Educational deficits in survivors of childhood cancer

Some long-term survivors of childhood cancer experience changes in cognitive functioning and have learning difficulties in school. Psychological and educational studies of children who received cranial irradiation in treatment for acute lymphocytic leukemia or brain tumor have identified specific disabilities. A coordinated educational intervention approach is needed, using special education services available through local school districts.     

Monitoring for cardiovascular disease in survivors of childhood cancer: report from the Cardiovascular Disease Task Force of the Children's Oncology Group

Curative therapy for childhood cancer has improved significantly in the last 2 decades such that, at present, approximately 80% of all children with cancer are likely to survive > or = 5 years after diagnosis. Prevention, early diagnosis, and treatment of long-term sequelae of therapy have become increasingly more significant as survival rates continue to improve. Cardiovascular disease is a well-recognized cause of increased late morbidity and mortality among survivors of childhood cancer. The Children's Oncology Group Late Effects Committee and Nursing Discipline and Patient Advocacy Committee have recently developed guidelines for follow-up of long-term survivors of pediatric cancer. A multidisciplinary task force critically reviewed the existing literature to evaluate the evidence for the cardiovascular screening recommended by the Children's Oncology Group guidelines. In this review we outline the clinical manifestations of late cardiovascular toxicities, suggest modalities and frequency of monitoring, and address some of the controversial and unresolved issues regarding cardiovascular disease in childhood cancer survivors.     

Educational achievement of long-term survivors of childhood and adolescent cancer

In a retrospective cohort study, the level of education attained by 2,283 long-term survivors of childhood and adolescent cancer was investigated and compared with that of 3,270 sibling controls. Survivors of central nervous system tumors were significantly less likely than controls to complete eight grades of school or, if they completed high school, to enter college. No significant differences in educational achievement were found for survivors of non-central nervous system cancers. The educational deficit of survivors of brain tumors was especially striking for tumors of the ventricles or cerebral hemispheres, and the deficit was more severe for those treated with radiation therapy than by surgery alone. Early age at diagnosis of a central nervous system tumor was associated with a larger educational deficit than late age at diagnosis. These findings are reassuring for the majority of long-term survivors of childhood and adolescent cancers given therapies used prior to 1975.     

Langerhans cell histiocytosis: update for the pediatrician

PURPOSE OF REVIEW: Langerhans cell histiocytosis is the commonest of the histiocytic disorders. Owing to the relative rarity of the condition, it remains a disease in which the diagnosis is often delayed or missed and in which many questions remain unanswered, ranging from etiology and pathogenesis to therapy. The management is often frustrating for care-givers and parents/patients. The purpose of the review is therefore to raise awareness of the disease and to highlight the clinical findings that should make the pediatrician or primary care-giver suspect the diagnosis, as well as current thinking regarding management of the various and diverse manifestations of this disease. RECENT FINDINGS: We discuss new and interesting insights into the biology of Langerhans cell histiocytosis that raise the possibility of future targeted therapy. Important points in the diagnosis, investigation and management of the various forms of the disease are also discussed. SUMMARY: We present a review of childhood Langerhans cell histiocytosis, highlighting new insights into pathogenesis and management of the various forms of this complex disease.     

Hepatitis B in childhood: An update for the paediatrician

Hepatitis B virus (HBV) infection may lead to acute or chronic hepatitis, cirrhosis and hepatocellular carcinoma. The incidence rate of paediatric hepatitis B is 0.2/100,000 to 1.8/100,000 in Canada. Hepatitis B virus infection is acquired largely through mother-to-infant (vertical) or community-based (horizontal) transmission in early childhood, whereas older children are susceptible to HBV infection through exposure to contaminated blood during intravenous drug use or through sexual transmission. Immigrants from endemic areas and some Native Canadian populations are also at a higher risk for HBV infection. Infection with HBV may manifest in three forms: acute self-limited hepatitis, chronic hepatitis or massive hepatic necrosis causing acute liver failure. The identification of HBV infection and the characterization of the disease relies on serological and virological tests. The course of chronic hepatitis B may be classified into three phases: an immunotolerant phase, an active phase and an inactive phase. Current treatment options include interferon-alpha and lamivudine for individuals with elevated serum alanine aminotransferase levels and markers of persistent viral replication. Children with chronic hepatitis B require regular monitoring and age-appropriate lifestyle counselling. Paediatricians are well-positioned to promote vaccination and encourage testing of those who are at risk for hepatitis B. With effective universal vaccination against hepatitis B, this infection could be essentially eliminated in Canada.     

What's new in pediatric dermatology: update for the pediatrician

PURPOSE OF REVIEW: Common pediatric skin conditions such as infantile atopic dermatitis, vitiligo, hemangiomas of infancy, warts, and molluscum contagiosum do not always respond to standard therapy. In some settings pediatricians will use "off-label" medications if the benefit-to-risk ratio is favorable. This article reviews important literature from the past year related to "off-label" immune-based treatment of skin disease, using the topical immunomodulators tacrolimus, pimecrolimus, and imiquimod, as well as intravenous Ig. RECENT FINDINGS: The topical immunomodulators tacrolimus and pimecrolimus have been embraced by pediatricians as long awaited alternatives for treating atopic dermatitis in children 2 years of age and older. Their unique appeal as nonsteroidal topical agents with good safety profiles has led to their frequent use for unapproved indications. A number of recent publications detail their use in infantile atopic dermatitis in children as young as 3 months of age, as well as use in other conditions such as vitiligo. Imiquimod, another topical immunomodulator, approved for genital wart treatment in adults, has also been examined for "off-label" pediatric use in nongenital warts, molluscum contagiosum, hemangiomas of infancy, and basal cell carcinoma. Finally, "off-label" use of intravenous Ig has been evaluated for the life-threatening dermatoses Stevens-Johnson syndrome and toxic epidermal necrolysis. SUMMARY: In the absence of larger controlled trials, pediatricians must consider the cumulative weight of smaller studies with their personal experience when assessing any role for "off label" therapy. The recent literature reviewed herein will facilitate such assessments of the non-steroid topical immune modifiers tacrolimus, pimecrolimus, and imiquimod as well as intravenous immunoglobulin.     

Congenital melanocytic nevi: an update for the pediatrician

While melanoma is uncommon in childhood, recent evidence suggests that its incidence is increasing in both adolescence and adulthood. Risk factors may be identifiable during childhood and include congenital nevi. Large congenital nevi carry a significantly increased risk for the development of melanoma, both cutaneous and extracutaneous. This risk appears to be greatest during early childhood. Large congenital nevi, particularly those overlying the head and neck, may also be associated with neurocutaneous melanosis. Symptomatic neurocutaneous melanosis, although rare, carries a poor prognosis. Conversely, asymptomatic neurocutaneous melanosis may be more common than previously recognized. For the most part, large congenital nevi are treated with primary excisions and closures, assisted by tissue-expansion techniques and skin grafting. Until the associated risks are better defined, therapy of small congenital nevi should be individualized, with consideration given to additional melanoma risk factors.     

Bronchopulmonary dysplasia (chronic lung disease of infancy): an update for the pediatrician

This paper is a review of the changes that have occurred over the past 35 years in the clinical and radiologic presentation of bronchopulmonary dysplasia (BPD), now more commonly referred to as chronic lung disease of infancy (CLD). Curent thoughts on etiology are only briefly discussed. The major focus is the management of the patient with CLD by the primary care physician once the patient has been discharged from hospital. Oxygen, diuretic, bronchodilator, antiinflammatory and nutritional therapies are discussed in detail. Finally, current information on long-term prognosis and recommendations for the prevention of RSV and influenza infections are reviewed.     

Models of care for survivors of childhood cancer

With improvements in therapy for childhood cancer, the expectation that most childhood cancer patients will survive and enter adulthood is a reality. There is clear evidence that survivors are at risk for adverse health-related long-term sequelae associated with their cancer and its treatment, requiring appropriate health care resources. What is less clear is how this health care should optimally be delivered. We review the functional and operational needs for long-term follow-up for childhood cancer survivors and present alternatives for models of care. Programs for childhood cancer survivors should provide mechanisms for monitoring and management of late effects, as well as support and advocacy for addressing psychosocial issues, health education, and assistance with financial concerns. Access to research is an important component as clinical care and research are integrally related. A multidisciplinary model that provides continuity of care throughout the disease course is optimal, providing transitions from acute anti-neoplastic therapy to follow-up and primary care, as well as from pediatric care to adult-oriented care. There is no single best model of care for all childhood cancer survivors. In evaluating different models, considerations include available resources as well as the particular cancer population being served. Not all survivors require the same level of services and the service level requirement for individual patients may change with time. As outcome research progresses for childhood cancer survivors, methodological issues of optimal health care delivery for this population deserve to be the subject of such research.     

Clinic audit for long-term survivors of childhood cancer

Follow up for survivors of childhood cancer is considered essential in order to document any continuing impact on growth, fertility and other systems, as well as provide appropriate care and information to individuals themselves. Appropriate follow up needs to take into account the survivors' own views about reasons for attendance and perceived satisfaction with the services provided. Information was sought from 93 survivors (more than five years from diagnosis) and 68 of their parents regarding current attendance, understanding of the purpose of the clinic and satisfaction, and future preferences. Patients' main reasons for attending were to gain reassurance that they were well and information about the disease. There were some discrepancies between the types of information patients would like from clinic attendance and what they remembered being given. Parents were more positive than patients. Our data suggest that (i) knowledge in survivors is poor and (ii) it may be possible to define a subgroup for whom less frequent follow up is appropriate. A key component of care must involve education of patients, both about their past and the implications for future health.     

Educational and occupational outcomes among survivors of childhood cancer during the transition to emerging adulthood

PURPOSE: To examine educational and occupational outcomes among survivors of childhood cancer and peers during the transition from adolescence to emerging adulthood. METHODS: Families were recruited when children with cancer were 8 to 15 years old and receiving initial treatment for a malignancy that did not primarily affect the central nervous system (CNS). At that time, each child with cancer was matched to a classmate of similar age, gender, and race for inclusion in a comparison group. For the current follow-up (7.29 years postdiagnosis), 56 survivors, 60 peers, and their parents completed questionnaires soon after the youth's 18th birthday. Severity of treatment and late effects were rated by healthcare providers. RESULTS: Survivors and peers were similar on a variety of outcomes, including family background, scholastic and occupational self-concept, and academic competence. However, survivors were more likely to report repeating a grade and having more school absences. The proportion of participants who graduated from high school, were working, and expressed plans to attend postsecondary education or seek employment were similar between groups. Initial treatment intensity, time since diagnosis, and severity of late effects were associated with several indices of educational and occupational attainment. CONCLUSIONS: Despite being more likely to repeat a grade and miss school, survivors of nonCNS cancer were similar to peers on most educational and occupational outcomes during the transition from adolescence to emerging adulthood. Interventions to assist academic or occupational functioning may not be necessary for all survivors, but additional research is needed to identify subgroups at risk for difficulties.     

Alexithymia in long-term survivors of childhood cancer

OBJECTIVE: To investigate the incidence of alexithymia (difficulties in describing or recognizing one's own emotions, a limited fantasy life, and general constriction in the affective life) in a group of childhood cancer survivors and to explore medical determinants which predict alexithymia. METHODS: Five years after completing therapy, 72 participants were asked to complete the Bermond-Vorst Alexithymia Questionnaire (BVAQ). RESULTS: Male cancer survivors scored significantly lower on overall alexithymia compared to healthy males. They also showed higher ability to fantasize, a higher emotional arousal, and were better able to verbalize their emotional reactions. The female survivors did not show differences compared to the normal female population. No medical determinant was associated with alexithymia. CONCLUSIONS: Stress due to childhood cancer does not affect the alexithymia scores of females. However, male cancer survivors score less alexithymic than age matched controls.