Social competence in newly diagnosed pediatric brain tumor patients

Brain tumors (BTs) are a common pediatric malignancy. Improved treatment has resulted in higher survival rates. There is, however, increasing concern about adverse effects of the disease and its treatment, including effects on social competence (i.e. effective social functioning in everyday life). The aim of this study is to examine multiple levels of social competence (i.e. social skills and social adjustment) in newly diagnosed pediatric BT patients. Thirty newly diagnosed BT patients aged 5-12 years were assessed shortly after diagnosis with a neuropsychological test battery focusing on social competence, including tests for IQ, social skills (i.e. social-affective and executive functioning) and social adjustment (rated by parents and teachers). Their performance was compared to 95 healthy controls who completed the same assessment. Patients and healthy controls were largely comparable with regard to demographic and environmental factors and did not differ on measures of IQ, social skills and social adjustment. Furthermore, age was found to have a positive significant effect on social skills independent of group. Shortly after diagnosis, pediatric BT patients did not perform different from healthy controls on IQ and measures of social skills and social adjustment. This is an encouraging finding. However, because of potentially neurotoxic adjuvant therapy and the ongoing development of social skills, longitudinal follow-up studies are needed to investigate long-term outcome regarding social competence in BT survivors.

Consumption of diagnostic procedures and other cardiology care in chest pain patients after presentation at the emergency department

OBJECTIVE

The HEART score serves risk stratification of chest pain patients at the emergency department (ED). Quicker and more solid decisions may be taken in these patients with application of this score. An analysis of medical consumption of 122 acute chest pain patients admitted before the introduction of this score may be indicative of possible savings.

METHODS

Numbers of cardiology investigations and clinical admission days were counted. Charged cost of medicine was divided into three categories: ED, in-hospital, and outpatient clinic.

RESULTS

The total cost of care was <euro> 469,631, with an average of <euro> 3849 per patient. Seventy-five percent of this cost was due to hospitalisation under the initial working diagnosis of acute coronary syndrome (ACS). This diagnosis was confirmed in only 29/122 (24 %) of the patients. The low-risk group (41 patients with HEART scores 0-3) included one patient with a previously scheduled CABG. In the remaining 40 patients, hospitalisation occurred in 12/40 (30 %) patients and 30/40 (75 %) patients visited the outpatient clinic. The total cost of medical care after presentation of these 40 patients was <euro> 37,641; there were no cases where a new diagnosis of coronary artery disease was made. When medical care in this subgroup is declared redundant, major savings on national medical care budgets could be made.

CONCLUSION

If the HEART score were to be routinely applied, diagnostic pathways could be shortened and costs reduced, in particular in low-risk patients.

Neuropsychological Outcome in Chemotherapy-Only–Treated Children With Acute Lymphoblastic Leukemia

Purpose

To evaluate neuropsychological functioning over time in children treated for acute lymphoblastic leukemia (ALL) with chemotherapy only.

Patients and Methods

Forty-nine consecutive patients (median age at first assessment, 6.8 years; range, 4.0 to 11.8 years) treated with intrathecal and systemic chemotherapy were included in a nationwide, prospective-longitudinal, sibling-controlled study. Patients and siblings completed three extensive neuropsychological assessments: at diagnosis, 3 to 6 months after completion of (2-year) treatment and 4.5 years after diagnosis. Assessments included measures of learning, memory, attention, speed, executive functioning, visual-constructive functioning, and fine-motor functioning. Multilevel analyses were applied to evaluate patients' performances over time and to compare patients to 29 siblings (median age of siblings at first assessment, 8.2 years; range, 4.5 to 12.6 years) and to normative data.

Results

No major differences were found in neuropsychological performance between patients and siblings, with both groups performing mainly in the normal range. The patient group as a whole, however, scored significantly lower than the siblings on complex fine-motor functioning at the last evaluation. Large practice effects were found for both patients and siblings in four of 11 tasks. Patients who uttered physical complaints (ie, pain and/or tiredness) at the first pretreatment assessment scored significantly lower than siblings on attention and speed at the last two evaluations.

Conclusion

Despite intensive and potentially neurotoxic treatment, no evident negative, neuropsychological late effects were found 4.5 years after diagnosis, except for effects on complex fine-motor functioning. Both the large practice effects observed and the poorer performances on sustained attention for patients with physical complaints should be reckoned with in prospective, longitudinal neuropsychological research in children.

Post-treatment intellectual functioning in children treated for acute lymphoblastic leukaemia (ALL) with chemotherapy-only: A prospective, sibling-controlled study

Intellectual functioning (verbal, performance and full-scale IQ) in 43 children treated for acute lymphoblastic leukaemia (ALL) with chemotherapy-only was evaluated in a nationwide, prospective, sibling-controlled study. Intellectual assessment was performed at diagnosis and repeated shortly after cessation of 2 years treatment, including intrathecal and systemic chemotherapy. Using hierarchical regression analysis, patients' and siblings' (n=27) scores were longitudinally analysed and compared to assess possible changes and differences over time. At both assessments, before and after treatment, the patients showed average scores on intelligence tests compared to population norms. Longitudinal analysis and cross-sectional comparisons revealed no significant differences between patients and controls. Young patients showed a small relative decline, albeit not significant, on performance-IQ compared to healthy siblings. Despite intensive and potentially neurotoxic treatment, no evident negative effects on intelligence were found. However, it cannot be precluded that younger patients are at risk for a small decline in PIQ.

Feasibility of neuropsychological assessment in leukaemia patients shortly after diagnosis: directions for future prospective research

AIMS

To study neuropsychological functioning of newly diagnosed children with acute lymphoblastic leukaemia (ALL) within two weeks after diagnosis in order to determine the feasibility of a sibling controlled prospective study design.

METHODS

Fifty consecutive patients (median age at testing 6.6 years, range 4-12) were included in a prospective, longitudinal, nationwide study. Treatment would include intrathecal and systemic chemotherapy according to the DCLSG ALL-9 protocol. Children were evaluated with an extensive neuropsychological battery including measures of intelligence, memory, attention, language, visual-constructive function, and fine-motor abilities within two weeks after start of the chemotherapy. The control group consisted of 29 healthy siblings (median age at testing 8.2 years, range 4-12), who were tested <4 weeks after the patients' assessment.

RESULTS

Mean scores on Wechsler Intelligence Scales did not differ significantly between patients and siblings; mean IQ scores for both the patients and the controls were high average. To examine specific neuropsychological functions, norm scores based on the exact age were acquired by fitting procedures, but no significant differences were found.

CONCLUSIONS

Neuropsychological assessment of patients during early hospitalisation is feasible. The results indicate no adverse effect of illness and psychological factors on IQ and neuropsychological functioning of patients with recently diagnosed ALL. The prospective design of this study of cognitive late effects of chemotherapy will allow discrimination between adverse sequelae of disease and treatment.

Performance of 225 Dutch school children on Rey's Auditory Verbal Learning Test (AVLT): parallel test-retest reliabilities with an interval of 3 months and normative data

Performance on Dutch adaptations of Rey's AVLT was examined in a sample of 225 6- to 12-year-old Dutch school children, selected to be representative of the general population. With an interval of 3 months, they were tested twice, using two out of three test forms which proved to be parallel. No test-retest practice effects were apparent. Age had a considerable impact on test performance. Measured imperfectly, socioeconomic background and intellectual level had some additional influence, as did the examiner who administered the tests. Boys made more errors than girls. Normative data corresponded well with those collected in a smaller Australian sample, suggesting usefulness outside The Netherlands. With a parallel test-retest reliability of.70, which was reduced to.59 when the influence of age was taken into account, the most reliable AVLT measure was the total number of words correctly recalled over the five learning trials. On the basis of reliability data, implications for the clinical use of the AVLT are discussed.

No major cognitive impairment in young children with acute lymphoblastic leukemia using chemotherapy only: a prospective longitudinal study

PURPOSE

To study, using serial neuropsychological assessment and evaluation of school achievement, persistent neuropsychological late effects in children treated for acute lymphoblastic leukemia (ALL) at a young age with chemotherapy only.

PATIENTS AND METHODS

Twenty consecutive patients underwent three evaluations, including 12 psychometric measures beside IQ. The authors applied strict methodology and a prospective-longitudinal design that started at diagnosis and extended to a median follow-up of 7 years. This report focuses on the outcome of the last evaluation. Test results were compared with healthy controls and to patients with ALL treated on a previous chemotherapy-only protocol. School achievement was evaluated in patients and their siblings.

RESULTS

At the last evaluation, significantly lower test scores in patients compared with controls were found for only 2 of 14 cognitive measures (1 intelligence and 1 attention measure). No great differences were seen between school achievement of patients and siblings. Compared with the previous chemotherapy protocol, a better outcome was seen in the current study group on two measures (one memory and one attention measure).

CONCLUSIONS

Children surviving ALL have no major cognitive impairment after chemotherapy, including intrathecal and high-dose intravenous methotrexate. The slightly better outcome in the current group may indicate possible adverse effects of more dexamethasone treatment in the previous group.

Slight cognitive impairment and magnetic resonance imaging abnormalities but normal school levels in children treated for acute lymphoblastic leukemia with chemotherapy only

OBJECTIVES

To investigate persistent neuropsychologic late effects in children treated for acute lymphoblastic leukemia at a young age with chemotherapy only by means of serial neuropsychologic assessments (NPAs), magnetic resonance imaging (MRI) of the brain, and evaluation of school levels.

STUDY DESIGN

Consecutive patients (n = 17) had 2 extensive NPAs (12 psychometric measures) after cessation of therapy. Test results were compared with those of both healthy control subjects and 28 previously treated children who received cranial irradiation. MRI findings were related to test scores. School levels were evaluated in the patients and their healthy siblings.

RESULTS

Initial participation (n = 17) and availability of the study group after 8 years of follow-up were 100%. Significant group differences between patients who received chemotherapy and healthy control subjects were found for memory and fine-motor functioning. The 17 patients combined showed 16 deficits on various test measures. MRI abnormalities were seen in 6 children, but these did not correlate with cognitive performance. No differences in school levels were seen when the patients who received chemotherapy were compared with their siblings. The current nonirradiated patients demonstrated significantly better test results and significantly fewer learning disabilities and MRI abnormalities than did the previously irradiated group.

CONCLUSION

Treatment with chemotherapy only may be associated with some cognitive impairment. However, these children attained normal school levels.

Academic career after treatment for acute lymphoblastic leukaemia

AIM

To evaluate academic career in long term survivors of childhood acute lymphoblastic leukaemia (ALL), in comparison to their healthy siblings.

PATIENTS

Ninety four children treated for ALL with cranial irradiation 18 or 25 Gy and intrathecal methotrexate as CNS prophylaxis. Median age at evaluation was 20 years; median follow up since diagnosis was 15 years at the time of the study.

METHODS

Patients and their 134 siblings completed a questionnaire on school career. The percentage of referrals to special primary schools for learning disabled, and the final level of secondary education in patients and siblings were compared, using a six point classification. Within the patient group, the effect of possible risk factors (age at diagnosis, irradiation dose, and gender) was investigated.

RESULTS

Significantly more patients than siblings were placed in special educational programmes. A significant difference was found for level of secondary education. No effect of gender or irradiation dose was found, but younger age at diagnosis was significantly related to both referrals and school levels.

CONCLUSION

Treatment for childhood ALL with cranial irradiation and chemotherapy at a young age is clearly associated with poorer academic career.

Fine motor and handwriting problems after treatment for childhood acute lymphoblastic leukemia

Motor skills were investigated in 18 children 2 years after treatment for acute lymphoblastic leukemia (ALL). Gross and fine motor functioning were examined with the Movement Assessment Battery for Children. Handwriting as a specific fine motor skill was studied with a computerized writing task. We conclude that 2 years after cessation of treatment motor problems in ALL survivors were still present. Dysfunctions were mainly pronounced in handwriting and fine motor skills.

Stroop interference and disorders of selective attention

Fourteen patients with right-hemisphere CVA and 8 patients with a left-hemisphere CVA were examined for selective attention deficits using a variant of the Stroop color-word task: the picture-word interference task. Experiments 1 and 2 first compared the performance of the two patient groups and a control group in three tasks of increasing difficulty: picture-word detection, word reading, and picture naming. The results showed that (a) the two patient groups were significantly slower than the control group, but did not differ from each other, and (b) the difference in mean RT between the two patient groups and the control group did not increase with task difficulty. In Experiment 3, the subjects were required to name pictures while ignoring accompanying distractors: nonletter symbols, unrelated words or semantically related words. In this task, the right hemisphere patients showed a much larger semantic interference effect than both the left hemisphere patients and the control group. It is argued that this finding most probably reflects problems in visual selective attention with the right hemisphere patients.

Association of 1800 cGy cranial irradiation with intellectual function in children with acute lymphoblastic leukaemia. ISPACC. International Study Group on Psychosocial Aspects of Childhood Cancer

Cranial radiation therapy in childhood acute lymphoblastic leukaemia has been associated with adverse neuropsychological effects, such as low intelligence. However, records show that these associations usually occur when the dose of radiation used is 2400 cGy. We investigated whether a lower dose of 1800 cGy had the same adverse effects on long-term survivors and whether high doses of methotrexate but no radiation therapy would have a more beneficial effect. We evaluated 203 children for six years in a multi-centre European study. The patients were divided into two groups: 129 children treated with 1800 cGy of cranial radiation therapy and 74 children who received high-dose methotrexate but no radiation therapy. We used full scale intelligence quotient, verbal, and performance IQ tests to assess the patient's intelligence. We found a significant decline in full scale intelligence quotient in the irradiated group that increased with the length of time from diagnosis. Younger age at diagnosis was associated with lower full scale intelligence quotient in the radiated group. Our results indicate that a radiation dose of 1800 cGy can have negative effects on neurocognitive function and we continue to question the benefit of low-dose cranial radiation therapy.

Transient mutism and speech disorders after posterior fossa surgery in children with brain tumours

Four patients aged 5 to 9 years with large tumours located in the posterior fossa (PNET, ependymoma or astrocytoma) are presented. Patients received standard neuropsychological assessments, including speech evaluation, prior to surgery. Following tumour resection, these 4 children developed transient mutism or different types of speech and cognitive disorders, associated with behavioural disturbances. We describe course and results of repeated postoperative neurological and neuropsychological evaluations. Full recovery of speech was seen in 3 out of 4 patients; the only child with persistent symptoms was the one who already had neuropsychological deficits before surgery. However, despite fast recovery of the speech disorders more persistent behavioural problems were found in 3 out of 4 patients. Possible pathogenesis anatomical location of this "cerebellar speech syndrome" are discussed, as well as the relevance of repeated neuropsychological assessments.

Cerebrovascular complications of L-asparaginase therapy in children with leukemia: aphasia and other neuropsychological deficits

Children with acute lymphoblastic leukemia (ALL), treated with L-asparaginase are at risk for cerebral thrombosis or hemorrhage because of coagulation protein deficiencies. The results and the importance of serial neuropsychological examinations after such complications in three children with ALL are presented. All patients showed marked aphasia and other cognitive deficits. Recovery was complete in two of three children.

Magnetic resonance imaging of the brain and neuropsychological evaluation in children treated for acute lymphoblastic leukemia at a young age

PURPOSE

To evaluate the adverse late effects of ALL treatment on cognitive functions and brain morphology; to integrate the results of a neuropsychological and neuroradiological study.

PATIENTS AND METHODS

Cranial magnetic resonance imaging (MRI) and neuropsychological assessments (NA) were performed in 35 children treated for acute lymphoblastic leukemia (ALL) with cranial irradiation (CI) and intrathecal and intravenous methotrexate. Patients were under the age of 7 years (MD: 3.5 years) at diagnosis; median follow-up at MRI and NA was 8 years since diagnosis.

RESULTS

MRI's were classified as definitely abnormal in 51% and as probably abnormal in another 17% of the patients. White matter damage was most frequently seen. MRI abnormalities were not related to CI dose or age at diagnosis. Patients showed significantly lower scores, compared to the norm group on measures of intelligence, verbal auditory memory, visual motor integration, and fine motor functioning. Lower scores significantly correlated with higher CI dose (25-32 Gy compared to 18-20 Gy) and younger age at diagnosis (< 4.0 years compared to > or = 4.0 years). Forty percent of the patients had to be referred to schools for learning disabled.

CONCLUSIONS

ALL treatment, including CI and MTX, at a young age is associated with persistent cognitive impairment and MRI abnormalities. However, no correlation was found between MRI results and neuropsychological or academic performance.

Quality of life in bone tumor patients comparing limb salvage and amputation of the lower extremity

In 33 long-term survivors of lower extremity bone cancer quality-of-life data were studied following limb salvage compared to amputation. Self-report questionnaires, semistructured interviews and visual analog scales were used to measure psychoneurotic and somatical distress, activities of daily living, self-esteem, and adjustment to illness. Fourteen patients with limb salvage (age 13-56 years, median 24) and 19 patients with an amputation (age 21-53 years, median 27) were evaluated 2-17 years (median 10 years) after surgery. The differences between the two groups were not statistically significant. However, physical complaints were reported more often by limb salvage patients, whereas the amputees showed a trend toward lower self-esteem and isolation in social life, due to their disability. Both groups felt equal diminution of quality of life and disability as measured on the visual analog scale. These findings could support the cosmetic advantage of limb salvage compared to amputation.

[Cognitive functions and school achievement of children who were treated for acute lymphatic leukemia at a young age]

Neuropsychologic tests were performed in 40 children with acute lymphoblastic leukemia. They all had been treated at a young age with systemic chemotherapy, cranial irradiation and intrathecal methotrexate. The test results showed a high risk for learning disabilities. Visual motor integration problems were present early after cessation of treatment, but most cognitive defects became apparent about 2 years after stopping therapy. At that time 23% (9/40) of the children required special school types and 30% (12/40) needed additional help within their residential school. Problems with arithmetic were most prominent. Future study of patients who did not receive prophylactic irradiation of the brain will help to clarify the potential causative role of cranial irradiation in these cognitive defects.

Experimental chemotherapy in children with cancer--a parent's view

Parental attitude and the parents' perceptions of a child's responsibilities were measured by mailing a questionnaire to 156 parents of cured children of the Pediatric Oncology Center, University of Groningen. Simplistically, the questionnaire concerned parental judgment on (1) the role of the child in decisions about experimental therapy, (2) what information should be related to the child and by whom, (3) parental attitudes toward experimental therapy, and (4) the parents' opinions about ethical aspects of proposing experimental therapy. A high response rate (87.8%) was achieved. A majority of the respondents would allow a child take responsibility in deciding about experimental therapy. In their opinion the median age (16 years) at which a child should be allowed to give consent was higher than the median age (12 years) at which a child should merely be involved in the decision. Parents were more likely to overrule the child's decision if the child decided against experimental therapy than if the child chose the therapy (p less than 0.001). Parents found it more difficult to talk about death than about experimental therapy, and parents would be more willing to involve the physician in discussing experimental therapy than in discussing imminent death with a child (p less than 0.001). Many respondents (68%) felt that the child should be given both altruistic reasons and reasons of self-interest for participating in experimental therapy. About half of all of the respondents believed that a pediatric oncologist should always advise experimental therapy for the benefit of similarly afflicted patients.