Guideline for Children With Cancer Receiving General Anesthesia for Procedures and Imaging

Children with cancer and those undergoing hematopoietic stem cell transplantation frequently require anesthesia for imaging as well as diagnostic and therapeutic procedures from diagnosis through follow-up. Due to their underlying disease and side effects of chemotherapy and radiation, they are at risk for complications during this time, yet no published guideline exists for preanesthesia preparation. A comprehensive literature review served as the basis for discussions among our multidisciplinary panel of oncologists, anesthesiologists, nurse practitioners, clinical pharmacists, pediatric psychologists, surgeons and child life specialists at the Children's Hospital of Philadelphia. Due to limited literature available, this panel created an expert consensus guideline addressing anesthesia preparation for this population.

COVID-19 Exposure and Family Impact Scales: Factor Structure and Initial Psychometrics

Objective

In response to the rapidly unfolding coronavirus disease 2019 (COVID-19) pandemic in spring 2020, we developed a caregiver-report measure to understand the extent to which children and families were exposed to events related to COVID-19 and their perceptions of its impact. This article reports on the factor structure and psychometric properties of this measure.

Methods

The COVID-19 Exposure and Family Impact Scales (CEFIS) were developed by a multidisciplinary, multi-institutional team using a rapid iterative process. Data from 1805 caregivers recruited from 28 programs at 15 institutions across the United States were collected from May—September 2020. We examined the underlying structure of the CEFIS using exploratory factor analyses and its internal consistency (Cronbach’s alpha).

Results

Participants reported a range of COVID-19-related events (M = 8.71 events of 25). On the bidirectional 4-point impact scale, mean scores were mostly above the midpoint, indicating a slightly negative impact. Cronbach’s alpha was excellent for Exposure (α = .80) and Impact (α = .92). Factor analysis identified six factors for Exposure (COVID-19 experiences, Access to essentials, Disruptions to living conditions, Loss of income, Family caregiving and activities, and Designation as an essential worker). There were three factors for Impact (Personal well-being, Family interactions, and Distress).

Discussion

The CEFIS has strong factors assessing Exposure to events related to COVID-19, and the Impact of these events on families of children in pediatric healthcare. These initial validation data support use of the CEFIS for measuring the effect of the pandemic.

Omega-3 offers better hypothalamus protection by decreasing POMC expression and elevating ghrelin hormone: a prospective trial to overcome methotrexate-induced anorexia

PURPOSE

Methotrexate (MTX) therapy is widely used in treatment of different types of diseases including inflammatory diseases, autoimmune disorders, and cancer. However, most of patients respond well to MTX, they suffer from multiple side effects including severe anorexia. Omega-3 fatty acid possesses many beneficial biological activities. Therefore, the objective of our study is to explore the effect of the combined modality of omega-3 (400 mg/kg/day) in MTX-induced anorexia in rats.

METHODS

The effect of MTX alone and in combination with omega-3 on the body weight, ghrelin hormone level, histopathological findings of taste buds and hypothalamus and POMC gene expression were investigated.

RESULTS

Interestingly, the capability of omega-3 to overcome the anorexic effect of MTX could be manifested by controlling weight loss, increasing serum HDL, elevating the ghrelin level as well as reducing both lesions within taste buds and hypothalamus and hypothalamic POMC gene expression.

CONCLUSIONS

our findings revealed that the omega-3 might be used as a complementary supplement during the MTX therapy to ameliorate its anorexic effect.

0990 Evaluating Components Of Sleep Quality And The Sleep-Quality Of Life Relationship For Children With Acute Lymphoblastic Leukemia

Introduction

Poor sleep quality is associated with reduced health-related quality of life (HRQL) for children with Acute Lymphoblastic Leukemia (ALL). Research has yet to evaluate how components of child sleep quality uniquely contribute to HRQL beyond demographic characteristics. This study evaluates features of sleep and the relationship between sleep and HRQL for children in the maintenance phase of ALL treatment.

Methods

89 caregivers (ages 20-52, M=35.95, SD=7.10) of children with ALL (ages 3-12, M=5.73, SD=2.21; 13.76 months from diagnosis) completed demographic questionnaires and reports of child sleep quality (Child Sleep Habits Questionnaire; CSHQ), and 64 caregivers reported on child HRQL (Pediatric Quality of Life Inventory). Descriptive statistics were calculated. T-tests compared CSHQ subscales to ratings of healthy normative values. Pearson correlations evaluated associations between sleep and overall HRQL. Hierarchical regression assessed whether CSHQ subscales uniquely predicted HRQL beyond demographic characteristics.

Results

This sample reported greater bedtime resistance [t(88)=6.413, p<.001], sleep onset delay [t(88)=3.180, p=.002], sleep anxiety [t(88)=4.271, p<.001], night awakenings [t(88)=6.031, p<.001], parasomnias [t(88)=3.900, p<.001], and daytime sleepiness [t(87)=1.781, p=.078] than normative values, although sleep duration [t(88)=1.781, p=.078] and sleep disordered breathing (SDB) [t(88)=-.061, p=.951] did not differ. HRQL was related to SDB (r=-.289, p=.021), bedtime resistance (r=-.263, p=.036), and total sleep score (r=-.34, p=.006). The regression model with SDB and bedtime resistance explained 24.2% of variance but was not significant [F(6,31)=1.651, p=.167].

Conclusion

Caregiver ratings showed greater sleep impairments for children in this sample than of norms. Sleep subscales were associated with HRQL, but did not predict HRQL beyond demographic factors. Caregiver reports of child sleep and HRQL may vary depending on when during the monthly chemotherapy cycle questionnaires were completed. SDB did not differ from normative values but was related to HRQL, suggesting the need to screen for SDB symptoms to potentially improve child outcomes.

Support

This study was supported by funding from the American Cancer Society PF-13-238-01-PCSM (PI: Daniel).

0981 Sleep Practices In Pediatric Cancer—Does Sleep Hygiene Matter For Reducing Cancer Symptom Burden?

Introduction

Sleep disturbances are common during pediatric cancer treatment and recent evidence suggests a correlation between sleep and symptom burden. Improving nighttime sleep may impact patients’ ability to cope with symptoms. The current study tests the interaction between sleep hygiene and sleep disturbances in predicting cancer-related symptoms to determine if the relationship between sleep and symptoms is different for patients with better sleep hygiene.

Methods

102 caregivers of children with cancer (ages 5-17, M=10.12, SD=4.02; 58% female) completed parent-proxy Pediatric Sleep Practices Questionnaire (yielding routine consistency and sleep opportunity scores) and measures of cancer-related symptoms (PROMIS Sleep Disturbance, Fatigue, and Pain Interference; PedsQL—Cancer Module-Nausea subscale). The interaction between sleep disturbances and sleep hygiene (consistency, opportunity) on each symptom (pain, nausea, fatigue) were tested using PROCESS moderation.

Results

81% of caregivers report that their child receives sufficient sleep but only 12% reported regular consistent sleep patterns/routines. Sleep opportunity was not related to sleep disturbances or cancer-related symptoms, but more routine consistency was related to fewer sleep disturbances (r=.30, p=.003). The interaction between sleep disturbances and routine consistency significantly predicted pain interference [R2=.16, F(3, 98)=6.37, p<.001; Bint =-0.17, p=.028] and nausea [R2=.16, F(3, 98)=6.47, p<.001; Bint=0.46, p=.004]. The interaction between sleep disturbances and sleep opportunity significantly predicted nausea [R2=.15, F(3, 98)=5.76, p=.001; Bint =0.68, p=.016] but not pain interference. Both interaction models predicting fatigue were not significant.

Conclusion

The sleep/pain and sleep/nausea relationships are stronger in patients with more consistent sleep routines and the sleep/nausea relationship is also stronger in patients with sufficient/well-timed sleep opportunities. Sleep and fatigue were moderately related across all levels of both sleep hygiene components. Clinical interventions that target sleep hygiene together with sleep disturbances such as nighttime awakenings and poor sleep quality may be more effective in addressing cancer-related symptoms such as pain and nausea.

Support

This work was supported in part by funding from the Patient-Centered Outcomes Research Institute (PCORI-D-17-00187; PI Christopher Forrest).

Dysfunctional posttraumatic cognitions, posttraumatic stress and depression in children and adolescents exposed to trauma: a network analysis

BACKGROUND

The latest version of the International Classification of Diseases (ICD-11) proposes a posttraumatic stress disorder (PTSD) diagnosis reduced to its core symptoms within the symptom clusters re-experiencing, avoidance and hyperarousal. Since children and adolescents often show a variety of internalizing and externalizing symptoms in the aftermath of traumatic events, the question arises whether such a conceptualization of the PTSD diagnosis is supported in children and adolescents. Furthermore, although dysfunctional posttraumatic cognitions (PTCs) appear to play an important role in the development and persistence of PTSD in children and adolescents, their function within diagnostic frameworks requires clarification.

METHODS

We compiled a large international data set of 2,313 children and adolescents aged 6 to 18 years exposed to trauma and calculated a network model including dysfunctional PTCs, PTSD core symptoms and depression symptoms. Central items and relations between constructs were investigated.

RESULTS

The PTSD re-experiencing symptoms strong or overwhelming emotions and strong physical sensations and the depression symptom difficulty concentrating emerged as most central. Items from the same construct were more strongly connected with each other than with items from the other constructs. Dysfunctional PTCs were not more strongly connected to core PTSD symptoms than to depression symptoms.

CONCLUSIONS

Our findings provide support that a PTSD diagnosis reduced to its core symptoms could help to disentangle PTSD, depression and dysfunctional PTCs. Using longitudinal data and complementing between-subject with within-subject analyses might provide further insight into the relationship between dysfunctional PTCs, PTSD and depression.

Challenges to Family Management for Caregivers of Adolescent and Young Adult Survivors of Childhood Brain Tumors [Formula: see text]

Due to the complexity of cancer late effects, the education required to provide anticipatory guidance and support to the caregivers of adolescent and young adult (AYA) survivors of childhood brain tumors can be difficult. Therefore, identifying challenges to family management (FM) could be helpful in anticipating complications with the integration of tumor and treatment late effects into family life. Building on previous research that described FM for children with chronic conditions, children who survived cancer, and the Family Management Styles Framework, the purpose of this study was to identify FM challenges for caregivers of AYA survivors of childhood brain tumors to guide clinical practice and research. Directed content analysis was used to identify FM challenges in data from semistructured interviews with 45 maternal caregivers for AYA survivors of childhood brain tumors living with them. Caregivers were largely White (89%) with an average age of 52 years, educated beyond the high school level (67%), and were partnered or married (53%). On average, caregivers had been caring for the AYA for 21 years since diagnosis, and 56% of their survivors had moderate functional restrictions. A primary and a secondary analyst were assigned to the data for each interview and completed a single summary matrix. A list of challenges was created by the research team based on Family Management Styles Framework, the literature, and clinical expertise. Seven core challenges to FM were identified: ensuring survivor well-being, supporting survivor independence, encouraging sibling well-being, planning family activities, sustaining parents as caregivers, attending to survivor late effects, and providing support and advocacy.

Competence in caregivers of adolescent and young adult childhood brain tumor survivors

OBJECTIVE

Caregivers of adolescents and young adults (AYA) with complex medical conditions, including brain tumor survivors, have protracted and often complex roles, yet a gap exists in understanding their perceived competence. The aim of this study is to test a hypothesized model based on the theoretical and empirical literature: better caregiver health, better survivor health, and better family functioning contribute directly to fewer caregiving demands, which in turn contribute to greater caregiver competence.

METHOD

Telephone interviews using structured self-report questionnaires were conducted in this cross-sectional study with a sample of 186 caregivers (mothers) of childhood brain tumor survivors aged 14-40 years old who live with at least one parent. Structural equation modeling (SEM) was used to test the hypothesized model.

RESULTS

The final SEM model suggests that survivor health and family functioning directly predict caregiver competence. Caregiver health indirectly predicts caregiver competence through caregiver demands and then family functioning. Family income directly predicts family functioning. The model showed adequate fit (CFI = 0.905, TFI = 0.880, and RMSEA = 0.081). Overall, the model accounted for 45% of variance in caregiver competence.

CONCLUSIONS

For this sample of caregivers of AYA with medically complex conditions, family functioning and the health of survivors are both important to how they evaluate their skills as caregivers. The results of this study underscore the crucial role of care models that focus on optimizing the health of the survivor, caregiver, and family, along with supporting a family centered approach to their care.

Vasopressin-containing neurons of the hypothalamic parvocellular paraventricular nucleus of the jerboa: plasticity related to immobilization stress

The corticotropin-releasing hormone (CRH) neurons of the hypothalamic parvocellular paraventricular nucleus (PVN) have a high potential for phenotypical plasticity, allowing them to rapidly modify their neuroendocrine output, depending upon the type of stressors. Indeed, these neurons coexpress other neuropeptides, such as cholecystokinin (CCK), vasopressin (VP), and neurotensin, subserving an eventual complementary function to CRH in the regulation of the pituitary. Unlike in rats, our previous data showed that in jerboas, CCK is not coexpressed within CRH neurons in control as well as stressed animals. The present study explored an eventual VP participation in the phenotypic plasticity of CRH neurons in the jerboa. We analyzed the VP expression within the PVN by immunocytochemistry in male jerboas submitted to acute stress. Our results showed that, contrary to CRH and CCK, no significant change concerned the number of VP-immunoreactive neurons following a 30-min immobilization. The VP/CRH coexpression within PVN and median eminence was investigated by double immunocytochemistry. In control as well as stressed animals, the CRH-immunopositive neurons coexpressed VP within cell bodies and terminals. No significant difference in the number of VP/CRH double-labeled cells was found between both groups. However, such coexpression was quantitatively more important into the posterior PVN as compared with the anterior PVN. This suggests an eventual autocrine/paracrine or endocrine role for jerboa parvocellular VP which is not correlated with acute immobilization stress. VP-immunoreactive neurons also coexpressed CCK within PVN and median eminence of control and stressed jerboas. Such coexpression was more important into the anterior PVN as compared with the posterior PVN. These results showed the occurrence of at least two VP neuronal populations within the jerboa PVN. In addition, the VP expression did not depend upon acute immobilization stress. These data highlight differences in the neuroendocrine regulatory mechanisms of the stress response involving CRH/CCK or VP. They also underline that adaptative physiological mechanisms to stress might vary from one mammal species to another.

GAT-1 and reversible GABA transport in Bergmann glia in slices

Although glial GABA uptake and release have been studied in vitro, GABA transporters (GATs) have not been characterized in glia in slices. Whole cell patch-clamp recordings were obtained from Bergmann glia in rat cerebellar slices to characterize carrier-mediated GABA influx and efflux. GABA induced inward currents at -70 mV that could be pharmacologically separated into GABA(A) receptor and GAT currents. In the presence of GABA(A/B/C) receptor blockers, mean GABA-induced currents measured -48 pA at -70 mV, were inwardly rectifying between -70 and +50 mV, were inhibited by external Na(+) removal, and were diminished by reduction of external Cl(-). Nontransportable blockers of GAT-1 (SKF89976-A and NNC-711) and a transportable blocker of all the GAT subtypes (nipecotic acid) reversibly reduced GABA-induced transport currents by 68 and 100%, respectively. A blocker of BGT-1 (betaine) had no effect. SKF89976-A and NNC-711 also suppressed baseline inward currents that likely result from tonic GAT activation by background GABA. The substrate agonists, nipecotic acid and beta-alanine but not betaine, induced voltage- and Na(+)-dependent currents. With Na(+) and GABA inside the patch pipette or intracellular GABA perfusion during the recording, SKF89976-A blocked baseline outward currents that activated at -60 mV and increased with more depolarized potentials. This carrier-mediated GABA efflux induced a local accumulation of extracellular GABA detected by GABA(A) receptor activation on the recorded cell. Overall, these results indicate that Bergmann glia express GAT-1 that are activated by ambient GABA. In addition, GAT-1 in glia can work in reverse and release sufficient GABA to activate nearby GABA receptors.

Carrier-mediated uptake and release of taurine from Bergmann glia in rat cerebellar slices

Taurine uptake is essential for the maintenance of millimolar intracellular concentrations of taurine, which is released during ischaemia and is thought to be neuroprotective. To determine whether Bergmann glia express functional transporters that can mediate both taurine uptake and efflux, whole-cell patch-clamp recordings were obtained from these cells in rat cerebellar slices. Taurine-induced inward currents can be pharmacologically separated into GABA(A) receptor and taurine transporter currents. In the presence of GABA receptor blockers, residual taurine currents averaged -28 pA at -70 mV and were strictly inwardly rectifying between -70 and +50 mV. These residual currents were also abolished by external Na+ removal and diminished by reduction of external Cl-, consistent with transport currents. Taurine transport currents were reduced by a taurine transporter inhibitor, guanidinoethyl sulphonate (GES). Other classical inhibitors reduced taurine transport currents with an order of potency (hypotaurine > beta-alanine > GES > GABA) similar to that reported for cloned rat taurine transporters. Following intracellular taurine perfusion during the recording, a progressively developing outward current could be observed at -50 mV but not at -70 mV. Intracellular perfusion of taurine also decreased taurine-induced inward currents at both holding potentials. Outward currents induced by intracellular taurine increased in amplitude with depolarization, activated near -50 mV, and were affected by GES. For the first time, these results demonstrate that taurine activates both GABA(A) receptors and Na+/Cl--dependent taurine transporters in Bergmann glia in slices. In addition, our data show that taurine transporters can work in reverse and can probably mediate taurine efflux under ischaemic conditions.

Surviving cancer competently intervention program (SCCIP): a cognitive-behavioral and family therapy intervention for adolescent survivors of childhood cancer and their families

Psychological reactions to having had childhood cancer often continue after treatment ends, for survivors and their parents. Based on our previous research, we developed an intervention program for adolescent survivors of childhood cancer, their parents, and siblings. Surviving Cancer Competently: An Intervention Program--SCCIP--is a one-day family group intervention that combines cognitive-behavioral and family therapy approaches. The goals of SCCIP are to reduce symptoms of distress and to improve family functioning and development. SCCIP is described and data from a pilot study of 19 families are presented. Program evaluation data indicated that all family members found SCCIP helpful. Standardized measures administered before the intervention and again at 6 months after SCCIP showed that symptoms of posttraumatic stress and anxiety decreased. Changes in family functioning were more difficult to discern. Overall, the results were promising with regard to the feasibility of the program and its potential for reducing symptoms of distress for all family members.

Vitamin D3 deficiency and alterations of glucose metabolism in rat endocrine pancreas

After 5 weeks of vitamin D3 deficiency, rats exhibited signs of rachitism, hypocalcaemia and hypoinsulinaemia. As the glucose-induced insulin release process requires calcium and energy production from glucose metabolism within beta cells of Langerhans islets, several steps in the glycolytic pathway and the tricarboxylic acid cycle within beta cells were investigated in vitro. The sensitivity of islets to glucose was studied during incubations in the presence of crescent concentrations of glucose (4.2 to 16.7 mM). Comparison of 50% maximal insulin response showed no modifications induced by vitamin D3 deficiency despite a large fall in the secretory capacity of beta cells. The use of two secretagogues (D-glucose and D-glyceraldehyde) to stimulate insulin release at two different glycolysis steps gave similar responses during perifusions performed in the presence of crescent concentrations of these nutrients, indicating that vitamin D3 deficiency was not a major influence on the first steps in glycolysis. Glucose utilisation by islets, as determined by 3HOH production from D-[5-3H]glucose, was slightly decreased during glucose stimulation of islets from vitamin D3-deficient rats, whereas glucose oxidation inside the tricarboxylic acid cycle, as measured by 14CO2 production from D-[6-14C]glucose, was severely affected. These data, which suggest that vitamin D3 deficiency affects the glycolytic pathway after the D-glyceraldehyde step and mainly alters oxidative events within the tricarboxylic acid cycle, support the hypothesis of an alteration of mitochondrial metabolism.

Is posttraumatic stress a viable model for understanding responses to childhood cancer?

The application of a trauma model to understanding the impact of life-threatening illness has been informative. In the case of childhood cancer patients, it appears clear that a full PTSD syndrome is not the normative response either during or after treatment. Some aspects of cancer diagnosis and treatment, however, are experienced as traumatic by a subset of children, some of whom report symptoms of posttraumatic stress. There is some evidence that children may respond to cancer treatment as a repeated trauma, with the result of more subtle changes in affect modulation, world view, and interpersonal relationships. This area requires further investigation. The trauma model is also useful in understanding parental responses to childhood cancer. The epidemiologic data to date regarding posttraumatic stress symptoms in parents of childhood cancer survivors is consistent with the trauma literature regarding responses to moderate-magnitude traumatic exposure. These findings have important implications for clinical interventions for families of childhood cancer patients. More research is needed in the prediction and prevention of the long-term distress reported by so many parents of children who have undergone successful treatment for life-threatening illness.

Predictors of posttraumatic stress symptoms in childhood cancer survivors

OBJECTIVE

The diagnosis and treatment of childhood cancer are extremely stressful experiences, with psychological sequelae which can persist many years after the end of treatment. This study investigated the relative contributions of general anxiety, treatment intensity, medical sequelae of treatment, and the subjective appraisal of life threat and treatment intensity to later posttraumatic stress symptoms, such as intrusive memories, avoidance, and hypervigilance.

METHOD

One hundred eighty-six childhood cancer survivors ages 8 through 20 years, off of treatment for more than 1 year, and their parents completed questionnaires. Medical sequelae of treatment and intensity of treatment were rated by a pediatric oncologist.

RESULTS

Significant, independent predictors of persistent posttraumatic stress symptoms included: 1) the survivor's retrospective subjective appraisal of life threat at the time of treatment, and the degree to which the survivor experienced the treatment as "hard" or "scary"; 2) the child's general level of anxiety; 3) history of other stressful experiences; 4) time since the termination of treatment (negative association); 5) female gender; and 6) family and social support. Mother's perception of treatment and life threat contributed to anxiety and subjective appraisal for the survivor, but did not independently contribute to posttraumatic stress symptoms.

CONCLUSIONS

Symptoms of posttraumatic stress seem to decrease with time, but are persistent in a subset of childhood cancer survivors. Other than time and gender, the predictors of posttraumatic stress symptoms are primarily subjective factors (ie, anxiety and subjective appraisal) rather than objective stressors of treatment and medical sequelae.

Involvement of both calcium influx and calcium mobilization in growth hormone-induced [Ca2+]i increases in Chinese hamster ovary cells

This study reports rapid effects of growth hormone (GH) on the intracellular free calcium concentration ([Ca2+]i) in Chinese hamster ovary (CHO) cells stably expressing rabbit GH receptor. [Ca2+]i was measured by spectrofluorimetric methods in single cells and membrane Ca2+ currents by patch clamp techniques in the whole-cell configuration. In individual CHO cells, bathed in a standard saline solution containing 2 mM Ca2+, basal [Ca2+]i was 191 +/- 27 nM (mean +/- S.D.; n=83). Short term administration of GH (100 ng/ml, 30 s) induced a [Ca2+]i increase in 54% of cells tested (n = 398 of 743). Responses were clearly heterogeneous. Maximum calcium increase varied from 16 to 853 nM and time to peak varied from 4 to 320 s. On examination of the [Ca2+]i increases, it was possible to define two different types of calcium responses to GH. Experimental manipulations of extracellular and intracellular calcium concentrations demonstrated that GH-induced calcium increases involved both calcium influx and calcium mobilization. Calcium influx, a long lasting, small amplitude (63 +/- 34 nM) response, was observed in 121 out of 398 cells (30%) whereas calcium mobilization, a transient, large amplitude (263 +/- 175 nM) response, was observed in 277 out of 398 cells (70%). Moreover, patch clamp data show that influx did not involve the dihydropyridine-sensitive calcium channels.