Effects of resistive exercise on skeletal muscle in marrow transplant recipients receiving total parenteral nutrition

Skeletal muscle protein loss occurs during marrow transplantation despite total parenteral nutrition. To determine if muscle atrophy could be minimized with exercise therapy, 30 patients undergoing marrow transplantation for acute leukemia completed a prospective randomized trial to receive: (1) no therapy (controls), (2) physical therapy thrice weekly (PT3), or (3) physical therapy five times weekly (PT5). Patients were studied through 35 days posttransplant. Muscle protein status and turnover was assessed by weekly nitrogen balance, and creatinine and 3-methylhistidine excretion. Results favored a muscle protein-sparing effect of exercise, as a significant decrease in creatinine excretion in controls only suggested muscle protein loss associated with inactivity. Changes in arm muscle area correlated with energy, but not protein intake. Large individual variation, inadequate nutritional support and differences in admission arm muscle area may have clouded these results.

EARLY-PHASE ADAPTATIONS TO INTRAHOSPITAL TRAINING IN STRENGTH AND FUNCTIONAL MOBILITY OF CHILDREN WITH LEUKEMIA

Improvements in chemotherapy and radiotherapy have contributed to the high survival rate (approximately 70%) of childhood acute lymphoblastic leukemia (ALL). However, during treatment, lack of physical activity and treatment cause various short- to long-term side effects, such as muscle atrophy and physical deconditioning. The purpose of this study was to determine the effects of an intrahospital, short-duration (8 weeks) exercise training program on muscle strength and endurance and functional mobility of children with ALL. Seven children (4 boys and 3 girls; 4-7 years of age) who were in the maintenance phase of treatment for ALL were selected as subjects. Three training sessions of 90- to 120-minute duration were performed each week. Each session included 11 different strength exercises engaging the major muscle groups and aerobic training. Gains in strength and endurance were assessed with a 6 repetition maximum test for upper (seated bench press and seated lateral row) and lower extremities (leg press). Gains in functional mobility were assessed with the time up and go test (TUG) and the timed up and down stairs test (TUDS). Performance was significantly improved after the training program in all strength tests (p < 0.01 for seated bench press and p < 0.05 for both seated lateral row and seated leg press) and in the TUG test (p < 0.05). In summary, a period of time as short as 8 weeks is enough to produce clinically relevant early-phase adaptations in children receiving treatment against ALL (i.e., improved functional mobility and muscle strength). Although more research is needed in the area of exercise training and pediatric cancer, exercise sciences can play a beneficial role in assisting both oncologists in treating cancer and improving children's quality of life during and after treatment.

The cancer patient at work

The person who has been treated for cancer may have unique problems resuming employment or starting a new job. Cancer represents a spectrum of diseases, and posttreatment impairments may vary from none, in the majority of cases, to major functional disability. Employers understandably have difficulty recognizing the variability that exists, both in terms of functional capacity and prognosis, and they are often unaware of the improved prognosis for many cancers. Today, many patients receive adjuvant chemotherapy or prolonged intermittent treatment and need to adjust their work schedule to allow for this. Some people need job training or vocational counseling; in many states, vocational rehabilitation agencies now have an increased interest in providing services to cancer patients. Discrimination against the cancer patient has been demonstrated; the major problems are in the area of hiring practices. Efforts need to be continued to educate employers and the public and to ensure that the rights of the cancer patient are recognized. We may, however, do our patients a disservice if we overemphasize potential problems to a degree that increases patient fear and insecurity in regard to employment. Instead, we as physicians may be able to help prevent problems by more effective communication with employers on behalf of our patients, as well as by direct patient counseling. The insurance problems of cancer patients, particularly those relating to health insurance, do require major attention. The potential productivity, as well as the quality of life, of the cancer patient are jeopardized when he or she feels unable to change jobs because of fear of loss of insurance coverage. The relatively high number of reported cancellations and changes in insurance benefits that have been reported by cancer patients also represents an area of concern, since some of these appear medically unjustified. The physician's opinion and input may be of importance in preventing or solving individual insurance problems. The physician can also help the cancer patient who has employment problems by providing information about available resources. The above-mentioned employment booklet (#4585-PS), available from the ACS, may be useful and contains information about legal resources. Referral to a vocational rehabilitation agency may be indicated. The best medicine of all may be a positive and optimistic attitude toward the patient's participation in the work force.

A Feasibility Study of Virtual Reality Exercise in Elderly Patients with Hematologic Malignancies Receiving Chemotherapy

OBJECTIVE

Adherence to rehabilitation exercise is much lower in patients with hematologic malignancies (22.5-45.8%) than in patients with solid tumors (60-85%) due to the administration of more intensive chemotherapeutic regimens in the former. Virtual reality exercise can be performed even in a biological clean room and it may improve the adherence rates in elderly patients with hematologic malignancies. Thus, in this pilot study, we aimed to investigate the feasibility and safety of virtual reality exercise intervention using Nintendo Wii Fit in patients with hematologic malignancies receiving chemotherapy.

METHODS

In this feasibility study, 16 hospitalized patients with hematologic malignancies aged ≥60 years performed virtual reality exercise for 20 minutes using the Nintendo Wii Fit once a day, five times a week, from the start of chemotherapy until hospital discharge. The adherence rate, safety, and physical and psychological performances were assessed.

RESULTS

The adherence rate for all 16 patients was 66.5%. Nine patients completed the virtual reality exercise intervention with 88 sessions, and the adherence rate was 62.0%. No intervention-related adverse effects >Grade 2, according to National Cancer Institute Common Terminology Criteria for Adverse Events version 3.0, were observed. We noted maintenance of the physical performance (e.g., Barthel index, handgrip strength, knee extension strength, one-leg standing time, and the scores of timed up and go test and Instrumental Activities of Daily Living) and psychosocial performance (e.g., score of hospital anxiety and depression scale).

CONCLUSION

Virtual reality exercise using the Wii Fit may be feasible, safe and efficacious, as demonstrated in our preliminary results, for patients with hematologic malignancies receiving chemotherapy.

Patient involvement in research priorities (PIRE): a study protocol

INTRODUCTION

Patient involvement in healthcare has expanded from the clinical practice setting to include collaboration during the research process. There has been a growing international interest in patient and public involvement in setting research priorities to reduce the risk of discrepancy between what patients with cancer and their relatives experience as important unanswered questions and those which are actually researched. This study aims to challenge the conventional research process by inviting patients with life-threatening cancer (primary malignant brain tumours or acute leukaemia), relatives and patient organisations to join forces with clinical specialists and researchers to identify, discuss and prioritise supportive care and rehabilitation issues in future research.

METHODS AND ANALYSIS

This is an exploratory qualitative study comprising two sets of three focus group interviews (FGIs): one set for primary malignant brain tumours and the other for acute leukaemia. Separate FGIs will be carried out with patients and relatives including representation from patient organisations and clinical specialists to identify important unanswered questions and research topics within each group. The FGIs will be video/audio recorded, transcribed and thematically analysed. This study will contribute to a patient-centred research agenda that captures issues that patients, their relatives, clinical specialists and researchers consider important.

ETHICS AND DISSEMINATION

The study is registered at the Danish Data Protection Agency (number: 2012-58-0004) and the Scientific Ethics Review Committee of the Capital Region of Denmark (number: H-15001485). Papers will be published describing the methods applied and the supportive care and rehabilitation issues that are identified as important for future research.

TRIAL REGISTRATION NUMBER

ISRCTN57131943; Pre-results.

Preliminary study of the lived experience of exercise for cancer survivors

There is a growing body of evidence indicating the physical and psychosocial health benefits of exercising during cancer rehabilitation. However, physical activity levels of cancer survivors are generally low. This study adopted a qualitative approach to increase understanding of the lived experience of exercise for cancer survivors. Semi-structured interviews were carried out with six female cancer survivors who had taken part in the 2003 Race for Life fundraising event for Cancer Research UK. Following verbatim transcription of interviews, data reduction was carried out using Van Manen's method of thematic content analysis. Assimilation of central themes forms the basis of the final report. The essence of cancer survivors' experience of exercise was determined as 'going forward'-to move on, physically and mentally following treatment, to rebuild social networks, and to restore a positive, confident outlook towards the future. The central theme of 'going forward' was identified in aspects of participants' physical and mental recovery, and their future intentions for exercise. Race for Life represented a positive focus for participants after cancer treatment, and proved to be an appropriate starting point for initiating, or returning to exercise following cancer. The results of the study support the suggestion that advice regarding exercise should be included in rehabilitation care for some cancer patients.

A summer camp for children with cancer

The prognosis for children with cancer has changed significantly over the past 10 years. Currently, it is anticipated that cure can be achieved in approximately 50% of newly diagnosed cases of childhood cancer. The quality of life for these children depends not only on their medical treatment but also on the successful management of the psychological problems related to their diagnosis. A summer camp was established in Florida as a part of our psychosocial rehabilitation program for pediatric cancer patients. Participating in the day-to-day camp life were 26 children with various forms of cancer. Each child not only had the opportunity to enjoy a normal out-of-door life style, away from their overprotective parents, but experienced daily contact with other children who shared a similarly stressful existence. It is felt the awareness gained through the realization that they were not along in their plight and the independence instilled through separation from parents was beneficial to each child. It is anticipated that future camps with the inclusion of psychological testing will provide us with the opportunity to further assess the need for psychosocial rehabilitation for the child with cancer.

Survivors of childhood leukaemia treated with haematopoietic stem cell transplantation and total body irradiation should undergo screening for diabetes by oral glucose tolerance tests

AIMS

Childhood cancer survivors treated with haematopoietic stem cell transplantation (HSCT) and total body irradiation are at an increased risk of developing diabetes early in life due to insulin resistance and β-cell dysfunction, but the optimal screening method is unknown. The National Institute for Health and Care Excellence guidelines for community diabetes screening recommend using fasting glucose ≥ 7 mmol/l and/or HbA1c ≥ 48 mmol/mol (6.5%) for diagnosis and, fasting glucose 5.5-6.9 mmol/l or HbA1c 42-47 mmol/mol (6-6.5%) to indicate high risk. This study aimed to evaluate the sensitivities of fasting glucose and HbA1c in the diagnosis of diabetes and impaired glucose tolerance in childhood HSCT survivors.

METHOD

The patients were 35 (male = 19) HSCT survivors from a single UK centre under follow-up from 2006 to 2013. Patients had a median age (range) of 19.2 (13.1-26.2) years and had been treated for acute lymphoblastic (n = 31) or myeloid (n = 4) leukaemia when aged 7.8 (2.4-16.7) years. The outcome measures were oral glucose tolerance test (OGTT), fasting glucose and HbA1c .

RESULTS

OGTT identified 6 patients with diabetes (120-min glucose ≥ 11.1 mmol/l), 12 with impaired glucose tolerance (120-min glucose 7.8-11.0 mmol/l) and 2 with impaired fasting glucose (≥ 7 mmol/l). Fasting glucose ≥ 7 mmol/l or HbA1c ≥ 48 mmol/mol identified two of the six patients with diabetes diagnosed on OGTT. Fasting glucose ≥ 5.5 mmol/l and HbA1c ≥ 42 mmol/mol identified three and two patients, respectively, with diabetes. Only 1 of 12 patients with impaired glucose tolerance had a fasting glucose ≥ 5.5 mmol/l and none had HbA1c ≥ 42 mmol/mol (≥ 6%).

CONCLUSIONS

The fasting glucose and HbA1c cut-offs used in UK population screening only identified one-third of HSCT survivors with diabetes and do not identify those at risk. Diabetes screening in HSCT survivors requires standard OGTTs.

The role of rehabilitation measures in reintegration of children with brain tumours or leukaemia and their families after completion of cancer treatment: a study protocol

INTRODUCTION

For ill children as well as for their parents and siblings, childhood cancer poses a major challenge. Little is known about the reintegration into daily life of childhood cancer survivors and their families. The aim of this prospective observational study is to further the understanding of the role of rehabilitation measures in the reintegration process of childhood leukaemia or brain tumour survivors and their family members after the end of cancer treatment.

METHODS AND ANALYSIS

This prospective observational study consists of three study arms: a quantitative study in cooperation with three German paediatric oncological study registries (study arm 1), a quantitative study in cooperation with a rehabilitation clinic that offers a family-oriented paediatric oncological rehabilitation programme (study arm 2) and a qualitative study at 12-month follow-up including families from the study arms 1 and 2 (study arm 3). In study arm 1, children, parents and siblings are surveyed after treatment (baseline), 4-6 months after baseline measurement and at 12-month follow-up. In study arm 2, data are collected at the beginning and at the end of the rehabilitation measure and at 12-month follow-up. Families are assessed with standardised questionnaires on quality of life, emotional and behavioural symptoms, depression, anxiety, fear of progression, coping and family functioning. Furthermore, self-developed items on rehabilitation aims and reintegration into daily life are used. Where applicable, users and non-users of rehabilitation measures will be compared regarding the outcome parameters. Longitudinal data will be analysed by means of multivariate analysis strategies. Reference values will be used for comparisons if applicable. Qualitative data will be analysed using thematic analysis.

ETHICS AND DISSEMINATION

This study has been approved by the medical ethics committee of the Medical Chamber of Hamburg. Data will be published in peer-reviewed journals and presented at conferences.

Health-related Quality of Life for Children With Leukemia: Child and Parental Perceptions

BACKGROUND

The importance of health-related quality of life (HRQoL) in patients with acute lymphoblastic leukemia (ALL) has increased in recent years. This study aimed to assess HRQoL in children with ALL, affecting factors, and the relationship between parent proxy-report and child self-report HRQoL.

MATERIALS AND METHODS

A total of 59 children and their parents (both mother and father) were enrolled in this cross-sectional study. Turkish version of the Pediatric Quality of Life Inventory (PedsQL) 3.0 Cancer Modules were used to determine HRQoL.

RESULTS

According to subscales of the self-report form, nausea and operational anxiety scores differed significantly by the treatment status; communication score varied considerably by the hospitalization length of stay; pain and hurt, cognitive problems, and perceived physical appearance scores differed significantly by the maternal chronic disease status (P<0.05). The presence of maternal chronic disease was significantly related to the total score of the parent-proxy report (mother) (P<0.05). There was a moderate correlation between total scores of child and mother (P<0.05, r=0.419) but not with the father.

CONCLUSION

Children on-treatment had significant problems in nausea and procedural anxiety subscales; however, children who were hospitalized more had fewer issues in the communication subscale. Also, children whose mother had chronic disease had poorer HRQoL regarding pain and hurt cognitive problems and treatment anxiety. Given the importance of assessment and monitoring HRQoL in children with ALL, health professionals should be aware of how parents' chronic disease affects HRQoL. Psychosocial support should be provided to children and their parents, especially for those whose parents have a chronic illness.

Growth factors and DLI in adult haploidentical transplant: a three-step pilot study towards patient and disease status adjusted management

Haploidentical transplant is now established as a procedure of choice for patients who lack a compatible donor. However, they are still referred too late, heavily pretreated, at very advanced stages. We initiated a three-step phase I study trying improve transplant-related mortality, relapse rate, and immunity: G-CSF + DLI, GM-CSF + DLI, patient- and disease-adapted strategy. Thirty-three consecutive leukemia patients, aged 18-55, were investigated (20 very poor risk, 11 poor risk, and 2 better risk). GvH type NK alloreactivity was chosen when possible (18/33) and balanced across the three groups. In the first nine patients, G-CSF was used and escalated prophylactic DLI started at month 1. Thus, G-CSF and 1-3 DLI (10(4) CD3/kg) is safe. It results in faster CD4 recovery and a low rate of infections. However, it was insufficient to induce a GVL effect. In the next 12 patients, GM-CSF was used plus 1 DLI (10(4) CD3/kg) at day 30 unless aGVHD (3 patients). The comparison between the two first groups can be summarized as follows: G-CSF + DLI: TRM at day 100: 0, RR: 6/9, severe aGVHD: 0. GM-CSF + 1 DLI group: RR: 1/12, TRM at day 100: 3, aGVHD > 1: 9/12, price to pay: GVHD resulting in five deaths in total. Step 3 (13 patients) consists of a patient-adapted strategy: no more aspecific DLI (selected anti-CMV and aspergillus DLI planned in all patients); in myeloid disorders with NK alloreactivity: no GF. In the other cases, GM-CSF (at a reduced total dose of 500 mug) is given the follow-up of these 13 patients, although promising is currently short (median 5 months). Overall, TRM at day 100 is 3/29, reflecting the good tolerance of the conditioning in a heavily pretreated population (median age: 43). NRR mortality (8/26) at 1 year is greater in the GM-CSF + DLI group, reflecting the impact of severe aGVHD. We conclude that the third strategy might improve the outcome without exposing patients to unnecessary severe GVHD.

[Promoting social integration as the responsibility of rehabilitation in pediatric oncology]

Survival rates of most paediatric cancers are steadily improving as a result of improvements in diagnostics and treatment protocols. Long-term survival renders physical late effects and psychosocial adjustment problems ever more visible. The focus of this article is on school re-entry and social reintegration as core tasks of comprehensive rehabilitation efforts. So far only few systematic programmes exist in Germany to facilitate school re-entry and social integration of paediatric cancer survivors. The article outlines the prerequisites for such interventions and provides examples of re-entry programmes.

The Italian Consensus Conference on the role of rehabilitation for children and adolescents with leukemia, central nervous system tumors, and bone cancer, part 2: general principles for the rehabilitation treatment of motor function impairments

In Italy, 1400 children and 800 adolescents are diagnosed with cancer every year. About 80% of them can be cured but are at high risk of experiencing severe side effects, many of which respond to rehabilitation treatment. Due to the paucity of literature on this topic, the Italian Association of Pediatric Hematology and Oncology organized a Consensus Conference on the role of rehabilitation of motor impairments in children/adolescents affected by leukemia, central nervous system tumors, and bone cancer to state recommendations to improve clinical practice. This paper includes the consensus on the rehabilitation of children and adolescents with these cancers.

[Multiple organ failure in patients with hemoblastosis during long-term follow-up of treatment]

AIM

Investigation of the condition of the liver, gastrointestinal tract, heart in patients at the stage of clinicohematological remission after treatment for hemoblastosis (acute leukemia, Hodgkin's disease, non-Hodgkin's lymphoma).

RESULTS

Marked functional-morphological changes were found: endomyocardial fibrosis, cardiopathy, pulmonary hypertension, chronic atrophic gastritis, colon lesions, dysbacteriosis, viral or drug-induced hepatitis.

CONCLUSION

The above affections have developed because of the treatment: chemotherapy, radiotherapy, hemotransfusions, antibacterial drugs. They deteriorate life quality and require a special system of rehabilitation measures.