMD at diagnosis using weight (β = -0.70) and age (β = -0.10) at diagnosis revealed an AUC of 0.71 (95% CI, 0.63-0.78) in DCOG-ALL9 and 0.74 (95% CI, 0.63-0.84) in STOPP, and resulted in correct identification of 71% of the patients with low LS BMD. We confirmed that low LS BMD at diagnosis is associated with LS BMD at treatment cessation (OR 5.9; 95% CI, 3.2-10.9) and with symptomatic fractures (OR 1.7; 95% CI, 1.3-2.4) that occurred between diagnosis and 12 months following treatment cessation. In meta-analysis, LS BMD at diagnosis (OR 1.6; 95% CI, 1.1-2.4) and the 6-month cumulative glucocorticoid dose (OR 1.9; 95% CI, 1.1-3.2) were associated with fractures that occurred in the first year of treatment. In summary, a prediction model for identifying pediatric ALL patients with low LS BMD at diagnosis, as an important indicator for bone fragility, was successfully developed and validated. This can facilitate identification of future bone fragility in individual pediatric ALL patients. © 2021 American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Emma J Verwaaijen
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Jinhui Ma
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Hester A de Groot-Kruseman
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands.,Dutch Childhood Oncology Group, Utrecht, The Netherlands
| | - Rob Pieters
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | | | | | | | | | - Annelies Hartman
- Department of Pediatric Physiotherapy, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Robert de Jonge
- Department of Clinical Chemistry, Academic Medical Center, Amsterdam, The Netherlands
| | - Maarten H Lequin
- Department of Radiology, University Medical Center, Amsterdam, The Netherlands
| | | | - Nathalie Alos
- Département de Pédiatrie, Université de Montréal, Montréal, QC, Canada
| | | | - Ronald Barr
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Ronald M Grant
- Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - John Hay
- Department of Health Sciences, Brock University, St. Catharines, ON, Canada
| | - Adam M Huber
- Department of Pediatrics, Dalhousie University, Halifax, NS, Canada
| | - Josephine Ho
- Department of Pediatrics, University of Calgary, Calgary, AB, Canada
| | - Jacob Jaremko
- Department of Radiology & Diagnostic Imaging, University of Alberta, Edmonton, AB, Canada
| | - Khaldoun Koujok
- Department of Medical Imaging, University of Ottawa, Ottawa, ON, Canada
| | - Bianca Lang
- Department of Pediatrics, Dalhousie University, Halifax, NS, Canada
| | | | - Nazih Shenouda
- Department of Medical Imaging, University of Ottawa, Ottawa, ON, Canada
| | - Frank Rauch
- Department of Pediatrics, McGill University, Montréal, QC, Canada
| | - Celia Rodd
- Department of Pediatrics, University of Manitoba, Winnipeg, MB, Canada
| | | | - Saskia M F Pluijm
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Leanne M Ward
- Department of Pediatrics, University of Ottawa, Ottawa, ON, Canada
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- Canadian Pediatric Bone Health Working Group, Ottawa, ON, Canada
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9
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van Gerwen M, Maggen C, Cardonick E, Verwaaijen EJ, van den Heuvel-Eibrink M, Shmakov RG, Boere I, Gziri MM, Ottevanger PB, Lok CAR, Halaska M, Shao LT, Struys I, van Dijk-Lokkart EM, Van Calsteren K, Fruscio R, Zola P, Scarfone G, Amant F. Association of Chemotherapy Timing in Pregnancy With Congenital Malformation. JAMA Netw Open 2021; 4:e2113180. [PMID: 34106263 PMCID: PMC8190627 DOI: 10.1001/jamanetworkopen.2021.13180] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Chemotherapy during the first trimester of pregnancy should be avoided owing to the risk of congenital malformations. However, the precise gestational age at which chemotherapy can be initiated safely remains unclear. OBJECTIVE To assess congenital malformation rates associated with gestational age at initiation of chemotherapy among pregnant women with cancer. DESIGN, SETTING, AND PARTICIPANTS This multicenter cohort study evaluated all pregnant women who received chemotherapy between 1977 and 2019 registered in the International Network on Cancer, Infertility and Pregnancy (INCIP) database. Data were analyzed from February 15 to June 2, 2020. EXPOSURES Cancer treatment with chemotherapy during pregnancy. MAIN OUTCOMES AND MEASURES Analysis was focused on major and minor structural malformations in offspring, defined by EUROCAT, detected during pregnancy or at birth. RESULTS A total of 755 women in the INCIP database who underwent cancer treatment with chemotherapy during pregnancy were included in analysis. The median (range) age at cancer diagnosis was 33 (14-48) years. Among offspring, the major congenital malformation rate was 3.6% (95% CI, 2.4%-5.2%), and the minor congenital malformation rate was 1.9% (95% CI, 1.0%-3.1%). Chemotherapy exposure prior to 12 weeks gestational age was associated with a high rate of major congenital malformations, at 21.7% (95% CI, 7.5%-43.7%; odds ratio, 9.24 [95% CI, 3.13-27.30]). When chemotherapy was initiated after gestational age 12 weeks, the frequency of major congenital malformations was 3.0% (95% CI, 1.9%-4.6%), which was similar to the expected rates in the general population. Minor malformations were comparable when exposure occurred before or after gestational age 12 weeks (4.3% [95% CI, 0.1%-21.9%] vs 1.8% [95% CI, 1.0-3.0]; odds ratio, 3.13 [95% CI, 0.39-25.28]). Of 29 women who received chemotherapy prior to 12 weeks gestation, 17 (58.6%) were not aware of pregnancy, and 6 (20.7%) experienced a miscarriage (3 women [10.3%]) or decided to terminate their pregnancy (3 women [10.3%]). CONCLUSIONS AND RELEVANCE This cohort study found that chemotherapy was associated with an increased risk of major congenital malformations only in the first 12 weeks of pregnancy. The risk of congenital malformations when chemotherapy was administered during the first trimester and the high number of incidental pregnancies during cancer treatment in the INCIP registry underscore the importance of contraceptive advice and pregnancy testing at the start of chemotherapeutic treatment in young women with cancer.
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Affiliation(s)
- Mathilde van Gerwen
- Center for Gynecological Oncology Amsterdam, Antoni van Leeuwenhoek–Netherlands Cancer Institute, Amsterdam, the Netherlands
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | | | - Elyce Cardonick
- Department of Obstetrics and Gynecology, Cooper University Health Care, Camden, New Jersey
| | | | | | - Roman G. Shmakov
- National Medical Research Centre for Obstetrics, Gynaecology and Perinatology named after Academician V.I. Kulakov, Ministry of Healthcare of Russian Federation, Moscow, Russia
| | - Ingrid Boere
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Mina M. Gziri
- Department of Obstetrics, Cliniques Universitaires St Luc, Université Catholique de Louvain, Sint-Lambrechts-Woluwe, Belgium
| | - Petronella B. Ottevanger
- Department of Medical Oncology, Radboud University Nijmegen Medical Center, Nijmegen, the Netherlands
| | - Christianne A. R. Lok
- Center for Gynecological Oncology Amsterdam, Antoni van Leeuwenhoek–Netherlands Cancer Institute, Amsterdam, the Netherlands
- Center for Gynecological Oncology Amsterdam, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Michael Halaska
- University Hospital Kralovske Vinohrady, Third Medical Faculty, Charles University, Prague, Czech Republic
| | - Long Ting Shao
- Cooper Medical School, Rowan University, Camden, New Jersey
| | - Ilana Struys
- Department of Oncology, KU Leuven, Leuven, Belgium
| | - Elisabeth M. van Dijk-Lokkart
- Department of Child and Adolescent Psychiatry & Psychosocial Care, Emma Children’s Hospital, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Kristel Van Calsteren
- Department of Obstetrics, University Hospitals, Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Robert Fruscio
- Department of Obstetrics and Gynecology, San Gerardo Hospital, Milan, Italy
| | - Paolo Zola
- Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Giovanna Scarfone
- Gynecological Oncology Unit, Fondazione Istituto Di Ricovero e Cura a Carattere Scientifico, Ca’ Granda Ospedale Maggiore Policlinico Milan, Milan, Italy
| | - Frédéric Amant
- Center for Gynecological Oncology Amsterdam, Antoni van Leeuwenhoek–Netherlands Cancer Institute, Amsterdam, the Netherlands
- Department of Oncology, KU Leuven, Leuven, Belgium
- Center for Gynecological Oncology Amsterdam, Amsterdam University Medical Centers, Amsterdam, the Netherlands
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10
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Verwaaijen EJ, Catsman-Berrevoets CE, Maurice-Stam H, Dessens AB, Waslander R, van den Adel TPL, Pluijm SMF, Reddingius RE, Michiels E, van den Heuvel-Eibrink MM, Hartman A. Determinants of impairments in functioning, fatigue, and participation ability in pediatric brain tumor survivors. Neurooncol Adv 2021; 3:vdab161. [PMID: 34988449 PMCID: PMC8704380 DOI: 10.1093/noajnl/vdab161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Pediatric brain tumor survivors (PBTS) experience disease- and treatment-related sequelae. We aimed to investigate the occurrence of participation limitations, impairments in functioning, fatigue, and the association between patient, tumor- and treatment-related factors and these outcomes.
Methods
Children (4–18 years) after treatment for a brain tumor between 2005 and 2014 at the Erasmus Medical Center, Rotterdam, the Netherlands, were eligible. The parent-reported Child and Family Follow-up Survey developed to measure participation and impairments in functioning in youth with acquired brain injury, was used. Fatigue was assessed using the Pediatric Quality of Life Inventory Multidimensional Fatigue Scale. Associations with patient, tumor- and treatment-related factors were explored using univariable analyses.
Results
Ninety-one PBTS (median age: 11.3 years [range: 9.5–14.1], time since treatment: 3.9 years [range: 4–6.2]) were included (response rate: 55%). Participation limitations were reported in 53% and were associated with impairments in functioning (15–67%) (P ≤ .01) and fatigue (P ≤ .03).
Parent- and child-reported fatigue was increased compared to normative values (P ≤ .02). History of hydrocephalus was associated with increased fatigue (P ≤ .04). Younger age at diagnosis and longer time since diagnosis were associated with impairments in functioning and cognitive fatigue (P < .05).
Participation limitations, impairments in functioning and fatigue were similar in PBTS who were <3 or ≥3 years since completion of treatment.
Conclusion
More than half of PBTS reported limited participation ability, which is associated with impairments in functioning and fatigue. The complication hydrocephalus seems to lead to more fatigue. Participation limitations, impairments in functioning and fatigue appear not to diminish in the longer term.
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Affiliation(s)
- Emma J Verwaaijen
- Princess Maxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - Coriene E Catsman-Berrevoets
- Department of Pediatric Neurology, Erasmus Medical Center Rotterdam – Sophia Children’s Hospital, Rotterdam, the Netherlands
| | | | - Arianne B Dessens
- Department of Child and Adolescent Psychiatry and Psychology Erasmus Medical Center Rotterdam – Sophia Children’s Hospital, Rotterdam, the Netherlands
| | - Richelle Waslander
- Department of Child and Adolescent Psychiatry and Psychology Erasmus Medical Center Rotterdam – Sophia Children’s Hospital, Rotterdam, the Netherlands
| | - Tabitha P L van den Adel
- Department of Pediatric Physiotherapy, Erasmus Medical Center Rotterdam – Sophia Children’s Hospital, Rotterdam, the Netherlands
| | - Saskia M F Pluijm
- Princess Maxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - Roel E Reddingius
- Princess Maxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - Erna Michiels
- Princess Maxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | | | - Annelies Hartman
- Department of Pediatric Physiotherapy, Erasmus Medical Center Rotterdam – Sophia Children’s Hospital, Rotterdam, the Netherlands
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11
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Verwaaijen EJ, Corbijn DM, Hulst AM, Neggers SJ, Boot AM, Heuvel‐Eibrink MM, Hartman A, Pluijm SM. Frailty in long‐term Dutch adult survivors of childhood acute myeloid leukaemia, neuroblastoma, and Wilms' tumour. JCSM Clinical Reports 2020. [DOI: 10.1002/crt2.14] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Affiliation(s)
- Emma J. Verwaaijen
- Pediatric Oncology Princess Máxima Center for Pediatric Oncology Utrecht The Netherlands
| | - Daniëlle M. Corbijn
- Pediatric Oncology Princess Máxima Center for Pediatric Oncology Utrecht The Netherlands
| | - Annelienke M. Hulst
- Pediatric Oncology Princess Máxima Center for Pediatric Oncology Utrecht The Netherlands
| | - Sebastian J.C.M.M. Neggers
- Pediatric Oncology Princess Máxima Center for Pediatric Oncology Utrecht The Netherlands
- Section of Endocrinology, Department of Medicine Erasmus Medical Center Rotterdam The Netherlands
| | - Annemieke M. Boot
- Division of Endocrinology, Department of Pediatrics University Medical Center Groningen, University of Groningen Groningen The Netherlands
| | | | - Annelies Hartman
- Department of Pediatric Physiotherapy Erasmus Medical Center‐Sophia Children's Hospital Rotterdam The Netherlands
| | - Saskia M.F. Pluijm
- Pediatric Oncology Princess Máxima Center for Pediatric Oncology Utrecht The Netherlands
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