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Belsky JA, Brown AM. Investigating the safety and feasibility of osteopathic manipulative medicine in hospitalized children and adolescent young adults with cancer. J Osteopath Med 2024; 0:jom-2024-0013. [PMID: 38669608 DOI: 10.1515/jom-2024-0013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 04/08/2024] [Indexed: 04/28/2024]
Abstract
CONTEXT Children and adolescents young adults (AYAs) undergoing treatment for oncologic diagnoses are frequently hospitalized and experience unwanted therapy-induced side effects that diminish quality of life. Osteopathic manipulative treatment (OMT) is a medical intervention that utilizes manual techniques to diagnose and treat body structures. Few studies have investigated the implementation of OMT in the pediatric oncology outpatient setting. To date, no studies have investigated the safety and feasibility of OMT in the pediatric oncology inpatient setting. OBJECTIVES The objective of this study is to investigate the safety and feasibility of OMT in the pediatric oncology inpatient setting. METHODS This is a prospective, single-institution pilot study evaluating children and AYAs aged ≥2 years to ≤30 years with a diagnosis of cancer hospitalized at Riley Hospital for Children (RH) from September 2022 to July 2023. Approval was obtained from the Indiana University Institutional Review Board (IRB). Patients were evaluated daily with a history and physical examination as part of routine inpatient management. Patients who reported chemotherapy side effects commonly encountered and managed in the inpatient setting, such as pain, headache, neuropathy, constipation, or nausea, were offered OMT. Patients provided written informed consent/assent prior to receiving OMT. OMT was provided by trained osteopathic medical students under the supervision of a board-certified osteopathic physician and included techniques commonly taught in first- and second-year osteopathic medical school curricula. Safety was assessed by a validated pain (FACES) scale immediately pre/post-OMT and by adverse event grading per Common Terminology Criteria for Adverse Events (CTCAE) 24 h post-OMT. All data were summarized utilizing descriptive statistics. RESULTS A total of 11 patients were screened for eligibility. All patients met the eligibility criteria and were enrolled in the study. The majority of patients were male (n=7, 63.6 %) with a median age of 18.2 years at time of enrollment (range, 10.2-29.8 years). Patients had a variety of hematologic malignancies including B-cell acute lymphoblastic leukemia (ALL) (n=5, 45.5 %), T-cell ALL (n=1, 9.1 %), acute myeloid leukemia (AML) (n=2, 18.2 %), non-Hodgkin's lymphoma (n=2, 18.2 %), and Hodgkin's lymphoma (n=1, 9.1 %). All patients were actively undergoing cancer-directed therapy at the time of enrollment. There were 40 unique reasons for OMT reported and treated across 37 encounters, including musculoskeletal pain (n=23, 57.5 %), edema (n=7, 17.5 %), headache (n=5, 12.5 %), peripheral neuropathy (n=2, 5.0 %), constipation (n=2, 5.0 %), and epigastric pain not otherwise specified (n=1, 2.5 %). Validated FACES pain scores were reported in 27 encounters. Of the 10 encounters for which FACES pain scores were not reported, 8 encounters addressed lower extremity edema, 1 encounter addressed peripheral neuropathy, and 1 encounter addressed constipation. The total time of OMT was documented for 33 of the 37 encounters and averaged 9.8 min (range, 3-20 min). CONCLUSIONS Hospitalized children and AYAs with cancer received OMT safely with decreased pain in their reported somatic dysfunction(s). These findings support further investigation into the safety, feasibility, and efficacy of implementing OMT in the pediatric oncology inpatient setting and to a broader inpatient pediatric oncology population.
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Affiliation(s)
- Jennifer A Belsky
- Department of Pediatric Hematology/Oncology, Riley Hospital for Children, Indianapolis, IN, USA
| | - Amber M Brown
- Department of Pediatric Hematology/Oncology, Riley Hospital for Children, Indianapolis, IN, USA
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Jung SY. Commentary on "Long-term endocrine sequelae after hematopoietic stem cell transplantation in children and adolescents". Ann Pediatr Endocrinol Metab 2024; 29:73-74. [PMID: 38712490 PMCID: PMC11076229 DOI: 10.6065/apem.2423023edi02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/08/2024] Open
Affiliation(s)
- So Yoon Jung
- Department of Pediatrics, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
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Yamanishi AD, Determan D, Kuo DJ. Dose-Related Effect of Chemotherapy on Bone Mineral Density Among Pediatric Acute Lymphoblastic Leukemia Survivors. J Pediatr Pharmacol Ther 2024; 29:53-60. [PMID: 38332966 PMCID: PMC10849689 DOI: 10.5863/1551-6776-29.1.53] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 03/06/2023] [Indexed: 02/10/2024]
Abstract
OBJECTIVES Reduced bone mineral density (BMD) can negatively affect lifelong skeletal health by -increasing the risk for developing osteopenia and osteoporosis. This study evaluated the relationship between BMD and cumulative doses of intravenous (IV) methotrexate (MTX) and glucocorticoids in pediatric acute lymphoblastic leukemia (ALL) survivors. The association between BMD and vitamin D concentrations measured at the time of entry into the long-term follow-up program was also assessed. METHODS This retrospective study included pediatric ALL survivors who had received a dual-energy X-ray absorptiometry (DXA) scan after the end of therapy (EOT) or within the 6 months prior to the EOT. Low/-intermediate and high cumulative IV MTX doses were defined as doses less than 20,000 mg/m2 and -greater than or equal to 20,000 mg/m2, respectively. Descriptive statistics, Student t test, and linear -regression were used to analyze the data. RESULTS A total of 62 patients, with 34 patients in the low/intermediate and 28 patients in the high -cumulative IV MTX dose groups, were analyzed. The median time from EOT to DXA scan was 2.3 years. The mean DXA lumbar spine z score was significantly lower in the high cumulative IV MTX dose group -compared with the low/intermediate dose group (-0.86 vs -0.14; p = 0.008). Cumulative glucocorticoid doses and vitamin D concentrations were not associated with BMD. CONCLUSIONS Pediatric patients who had received cumulative IV MTX doses of greater than or equal to 20,000 mg/m2 during their ALL treatment had lower BMD than those who had received lower cumulative doses.
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Affiliation(s)
- Annie D. Yamanishi
- Department of Pharmacy (ADY, DD), Rady Children’s Hospital – San Diego, San Diego, CA
| | - Deb Determan
- Department of Pharmacy (ADY, DD), Rady Children’s Hospital – San Diego, San Diego, CA
| | - Dennis J. Kuo
- Division of Pediatric Hematology-Oncology (DJK), Department of Pediatrics, Rady Children’s Hospital – San Diego, San Diego, CA
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Nakamura M, Ohba T, Sasaki R, Saito F, Yamaguchi M, Motohara T, Mabe H, Lu X, Katabuchi H, Kondoh E. Advantages and limitations of estrogen replacement therapy on hypogonadal survivors of childhood cancer. Int J Clin Oncol 2023; 28:1563-1572. [PMID: 37646971 DOI: 10.1007/s10147-023-02405-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 08/14/2023] [Indexed: 09/01/2023]
Abstract
BACKGROUND Hypogonadism is a significant late complication in childhood cancer survivors (CCS). The aim of this study was to elucidate the advantages and limitations of estrogen replacement therapy (ERT) for CCS with hypogonadism. METHODS Seventeen CCS were divided into two groups: gonadal hypogonadism (GH) group (n = 8) and central hypogonadism (CH) group (n = 9). Pearson correlation coefficients were used to investigate the impact of cancer management on final height, bone density, and uterine development. RESULTS Seven of GH group had hematologic malignancies, and all of them underwent total body irradiation before bone marrow transplantation. The GH group showed significant positive correlations between the onset age of disease treatment and final height (p < 0.05, R = 0.712) and uterine size following ERT (p < 0.05, R = 0.775). All CCS in the CH group had brain tumors, and seven of them received chemotherapy. There were trends towards positive and negative correlations between the onset age of disease treatment and final height (p = 0.09, R = 0.598) or uterine size (p = 0.07, R = - 0.669), respectively. A negative correlation trend was observed between the age at ERT initiation and final height (p = 0.07, R = - 0.769) or bone density (p = 0.18, R = - 0.626) in six CH patients who received growth hormone therapy. Five CCS in both groups experienced osteoporosis, despite receiving ERT. CONCLUSION Individualized management strategies beyond ERT are essential to reduce long-term complications in CCS with hypogonadism, considering the type and timing of cancer treatment.
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Affiliation(s)
- Miwa Nakamura
- Department of Obstetrics and Gynecology, Faculty of Life Sciences, Kumamoto University, 1-1-1, Honjo, Chuo-Ku, Kumamoto City, Kumamoto, 860-8556, Japan.
| | - Takashi Ohba
- Department of Obstetrics and Gynecology, Faculty of Life Sciences, Kumamoto University, 1-1-1, Honjo, Chuo-Ku, Kumamoto City, Kumamoto, 860-8556, Japan
| | - Rumi Sasaki
- Department of Obstetrics and Gynecology, Faculty of Life Sciences, Kumamoto University, 1-1-1, Honjo, Chuo-Ku, Kumamoto City, Kumamoto, 860-8556, Japan
| | - Fumitaka Saito
- Department of Obstetrics and Gynecology, Faculty of Life Sciences, Kumamoto University, 1-1-1, Honjo, Chuo-Ku, Kumamoto City, Kumamoto, 860-8556, Japan
| | - Munekage Yamaguchi
- Department of Obstetrics and Gynecology, Faculty of Life Sciences, Kumamoto University, 1-1-1, Honjo, Chuo-Ku, Kumamoto City, Kumamoto, 860-8556, Japan
| | - Takeshi Motohara
- Department of Obstetrics and Gynecology, Faculty of Life Sciences, Kumamoto University, 1-1-1, Honjo, Chuo-Ku, Kumamoto City, Kumamoto, 860-8556, Japan
| | - Hiroyo Mabe
- Department of Pediatrics, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Xi Lu
- Department of Public Health, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Hidetaka Katabuchi
- Department of Obstetrics and Gynecology, Faculty of Life Sciences, Kumamoto University, 1-1-1, Honjo, Chuo-Ku, Kumamoto City, Kumamoto, 860-8556, Japan
| | - Eiji Kondoh
- Department of Obstetrics and Gynecology, Faculty of Life Sciences, Kumamoto University, 1-1-1, Honjo, Chuo-Ku, Kumamoto City, Kumamoto, 860-8556, Japan
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Lee D, Ahn MB. A Causality between Thyroid Function and Bone Mineral Density in Childhood: Abnormal Thyrotropin May Be Another Pediatric Predictor of Bone Fragility. Metabolites 2023; 13:metabo13030372. [PMID: 36984812 PMCID: PMC10058985 DOI: 10.3390/metabo13030372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 02/26/2023] [Accepted: 02/28/2023] [Indexed: 03/06/2023] Open
Abstract
Low bone mass can occur in children and adolescents with numerous chronic conditions; however, the influence of abnormal thyroid hormone and thyroid-stimulating hormone (TSH) levels on low bone mineral density (BMD) in children and adolescents remains controversial. Investigating the effects of excessive or deficient thyroid hormone and TSH levels on the risk of childhood bone fragility may provide a better understanding of the role of thyroid function on bone density in the pediatric population. The triiodothyronine (T3), thyroxine (T4), and TSH levels and BMD of 619 children diagnosed with various underlying conditions and whose treatment was completed were simultaneously assessed. The T3, free thyroxine (FT4), and TSH levels were subcategorized based on the age-matched reference range, and the lumbar spine BMD (LSBMD) data were compared. The mean LSBMD z-score was 0.49 ± 1.28, while T3, FT4, and TSH levels were 1.25 ± 0.29 ng/mL, 1.28 ± 0.19 ng/dL, and 2.76 ± 1.87 µU/mL, respectively. Both lumbar and femoral BMD z-scores were lower in children with abnormal TSH levels. TSH abnormality was the strongest risk factor for decreased LSBMD z-scores, and thus could be an early indicator of low BMD in children and adolescents with various underlying conditions.
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Rossi F, Tortora C, Paoletta M, Marrapodi MM, Argenziano M, Di Paola A, Pota E, Di Pinto D, Di Martino M, Iolascon G. Osteoporosis in Childhood Cancer Survivors: Physiopathology, Prevention, Therapy and Future Perspectives. Cancers (Basel) 2022; 14:cancers14184349. [PMID: 36139510 PMCID: PMC9496695 DOI: 10.3390/cancers14184349] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 09/01/2022] [Accepted: 09/06/2022] [Indexed: 11/29/2022] Open
Abstract
Simple Summary Anti-cancer treatments induced an increase in the childhood cancer survival rate. However, they are responsible for several long-term side effects in childhood cancer survivors, including osteoporosis. Cancer itself, a sedentary lifestyle, and an unhealthy diet might adversely affect bone health. Early identification and adequate management of bone fragility in childhood cancer survivors could be useful to prevent osteoporosis onset and consequently fragility fractures. Abstract The improvement of chemotherapy, radiotherapy, and surgical interventions, together with hematopoietic stem cell transplantation, increased childhood cancer survival rate in the last decades, reaching 80% in Europe. Nevertheless, anti-cancer treatments are mainly responsible for the onset of long-term side effects in childhood cancer survivors (CCS), including alterations of the endocrine system function and activity. In particular, the most frequent dysfunction in CCS is a metabolic bone disorder characterized by low bone mineral density (BMD) with increased skeletal fragility. BMD loss is also a consequence of a sedentary lifestyle, malnutrition, and cancer itself could affect BMD, thus inducing osteopenia and osteoporosis. In this paper, we provide an overview of possible causes of bone impairment in CCS in order to propose management strategies for early identification and treatment of skeletal fragility in this population.
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Affiliation(s)
- Francesca Rossi
- Department of Woman, Child and General and Specialist Surgery, University of Campania “Luigi Vanvitelli”, Via L. De Crecchio 4, 80138 Napoli, Italy
- Correspondence: ; Tel.: +39-081-566-5423
| | - Chiara Tortora
- Department of Woman, Child and General and Specialist Surgery, University of Campania “Luigi Vanvitelli”, Via L. De Crecchio 4, 80138 Napoli, Italy
| | - Marco Paoletta
- Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy
| | - Maria Maddalena Marrapodi
- Department of Woman, Child and General and Specialist Surgery, University of Campania “Luigi Vanvitelli”, Via L. De Crecchio 4, 80138 Napoli, Italy
| | - Maura Argenziano
- Department of Woman, Child and General and Specialist Surgery, University of Campania “Luigi Vanvitelli”, Via L. De Crecchio 4, 80138 Napoli, Italy
| | - Alessandra Di Paola
- Department of Woman, Child and General and Specialist Surgery, University of Campania “Luigi Vanvitelli”, Via L. De Crecchio 4, 80138 Napoli, Italy
| | - Elvira Pota
- Department of Woman, Child and General and Specialist Surgery, University of Campania “Luigi Vanvitelli”, Via L. De Crecchio 4, 80138 Napoli, Italy
| | - Daniela Di Pinto
- Department of Woman, Child and General and Specialist Surgery, University of Campania “Luigi Vanvitelli”, Via L. De Crecchio 4, 80138 Napoli, Italy
| | - Martina Di Martino
- Department of Woman, Child and General and Specialist Surgery, University of Campania “Luigi Vanvitelli”, Via L. De Crecchio 4, 80138 Napoli, Italy
| | - Giovanni Iolascon
- Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy
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Rossi F, Tortora C, Di Martino M, Di Paola A, Di Pinto D, Marrapodi MM, Argenziano M, Pota E. Alteration of osteoclast activity in childhood cancer survivors: Role of iron and of CB2/TRPV1 receptors. PLoS One 2022; 17:e0271730. [PMID: 35862357 PMCID: PMC9302719 DOI: 10.1371/journal.pone.0271730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 07/06/2022] [Indexed: 11/30/2022] Open
Abstract
Childhood cancer survivors (CCS) are predisposed to the onset of osteoporosis (OP). It is known that iron overload induces osteoclasts (OCs) overactivity and that the iron chelator Deferasirox (DFX) can counteract it. The Cannabinoid Receptor type 2 (CB2) and the transient receptor potential vanilloid type-1 (TRPV1) are potential therapeutic targets for OP. In this study we isolated OCs from peripheral blood of 20 CCS and investigated osteoclast biomarkers expression and iron metabolism evaluating iron release by OCs and the expression of several molecules involved in its regulation. Moreover, we analyzed the effects of CB2 and TRPV1 stimulation in combination with DFX on osteoclast activity and iron metabolism. We observed, for the first time, an osteoclast hyperactivation in CCS suggesting a role for iron in its development. Moreover, we confirmed the well-known role of CB2 and TRPV1 receptors in bone metabolism, suggesting the receptors as possible key biomarkers of bone damage. Moreover, we demonstrated a promising synergism between pharmacological compounds, stimulating CB2 or inhibiting/desensitizing TRPV1 and DFX, in counteracting osteoclast overactivity in CCS to improve their quality of life.
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Affiliation(s)
- Francesca Rossi
- Department of Woman, Child and General and Specialist Surgery, University of Campania “Luigi Vanvitelli”, Napoli, Italy
- * E-mail:
| | - Chiara Tortora
- Department of Woman, Child and General and Specialist Surgery, University of Campania “Luigi Vanvitelli”, Napoli, Italy
| | - Martina Di Martino
- Department of Woman, Child and General and Specialist Surgery, University of Campania “Luigi Vanvitelli”, Napoli, Italy
| | - Alessandra Di Paola
- Department of Woman, Child and General and Specialist Surgery, University of Campania “Luigi Vanvitelli”, Napoli, Italy
| | - Daniela Di Pinto
- Department of Woman, Child and General and Specialist Surgery, University of Campania “Luigi Vanvitelli”, Napoli, Italy
| | - Maria Maddalena Marrapodi
- Department of Woman, Child and General and Specialist Surgery, University of Campania “Luigi Vanvitelli”, Napoli, Italy
| | - Maura Argenziano
- Department of Woman, Child and General and Specialist Surgery, University of Campania “Luigi Vanvitelli”, Napoli, Italy
| | - Elvira Pota
- Department of Woman, Child and General and Specialist Surgery, University of Campania “Luigi Vanvitelli”, Napoli, Italy
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Ernst L, Schilling G. [Physical long-term consequences of cancer]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2022; 65:420-430. [PMID: 35312813 DOI: 10.1007/s00103-022-03504-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Accepted: 01/31/2022] [Indexed: 11/02/2022]
Abstract
The number of long-term survivors of malignant diseases is steadily increasing, which is due to the further development and optimization of multimodal therapy strategies and the mechanisms of new substance classes. These can now be combined with classical treatment methods or used sequentially. At the same time the number of patients who suffer from physical and psychosocial long-term consequences of cancer therapies or have to live with chronic side effects under the long-term therapies increases. Every therapy, whether radiation, chemotherapy, targeted therapy, or operation, has undesirable long-term side effects that contribute to the decrease of one's quality of life. These affect all parts of the body. As a result, patients can be heavily burdened. In oncology and in other disciplines involved in aftercare, these consequences must therefore be increasingly addressed and clarified and treatment strategies further developed. Unfortunately, there is still a considerable need for research in this area; moreover, there is a lack of clinical studies examining the evidence of a wide variety of holistic therapy methods.
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Affiliation(s)
- Lisa Ernst
- Medizinische Fakultät: Asklepios Campus Hamburg, Semmelweis Universität Budapest, Lohmühlenstr. 5, Haus P, 20099, Hamburg, Deutschland.
| | - Georgia Schilling
- Internistisch-onkologische Rehabilitation, Asklepios Nordseeklinik Westerland/Sylt, Westerland/Sylt, Deutschland.,Asklepios Tumorzentrum Hamburg, Asklepios Klinik Altona, Hamburg, Deutschland
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Ahn MB, Kim S, Cho WK, Lee JW, Jung MH, Chung NG, Cho B, Suh BK. Effect of Vertebral Fracture on Auxological Profiles of Children Undergoing Acute Lymphoblastic Leukemia Treatment. Front Pediatr 2021; 9:686128. [PMID: 34222152 PMCID: PMC8242175 DOI: 10.3389/fped.2021.686128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 05/17/2021] [Indexed: 11/21/2022] Open
Abstract
Background: Acute lymphoblastic leukemia (ALL) is the most common pediatric malignancy, and children with ALL often experience skeletal morbidity such as vertebral fractures (VF) during and after ALL treatment. Among various treatment-associated factors that affect growth pattern, the presence of VF might trigger growth impairment. Objective: This study aimed to investigate the overall VF incidence following childhood ALL treatment and examined the association of VF with growth. Methods: Children diagnosed with ALL whose treatment was completed between 2 and 15 years of age and who were screened with lateral thoracolumbar spine radiographs were enrolled. Clinical data, including anthropometric parameters were obtained at leukemia diagnosis (LD), treatment completion (TC), and 12 months following TC while VF assessment were obtained at TC and 12 months following TC. Results: In total, 155 children were included, and height status was decreased, whereas weight and BMI status were increased throughout three observational points. VF incidence at TC was 18.7%. Height status were lower in children with VF at LD, TC, and 12 months following TC, while a greater height decline was observed during the treatment period. Age and height status at LD and average glucocorticoid (GC) dose were associated VF incidence at TC. The presence of VF was a significant risk factor of height decline during the treatment period. Conclusion: A substantial number of children experienced VF following ALL treatment completion, and the presence of VF might adversely affect auxological status in children. VF detection by routine surveillance throughout childhood ALL treatment is recommended to try to prevent compromised growth.
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Affiliation(s)
- Moon Bae Ahn
- Department of Pediatrics, College of Medicine, Catholic University of Korea, Seoul, South Korea
| | - Seongkoo Kim
- Department of Pediatrics, College of Medicine, Catholic University of Korea, Seoul, South Korea
| | - Won Kyoung Cho
- Department of Pediatrics, College of Medicine, Catholic University of Korea, Seoul, South Korea
| | - Jae Wook Lee
- Department of Pediatrics, College of Medicine, Catholic University of Korea, Seoul, South Korea
| | - Min Ho Jung
- Department of Pediatrics, College of Medicine, Catholic University of Korea, Seoul, South Korea
| | - Nack-Gyun Chung
- Department of Pediatrics, College of Medicine, Catholic University of Korea, Seoul, South Korea
| | - Bin Cho
- Department of Pediatrics, College of Medicine, Catholic University of Korea, Seoul, South Korea
| | - Byung-Kyu Suh
- Department of Pediatrics, College of Medicine, Catholic University of Korea, Seoul, South Korea
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