Symptoms, Physical Activity, and Biomarkers in Children at the End of Leukemia Maintenance Therapy

Background: Symptoms in children with acute lymphocytic leukemia (ALL) change over the trajectory of treatment but little is known about their symptoms as treatment ends. Physical activity may help decrease symptom distress and is vital for ongoing development. The role of biomarkers in symptom science is emerging. The purpose of the study was to explore relationships between self-report of symptoms and physical activity, actigraphy measures, and cerebrospinal fluid (CSF) biomarkers. Methods: Participants were children who were ages 3 to 18 years at the time of ALL diagnosis and were now in the last 12-week cycle of ALL maintenance. Self-reports of fatigue, sleep disturbance, depressive symptoms, and physical activity were completed by participants and parents of younger children. Participants wore a wrist actigraph continuously for the 7 days before other measurements. F2-isoprostanes and interleukin-8 were evaluated in CSF samples. Results: Among the 15 participants, self-report of symptoms and physical activity indicated levels similar to healthy peers. F2-isoprostane had a strong positive correlation with fatigue levels and with depressive symptoms. Fatigue, sleep disturbance, and depressive symptoms positively correlated with each other. Actigraph measures showed children met the CDC guidelines for 60 min of daily moderate to vigorous activity; sleep time was slightly less than healthy norms. Discussion: During maintenance therapy, most children return to healthy norms in symptom burden and physical activity. F2-isoprostane in the CSF is a biomarker for fatigue and depressive symptoms. Children who had persistent symptoms experienced them as a cluster, which confirms previous symptom cluster research.

Assessment of proxy-reported responses as predictors of motor and sensory peripheral neuropathy in children with B-lymphoblastic leukemia

Chemotherapy-induced peripheral neuropathy (CIPN), a common condition in children with acute lymphoblastic leukemia, can be challenging to diagnose. Using data from Children's Oncology Group AALL0932 physical function study, we sought to determine if parent/guardian proxy-reported responses from the Pediatric Outcomes Data Collection Instrument could identify children with motor or sensory CIPN diagnosed by physical/occupational therapists (PT/OT). Four variables moderately discriminated between children with and without motor CIPN (c-index 0.76, 95% confidence interval [CI]: 0.64-0.84), but sensory and optimism-corrected models had weak discrimination (c-index sensory models 0.65, 95% CI: 0.54-0.74). New proxy-report measures are needed to identify children with PT/OT diagnosed CIPN.

Persistence of Chemotherapy-Induced Peripheral Neuropathy Despite Vincristine Reduction in Childhood B-Acute Lymphoblastic Leukemia

BACKGROUND

Children with B-acute lymphoblastic leukemia (B-ALL) are at risk for chemotherapy-induced peripheral neuropathy (CIPN). Children's Oncology Group AALL0932 randomized reduction in vincristine and dexamethasone (every 4 weeks vs 12 weeks during maintenance in the average-risk subset of National Cancer Institute standard-B-ALL (SR AR B-ALL). We longitudinally measured CIPN, overall and by treatment group.

METHODS

AALL0932 standard-B-ALL patients aged 3 years and older were evaluated at T1-T4 (end consolidation, maintenance month 1, maintenance month 18, 12 months posttherapy). Physical and occupational therapists (PT/OT) measured motor CIPN (hand and ankle strength, dorsiflexion and plantarflexion range of motion), sensory CIPN (finger and toe vibration and touch), function (dexterity [Purdue Pegboard], and walking efficiency [Six-Minute Walk]). Proxy-reported function (Pediatric Outcome Data Collection Instrument) and quality of life (Pediatric Quality of Life Inventory) were assessed. Age- and sex-matched z scores and proportion impaired were measured longitudinally and compared between groups.

RESULTS

Consent and data were obtained from 150 participants (mean age = 5.1 years [SD = 1.7], 48.7% female). Among participants with completed evaluations, 81.8% had CIPN at T1 (74.5% motor, 34.1% sensory). When examining severity of PT/OT outcomes, only handgrip strength (P < .001) and walking efficiency (P = .02) improved from T1-T4, and only dorsiflexion range of motion (46.7% vs 14.7%; P = .008) and handgrip strength (22.2% vs 37.1%; P = .03) differed in vincristine and dexamethasone every 4 weeks vs vincristine and dexamethasone 12 weeks at T4. Proxy-reported outcomes improved from T1 to T4 (P < .001), and most did not differ between groups.

CONCLUSIONS

CIPN is prevalent early in B-ALL therapy and persists at least 12 months posttherapy. Most outcomes did not differ between treatment groups despite reduction in vincristine frequency. Children with B-ALL should be monitored for CIPN, even with reduced vincristine frequency.

Association between fatigue and sleep disturbances during treatment for pediatric acute lymphoblastic leukemia and posttreatment neurocognitive performance

BACKGROUND

Survivors of pediatric acute lymphoblastic leukemia (ALL) are at increased risk of neurocognitive weakness in the areas of attention, executive function, and processing speed. Although fatigue and sleep disturbances are frequent complications of ALL therapy and associated with cognitive functions, the impact of fatigue and sleep profiles during active ALL treatment on posttreatment neurocognitive performance has received limited attention.

METHODS

Pediatric patients (n = 120) with ALL (diagnosed 2011-2016) who completed fatigue and sleep questionnaires at four time points during active treatment were enrolled in a study of neurocognitive performance. Latent class growth analysis identified subgroups of patients with similar sleep and fatigue profiles during treatment. Neurocognitive performance collected >6 months post treatment on 40 participants was compared between latent classes using multivariable linear regression models.

RESULTS

Participants (57.5% male and 79.1% Hispanic or non-Hispanic White) were classified into one of two fatigue and sleep profiles: Class 1 characterized by mild fatigue and sleep disturbances during treatment (50.8%), and Class 2 characterized by higher levels of fatigue and sleep disturbances (49.2%). Posttreatment cognitive performance was in the normal range for most measures, but significantly below normative means for executive function, verbal short-term memory, attention, and distractability measures. Compared to Class 1, Class 2 demonstrated significantly (p < .05) poorer posttreatment neurocognitive performance, particularly in measures of attention.

CONCLUSIONS

Our findings indicate that fatigue and sleep disturbances during the first year of pediatric ALL therapy may impact long-term neurocognitive performance. Sleep and fatigue may be targets for intervention to preserve cognitive functioning in survivors.

Biomarkers and Cognitive Function in Children and Adolescents During Maintenance Therapy for Leukemia

OBJECTIVES

To explore the relationship between biomarkers of oxidative stress and inflmmation in cerebrospinal fluid (CSF) and cognitive function in children receiving maintenance therapy for acute lymphocytic leukemia (ALL).

SAMPLE & SETTING

30 participants aged 4-17 years receiving ALL maintenance therapy at two pediatric cancer centers in the United States.

METHODS & VARIABLES

F2-isoprostane (F2-ISoP) and interleukin-8 (IL-8) were evaluated in CSF samples, and cognitive function measures were completed during the first and last cycles of ALL maintenance. The Flanker Inhibitory Control and Attention Test (Flanker) and Dimensional Change Card Sort were completed during the last cycle.

RESULTS

During maintenance therapy, IL-8 decreased, and parent reports of children's cognitive function improved. Higher IL-8 was associated with better parent reports of children's cognitive function at each timepoint. Higher F2-ISoP levels were associated with lower Flanker scores.

IMPLICATIONS FOR NURSING

F2-ISoP may be a useful biomarker in evaluating cognitive dysfunction in children with ALL and merits further investigation.

Ethnic Disparities in Methotrexate Neurotoxicity among Children and Adolescents with Acute Lymphoblastic Leukemia

Purpose of study: To identify factors related to the increased risk of neurotoxicity in children with acute lymphoblastic leukemia (ALL) after treatment with the antifolate agent methotrexate (MTX), a critical component of curative protocols. Methods: We analyzed the incidence of and factors associated with acute MTX neurotoxicity (neurologic episode within 14d of dose that resulted in treatment modification) in a multi-site study of 280 (48% Latino) newly diagnosed (between 2012–2017) patients treated on recent pediatric ALL protocols. We examined the effects of genetic ancestry and single nucleotide variants in a subset of 190 patients with genotype data. Results: MTX neurotoxicity occurred in 22% of Latino compared to 7% of non- Latino patients; a nearly 2.5-fold increased risk after accounting for other clinical and demographic factors. Patients with neurotoxicity received fewer total MTX doses, and their risk for relapse was 2-fold higher than patients who did not experience neurotoxicity. We also found that 42% of our Latino patients who experienced a first neurotoxic event went on to have additional events, compared to only 21% of non-Latino patients. The proportion of genetic variation that co-segregates with Native American ancestry was overrepresented in individuals with MTX-related neurotoxicity (mean = 35%) vs without neurotoxicity (mean = 23%, p = 0.025). In multivariable models accounting for sex, age at diagnosis, and treatment risk group, every 10% increase in the proportion of Native American genetic ancestry was associated with a 16% increase in neurotoxicity incidence (HR = 1.16; 95% CI: 1.02–1.32). Our data also suggest that Latinos are at higher risk for first (OR = 3.51, p = 0.02) and subsequent (OR = 6.10, p = 0.04) neurotoxic events associated with a missense variant in TCF12, which is more common in admixed Latino (23%) compared to European (3%) or African (&lt;1%) populations. Conclusions: MTX neurotoxicity is more common among Latino children and adolescents with ALL, compromises treatment efficacy, and may contribute to disparities in ALL relapse and survival. Our findings to date highlight that differences in inherited genetic variation, which segregate with ancestry, likely contribute to disparities in the incidence of treatment-related neurotoxicity.

Cerebrospinal Fluid Metabolomic Profiles Associated With Fatigue During Treatment for Pediatric Acute Lymphoblastic Leukemia

CONTEXT

Cancer-related fatigue (CRF) is one of the most distressing and persistent symptoms reported during pediatric acute lymphoblastic leukemia (ALL) therapy; however, information on the pathways underlying CRF severity is limited.

OBJECTIVES

We conducted global metabolomics profiling of cerebrospinal fluid (CSF) samples to provide insight into the underlying mechanisms of CRF.

METHODS

Fatigue in pediatric ALL patients (2012-2017) was assessed during postinduction therapy approximately six months after diagnosis. Postinduction CSF was collected from 171 participants, comprising discovery (n = 86) and replication (n = 85) cohorts. We also conducted secondary validation using diagnostic CSF from 48 replication cohort participants. CSF metabolomic profiling was performed using gas chromatography-mass spectrometry (MS) and liquid chromatography-MS/MS. Kendall's rank correlation was used to evaluate associations between metabolite abundance and CRF. False discovery rate was used to account for multiple comparisons.

RESULTS

Participants were 56% males and 59% Hispanic with a mean age at diagnosis of 8.5 years. A total of 274 CSF-derived metabolites were common to the discovery and replication cohorts. Eight metabolites were significantly associated with fatigue in the discovery cohort (P < 0.05), of which three were significant in the replication cohort, including false discovery rate-corrected associations with gamma-glutamylglutamine (P_combined = 6.2E-6) and asparagine (P_combined = 3.5E-4). Notably, the abundance of gamma-glutamylglutamine in diagnostic CSF samples was also significantly associated with fatigue (P = 0.0062).

CONCLUSION

The metabolites identified in our assessment have been implicated in neurotransmitter transportation and glutathione recycling, suggesting that glutamatergic pathways or oxidative stress may contribute to ALL-associated CRF. This information could inform targeted therapies for reducing CRF in at-risk individuals.

The Longitudinal Parallel Process Analysis of Biomarkers of Oxidative Stress, Symptom Clusters, and Cognitive Function in Children With Leukemia

Background: During treatment for acute lymphoblastic leukemia (ALL), children report co-occurring symptoms of fatigue, sleep disturbance, pain, nausea, and depression as a symptom cluster. Central nervous system-directed ALL therapies also put children at risk for cognitive impairments. Cancer therapies can cause an increase in oxidative stress, which may contribute to treatment-related symptoms. This study examined the longitudinal relationships between biomarkers of oxidative stress in the cerebrospinal fluid, the Childhood Cancer Symptom Cluster-Leukemia (CCSC-L), and cognition, in children over the first year of ALL treatment. Methods: Glutathione (GSH) biomarkers of oxidative stress were measured in cerebrospinal fluid collected during treatment lumbar punctures. GSH biomarkers, symptoms, and cognitive function of 132 children aged 3 to 18 years were evaluated at four time points during the first year of leukemia treatment. Participants, 7 years and older, completed self-report measures, and parents reported for younger children. Cognitive function measurements for all participants were completed by parents. A longitudinal parallel-process model was used to explore the influence of the initial measurement and the subsequent change over four time points of the GSH biomarkers on the CCSC-L and cognition. Results: GSH biomarkers increased over the four time points indicating decreasing oxidative stress. When GSH biomarkers were higher (less oxidative stress) at the initial measurement, the CCSC-L severity was lower, cognition was better, and cognition improved over the four measurements. Screening children for high levels of oxidative stress would be a foundation for future intervention studies to address symptom distress and cognitive impairments.

Influence of Inflammatory and Oxidative Stress Pathways on Longitudinal Symptom Experiences in Children With Leukemia

PURPOSE

The purpose of this study was to explore the influence of oxidative stress (F2-isoprostanes) and inflammatory (interleukin [IL]-8) biomarkers on symptom trajectories during the first 18 months of childhood leukemia treatment.

METHOD

A repeated-measures design was used to evaluate symptoms experienced by 218 children during treatment. A symptom cluster (fatigue, pain, and nausea) was explored over four time periods: initiation of post-induction therapy, 4 and 8 months into post-induction therapy, and the beginning of maintenance therapy (12 months postinduction). F2-isoprostanes and IL-8 were evaluated in cerebrospinal fluid (CSF) samples collected at baseline (diagnosis) and then at the four time periods. The longitudinal relationships of these biomarkers with the symptom cluster were examined using the longitudinal parallel process.

RESULTS

Pain and fatigue levels were highest during the post-induction phases of treatment and decreased slightly during maintenance therapy, while nausea scores were relatively stable. Even in the later phases of treatment, children continued to experience symptoms. CSF levels of the biomarkers increased during the post-induction phases of treatment. Early increases in the biomarkers were associated with more severe symptoms during the same period; patients who had increased biomarkers over time also experienced more severe symptoms over time.

CONCLUSIONS

Findings reveal that children experienced symptoms throughout the course of leukemia treatment and support hypothesized longitudinal relationships of oxidative stress and inflammatory biomarkers with symptom severity. Activation of the biomarker pathways during treatment may explain underlying mechanisms of symptom experiences and identify which children are at risk for severe symptoms.

Impact of Childhood Leukemia Treatment on Attention Measured by the Continuous Performance Test Factor Structure

OBJECTIVES

To describe the impact of central nervous system-directed treatment on attention and its relation to academic outcomes in childhood acute lymphoblastic leukemia (ALL) survivors.

SAMPLE & SETTING

51 children diagnosed with ALL at two pediatric oncology treatment centers in the southwestern United States.

METHODS & VARIABLES

A prospective, longitudinal design measured attention after a child was in remission, two years after the start of treatment, and at the end of treatment. Attention measures from the Conners' Continuous Performance Test were grouped into composite subdomains based on a factor structure describing focused attention, hyperactivity/impulsivity, sustained attention, and vigilance.

RESULTS

Children treated for ALL exhibited decreased focused attention, sustained attention, and vigilance during and at the end of treatment when compared to age- and gender-normed references.

IMPLICATIONS FOR NURSING

Pediatric oncology nurses are in a position to ask patients and parents about neuropsychological difficulties during ALL treatment. Patients who experience these effects are at risk for decreased academic abilities after treatment.

Childhood Cancer Symptom Cluster: Leukemia and Health-Related Quality of Life

OBJECTIVES

To examine the relationship of the Childhood Cancer Symptom Cluster-Leukemia (CCSC-L) with health-related quality of life (HRQOL).

SAMPLE & SETTING

327 children receiving treatment for acute lymphoblastic leukemia from four pediatric oncology programs across the United States.

METHODS & VARIABLES

Participants completed fatigue, sleep disturbance, pain, nausea, and depression symptom questionnaires at four time points; these symptoms comprised the CCSC-L. HRQOL was measured at the start of postinduction therapy and then at the start of maintenance therapy. Relationships between the CCSC-L and HRQOL scores were examined with longitudinal parallel-process modeling.

RESULTS

The mean HRQOL significantly increased over time (p < 0.001). The CCSC-L had a significant negative association with HRQOL scores at the start of postinduction therapy (beta = -0.53, p < 0.005) and the start of maintenance therapy (beta = -0.33, p < 0.015). Participants with more severe symptoms in the CCSC-L over time had significantly lower HRQOL at the start of maintenance therapy (beta = -0.42, p < 0.005).

IMPLICATIONS FOR NURSING

Nurses are pivotal in providing management strategies to minimize symptom severity that may improve HRQOL.

Improving Transitional Care: The Role of Handoffs and Discharge Checklists in Hematologic Malignancies

BACKGROUND

Transitional care from inpatient to outpatient settings is a high-risk time for medical errors and missed follow-up appointments. Discharge checklists and handoffs are effective tools that lead to improved quality of care and outcomes.

OBJECTIVES

The purpose of this project was to implement an evidence-based discharge checklist and handoff template to improve and standardize transitional care from hospital to home for patients with hematologic malignancies.

METHODS

The advanced practice providers (APPs) completed the discharge checklist at least 24 hours prior to discharge. The APPs requested appointments through the electronic health record using the discharge handoff tool. Chi-square analysis and descriptive statistics were used to analyze the data.

FINDINGS

Implementation of the discharge checklist resulted in a statistically significant increase in the number of patients who had a follow-up appointment scheduled prior to discharge. The discharge handoff tool standardized communication between inpatient and outpatient providers.

Disparities in Neurotoxicity Risk and Outcomes among Pediatric Acute Lymphoblastic Leukemia Patients

Purpose: Methotrexate chemotherapy can be associated with neurologic complications during therapy and long-term neurologic deficits. This study evaluated demographic and clinical factors associated with incidence of methotrexate neurotoxicity and described the impact of neurotoxicity on acute lymphoblastic leukemia (ALL) therapy in pediatric patients.Experimental Design: Patients were enrolled between 2012 and 2017 from three pediatric cancer treatment centers in the United States. Medical records for suspected cases of methotrexate neurotoxicity, defined as an acute neurologic event following methotrexate therapy, were reviewed. Cox proportional hazards models were used to estimate the association between race/ethnicity and methotrexate neurotoxicity. Multivariable linear regression models compared treatment outcomes between patients with and without methotrexate neurotoxicity.Results: Of the 280 newly diagnosed patients enrolled, 39 patients (13.9%) experienced methotrexate neurotoxicity. Compared with non-Hispanic whites, Hispanic patients experienced the greatest risk of methotrexate neurotoxicity (adjusted HR, 2.43; 95% CI, 1.06-5.58) after accounting for sex, age at diagnosis, BMI Z-score at diagnosis, and ALL risk stratification. Patients who experienced a neurotoxic event received an average of 2.25 fewer doses of intrathecal methotrexate. Six of the 39 cases of neurotoxicity (15.4%) experienced relapse during the study period, compared with 13 of the 241 (2.1%) patients without neurotoxicity (P = 0.0038).Conclusions: Hispanic ethnicity was associated with increased risk of methotrexate neurotoxicity, which was associated with treatment modifications and relapse. Understanding the mechanism and predictors of methotrexate neurotoxicity is important to improving treatment outcomes in pediatric ALL. Clin Cancer Res; 24(20); 5012-7. ©2018 AACR.

Abstract 2967: Ethnic-specific risk of neurotoxocity and its impact on treatment outcomes among pediatric patients receiving acute lymphoblastic leukemia therapy

Purpose: Because of the increasing awareness that Hispanics diagnosed with acute lymphoblastic leukemia (ALL) often experience worse outcomes, we sought to evaluate the risk of methotrexate (MTX)-related neurotoxicity (NT) by ethnic group and evaluate its effects on treatment outcomes in a multi-institutional prospective cohort of pediatric patients (2-17 years old).

Methods: Patients with ALL were prospectively recruited from 3 pediatric cancer centers in the United States for the period 2012-2017 and systematically followed for the development of treatment-related symptoms and toxicities. For this analysis, suspected NT cases were defined as patients with a neurologic event following intrathecal (IT) and/or intravenous (IV) MTX that led to a change in subsequent MTX therapy. Cumulative incidence of MTX NT was calculated by ethnic group. Multivariable linear regression models were generated to compare treatment differences between patients with and without MTX NT. The frequency of all-cause and central nervous system (CNS) relapse was compared between patients with and without MTX NT using the log-rank test and Cox regression models.

Results: Of the 280 patients enrolled, 39 (13.9%) experienced MTX NT (median follow-up = 22.6 months; range: 1.3 - 55.6 months). Cumulative incidence of MTX NT was 21.8% among Hispanic patients compared to 7.0% among non-Hispanic patients (p &lt;0.001). After adjusting for relevant clinical characteristics, Hispanic patients were 2.74 times more likely to develop MTX NT compared to non-Hispanic white patients (95% CI: 1.21-6.19). Patients who experienced MTX NT received an average of 2.25 fewer doses of IT MTX (95% CI: 1.73-2.77), independent of treatment risk group, sex, or age. Six cases of MTX NT (15.4%) experienced all-cause relapse during the study period, compared to 13 (2.1%) patients without MTX NT (log-rank p = 0.0038). Similarly, CNS relapse was more frequent among patients with MTX NT (10.3%) than patients without NT (2.1%; log-rank p = 0.0014). In univariate Cox regression models, MTX NT was significantly associated with CNS relapse (HR: 3.80, 95% CI: 1.44-10.02), a trend which remained after individually accounting for treatment risk arm (HR: 2.92, 95% CI: 1.07-7.95), MRD status at day 29 (HR: 3.49, 95% CI: 1.32-9.24), race and ethnicity (HR: 3.15, 95% CI: 1.13-8.79), age at diagnosis (HR: 2.56, 95% CI: 0.91-7.21), and sex (HR: 3.82, 95% CI: 1.44-10.10).

Conclusion: We identified an increased risk of relapse, specifically in the CNS, among ALL patients following MTX NT, which was not fully explained by other clinical risk factors. Further, incidence of NT was higher among Hispanic patients in our clincs. This is particularly interesting given that Hispanic patients typically present with more favorable disease characterstics, yet often experience worse treatment outcomes.

Citation Format: Michael E. Scheurer, Olga A. Taylor, Austin L. Brown, Julienne Brackett, ZoAnne E. Dreyer, Ida (Ki) Moore, Pauline Mitby, Mary C. Hooke, Philip J. Lupo, Marilyn J. Hockenberry. Ethnic-specific risk of neurotoxocity and its impact on treatment outcomes among pediatric patients receiving acute lymphoblastic leukemia therapy [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 2967.

Influence of Nitrosative Stress on Fatigue During Childhood Leukemia Treatment

The focus on a cure for childhood leukemia over the last three decades has resulted in survival rates of more than 80%. However, efforts to manage leukemia-treatment symptoms have not kept pace with new therapies. Symptom toxicity during treatment can result in complications, treatment delays, and therapy dose reductions. Compromise in therapy can negatively influence the quality of life and, even more notably, jeopardize chances for long-term survival. This study examined biologic mechanisms that influence fatigue caused by increased reactive oxidative species (ROS) or actual failure of the antioxidant defense system due to genetic variation by investigating reactive nitrosative species, a "downstream" consequence of ROS. The specific aims of this study were to characterize the trajectory of nitrosative stress during acute lymphoblastic leukemia treatment and evaluate the influence of nitrosative stress on fatigue. A repeated measures design was used to evaluate the fatigue experienced by 186 children and adolescents, 3-18 years of age, with a diagnosis of leukemia during the most intense phase of treatment. An established biomarker of nitrosative stress, protein 3-nitrotyrosine (3NT) residues in the cerebral spinal fluid, was evaluated at diagnosis, postinduction, and consolidation phases of treatment. Higher fatigue was associated with higher 3NT levels at the beginning of treatment. Two distinct groups of children experienced either consistently high or consistently low 3NT levels across the treatment trajectory, from diagnosis to 12 months postinduction. Findings from this study support continued exploration into the phenotypic biochemical mechanisms that influence a reactive response to childhood cancer treatment.

Declines Noted in Cognitive Processes and Association With Achievement Among Children With Leukemia

PURPOSE/OBJECTIVES

To assess change in specific cognitive processes during treatment with chemotherapy only among children with acute lymphoblastic leukemia (ALL). 
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DESIGN

A prospective, repeated measures design.
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SETTING

Pediatric oncology treatment centers at Banner-University Medical Center Tucson/Banner Children's-Diamond Medical Center (University of Arizona) and Texas Children's Cancer and Hematology centers (Baylor College of Medicine) in Houston. 
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SAMPLE

71 children with ALL, with a mean age of 6.18 years at the time of diagnosis. 
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METHODS

Using mixed-effects latent growth curve modeling with time since diagnosis as a fixed effect, age-adjusted standardized measures of working memory, processing speed, executive function, and attention were obtained and repeated about one and two years later. A subsample was tested for academic achievement at the end of treatment.
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MAIN RESEARCH VARIABLES

Verbal working memory, visual spatial memory, processing speed, academic achievement, age, and gender. 
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FINDINGS

A significant main effect was observed for age at diagnosis on decline in verbal working memory during treatment. Planned contrasts revealed greater decline among children who were diagnosed when aged younger than five years compared to those diagnosed when aged five years or older. Decline in verbal working memory and achievement in letter-word identification and calculation skills were associated, and decline in spatial memory was associated with calculation. A main effect of gender was observed on processing speed, with female patients showing greater decline than male patients. 
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CONCLUSIONS

Findings from this study may guide the timing of interventions that could improve school achievement among survivors. 
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IMPLICATIONS FOR NURSING

Children undergoing treatment for ALL may experience issues with verbal working memory and increased difficulty in school. Nurses are in a position to refer parents and children to school resources for additional academic support.

Changes in Oxidant Defense, Apoptosis, and Cognitive Abilities During Treatment for Childhood Leukemia

Aggressive central nervous system (CNS)-directed treatment for acute lymphoblastic leukemia (ALL), the most prevalent cancer among children and adolescents, prevents metastasis of leukemia cells into the brain. Up to 60% of survivors experience cognitive problems, but knowledge about risk factors for and mechanisms of neurologic injury is lacking. Objectives of the present study were to (1) quantify changes in oxidant defense and apoptosis over the course of ALL therapy and (2) elucidate risk factors for long-term cognitive problems. The sample included 71 children with ALL. Cerebrospinal fluid (CSF) samples were collected at diagnosis and during intrathecal chemotherapy administration. Oxidant defense was measured by reduced glutathione (GSH), oxidized glutathione (GSSG), and the ratio of GSH:GSSG. Apoptosis was measured by activity of several cysteine-dependent aspartate-specific protease (abbreviated as caspase) enzymes that initiate (caspases 8 and 9) or execute (caspases 3/7) apoptosis. Cognitive abilities were assessed by standardized measures of short-term memory, visual-motor integration, and attention 3 years after ALL diagnosis. GSH and GSSG concentration increased significantly during ALL therapy, and a low GSH:GSSG ratio was indicative of an oxidized extracellular environment. Caspase enzyme activity increased significantly, and caspases 3/7 activity was significantly and negatively associated with performance on measures of cognitive abilities. Younger age at time of ALL diagnosis was associated with some measures of attention. Efflux of glutathione into CSF maintains oxidant defense by scavenging free radicals and other reactive oxygen species and is an early event in apoptosis. These mechanisms may be involved in neurologic injury associated with CNS-directed treatment and subsequent cognitive problems.

Evidence-Based Practice Projects in Pediatric Oncology Nursing

This introduction article discusses the history and importance of evidence-based practice, along with describing the process that 6 nurse-led teams completed for the systematic reviews listed in this journal issue.

Symptom Trajectories in Children Receiving Treatment for Leukemia: A Latent Class Growth Analysis With Multitrajectory Modeling

CONTEXT

Cancer treatment symptoms play a major role in determining the health of children with cancer. Symptom toxicity often results in complications, treatment delays, and therapy dose reductions that can compromise leukemia therapy and jeopardize chances for long-term survival. Critical to understanding symptom experiences during treatment is the need for exploration of "why" inter-individual symptom differences occur; this will determine who may be most susceptible to treatment toxicities.

OBJECTIVES

This study examined specific symptom trajectories during the first 18 months of childhood leukemia treatment. Symptom measures included fatigue, sleep disturbances, pain, nausea, and depression.

METHODS

Symptom trajectories of 236 children with leukemia three to 18 years old were explored prospectively over four periods: initiation of post-induction therapy, four and eight post-induction therapy, and the last time point was at the beginning of maintenance/continuation therapy. Latent class growth analysis was used to classify patients into distinctive groups with similar symptom trajectories based on patients' response patterns on the symptom measures over time.

RESULTS

Three latent classes of symptom trajectories were identified and classified into mild, moderate, and severe symptom trajectories. The only demographic characteristic with a significant relationship to membership in the latent class symptom trajectories was race/ethnicity. All other demographic characteristics including leukemia risk levels showed no significant relationships.

CONCLUSION

This study is unique in that groups of patients with similar symptoms were identified rather than groups of symptoms. Further research using latent class growth analysis is needed.

Oxidative Stress, Motor Abilities, and Behavioral Adjustment in Children Treated for Acute Lymphoblastic Leukemia

PURPOSE/OBJECTIVES

To examine associations among oxidative stress, fine and visual-motor abilities, and behavioral adjustment in children receiving chemotherapy for acute lymphoblastic leukemia (ALL)
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DESIGN

A prospective, repeated-measures design
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SETTING

Two pediatric oncology settings in the southwestern United States.

SAMPLE

89 children with ALL were followed from diagnosis to the end of chemotherapy.

METHODS

Serial cerebrospinal fluid samples were collected during scheduled lumbar punctures and analyzed for oxidative stress biomarkers. Children completed fine motor dexterity, visual processing speed, and visual-motor integration measures at three time points. Parents completed child behavior ratings at the same times.

MAIN RESEARCH VARIABLES

Oxidative stress, fine motor dexterity, visual processing, visual-motor integration, and behavioral adjustment
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FINDINGS

Children with ALL had below-average fine motor dexterity, visual processing speed, and visual-motor integration following the induction phase of ALL therapy. By end of therapy, visual processing speed normalized, and fine motor dexterity and visual-motor integration remained below average. Oxidative stress measures correlated with fine motor dexterity and visual-motor integration. Decreased motor functioning was associated with increased hyperactivity and anxiety
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CONCLUSIONS

Oxidative stress occurs following chemo-therapy for childhood ALL and is related to impaired fine motor skills and visual symptoms
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IMPLICATIONS FOR NURSING

Early intervention should be considered to prevent fine motor and visual-spatial deficits, as well as behavioral problems.

Fatigue and Oxidative Stress in Children Undergoing Leukemia Treatment

Fatigue is a frequent and distressing symptom in children undergoing leukemia treatment; however, little is known about factors influencing this symptom. Antioxidants such as glutathione can decrease symptom severity in adult oncology patients, but no study has evaluated antioxidants' effects on symptoms in pediatric oncology patients. This study describes fatigue patterns and associations of fatigue with antioxidants represented by reduced glutathione (GSH) and the reduced/oxidized glutathione (GSH/GSSG) ratio among children receiving leukemia treatment. A repeated measures design assessed fatigue and antioxidants among 38 children from two large U.S. cancer centers. Fatigue was assessed among school-age children and by parent proxy among young children. Antioxidants (GSH and GSH/GSSG ratio) were assessed from cerebrospinal fluid at four phases during leukemia treatment. Young children had a steady decline of fatigue from the end of induction treatment through the continuation phase of treatment, but no significant changes were noted among the school-age children. Mean antioxidant scores varied slightly over time; however, the GSH/GSSG ratios in these children were significantly lower than the normal ratio. Mean GSH/GSSG ratios significantly correlated to fatigue scores of the school-age children during early phases of treatment. Children with low mean GSH/GSSG ratios demonstrated oxidative stress. The low ratios noted early in therapy were significantly correlated with higher fatigue scores during induction and postinduction treatment phases. This finding suggests that increased oxidative stress during the more intensive phases of therapy may explain the experience of fatigue children report.

Trajectories of Obesity and Overweight Rates Among Survivors of Childhood Acute Lymphoblastic Leukemia

PURPOSE/OBJECTIVES

To describe the trajectories of obesity/overweight rates by age group among survivors of childhood acute lymphoblastic leukemia (ALL) from diagnosis through several years post-therapy.

DESIGN

Longitudinal, descriptive.

SETTING

Hematology/oncology clinic in the southwestern United States.

SAMPLE

62 child and adolescent ALL survivors receiving treatment and follow-up care from 1999-2013.

METHODS

Retrospective chart review of height, weight, and body mass index.

MAIN RESEARCH VARIABLES

Annual obesity/overweight rates and developmental age groups.

FINDINGS

Different trajectories of obesity/overweight rates existed among age groups. Forty-seven percent of adolescents met the Centers for Disease Control and Prevention criteria for obesity/overweight status at some point following diagnosis, compared to 68% of school-age and 73% of preschool children. Preschool children demonstrated the most rapid rate increase following diagnosis, with a particularly susceptible period in the years immediately following therapy. Obesity/overweight persistence was most characteristic of school-age children.

CONCLUSIONS

Important variations in rate and pattern of weight status trajectories exist by age group, demonstrating that children diagnosed with ALL during the preschool and school-age developmental years have the greatest vulnerability of developing obesity/overweight status.

IMPLICATIONS FOR NURSING

Obesity/overweight prevention efforts are greatly needed in children with ALL, and efforts should occur before ALL treatment completion in preschool and school-age children.

Reconsidering Physical Activity Restrictions for Mononephric Survivors of Childhood Cancer: A Report From the Children's Oncology Group

Although traditional recommendations for mononephric childhood cancer survivors are to avoid contact sports in order to protect the remaining kidney, review of available evidence suggests that the majority of renal loss is caused by accidents not involving sports. An interdisciplinary team performed a review of the English literature published from 1999 to 2012 within the PubMed, Cochrane, Google Scholar, and National Guidelines Clearinghouse databases. The level of evidence and proposed recommendations were graded according to an established rubric and GRADE criteria. Our review found that kidney loss is most commonly caused by nonsports activities such as motor vehicle accidents and falls, implying that restrictions on sports-related activity in mononephric pediatric survivors are not well supported. This favors encouraging ordinary sports and related activities without restriction in mononephric childhood cancer survivors because the known benefits of exercise outweigh the exceedingly low risk of renal loss. Accordingly, activity recommendations for mononephric patients have been revised in the most current version of the Children's Oncology Group Long-term Follow-Up Guidelines for Survivors of Childhood, Adolescent and Young Adult Cancers. This has important implications for this and similar populations who may now undertake individual and organized sports without undue regard for their mononephric status.

The influence of oxidative stress on symptom occurrence, severity, and distress during childhood leukemia treatment

PURPOSE/OBJECTIVES

To explore the symptom trajectory during the first 16 months of childhood leukemia treatment and any associations with the oxidative stress pathway measured by cerebrospinal fluid (CSF) concentration of oxidized phosphatidylcholine (PC), the predominant glycerophospholipid in the brain and cell membranes.

DESIGN

Prospective, longitudinal design.

SETTING

Two cancer centers in the southwestern United States.

SAMPLE

36 children (aged 3-14 years) newly diagnosed with acute lymphoblastic leukemia.

METHODS

Symptoms were measured using the Memorial Symptom Assessment Scale at six specific time points during treatment. Biochemical changes in oxidative stress were measured by oxidized PC in the CSF.

MAIN RESEARCH VARIABLES

Childhood cancer symptoms, oxidized PC.

FINDINGS

Significant differences were found in the number of symptoms experienced during the three phases of treatment. Symptom trajectory changes and influence of the oxidative stress pathway on symptom experiences were identified.

CONCLUSIONS

Symptoms experienced during treatment for childhood leukemia are associated with increased oxidative stress.

IMPLICATIONS FOR NURSING

Children with leukemia experience symptoms throughout treatment. Physiologic measures indicate the influence of oxidative stress on symptoms.

Implementing a Daily Maintenance Care Bundle to Prevent Central Line-Associated Bloodstream Infections in Pediatric Oncology Patients

Eliminating central line-associated bloodstream infection (CLABSI) is a national priority. Central venous catheter (CVC) care bundles are composed of a series of interventions that, when used together, are effective in preventing CLABSI. A CVC daily maintenance care bundle includes procedural guidelines for hygiene, dressing changes, and access as well as specific timeframes. Failure to complete one of the components of the care bundle predisposes the patient to a bloodstream infection. A nurse-led multidisciplinary team implemented and, for six months, sustained a daily maintenance care bundle for pediatric oncology patients. This quality improvement project focused on nursing staffs' implementation of the daily maintenance care bundle and the sustainment of the intervention. The project used a pre-post program design to evaluate outcomes of CVC daily maintenance care bundle compliancy and CLABSI. A statistically significant increase between the pre- and post-assessments of the compliance was noted with the CVC daily maintenance care bundle. CLABSI infection rates decreased during the intervention. Strategies to implement practice change and promote sustainability are discussed.

Evaluation of Biomarkers of Oxidative Stress and Apoptosis in Patients With Severe Methotrexate Neurotoxicity: A Case Series

Central nervous system (CNS) treatment is an essential part of acute lymphocytic leukemia (ALL) therapy, and the most common CNS treatment is intrathecal (IT) and high-dose intravenous (IV) methotrexate (MTX). Treatment with MTX may cause neurotoxicity, which is often accompanied by neurologic changes, delays in treatment, and prolonged hospital stays. This article reports clinical presentations of 3 patients with severe MTX toxicity as well as levels of oxidative stress and apoptosis biomarkers in cerebrospinal fluid (CSF). Oxidative stress was measured by oxidized phosphatidylcholine (PC), oxidized phosphatidylinositol (PI), and F2 isoprostanes; apoptosis was measured by caspase 3/7 activity. Most consistent biomarker changes in all 3 cases were increases in caspase 3/7 and F2 isoprostanes prior to acute toxicity while increases in oxidized phospholipids occurred slightly later. Progressive increases in F2 isoprostanes and caspase 3/7 activity prior to and/or during acute toxicity suggests MTX induces oxidative stress and an associated increase in apoptosis. These findings support the role of oxidative stress in MTX-related neurotoxicity.

Symptom prevalence and physiologic biomarkers among adolescents using a mobile phone intervention following hematopoietic stem cell transplantation

PURPOSE/OBJECTIVES

To examine symptom reports and physiologic parameters in adolescents using the Eating After Transplant (EAT!) intervention during recovery after hematopoietic stem cell transplantation (HSCT).

DESIGN

Repeated measures design.

SETTING

HSCT service at a pediatric teaching institution in the southern United States.

SAMPLE

16 adolescents recovering from a first-time allogeneic HSCT.

METHODS

Use of EAT! was monitored electronically, symptom reports were obtained from a questionnaire, and physiologic parameters were obtained from the medical record at HSCT hospital discharge and 20, 40, and 60 days postdischarge.

MAIN RESEARCH VARIABLES

EAT! use, symptom prevalence, symptom-related distress, and physiologic parameters including weight, body mass index (BMI), pre-albumin, and albumin.

FINDINGS

Symptom prevalence was highest at hospital discharge and steadily declined; however, mean symptom distress scores remained stable. Mean weight and BMI significantly declined during the first 60 days postdischarge; pre-albumin and albumin markers were unchanged. No correlation was noted among use of EAT! and any research variables.

CONCLUSIONS

The most frequent symptoms were not always the most distressing symptoms. Weight and BMI significantly declined during HSCT recovery.

IMPLICATIONS FOR NURSING

Nurses should assess symptom frequency and distress to fully understand patients' symptom experiences. Nurses should monitor weight and BMI throughout HSCT recovery.

Fatigue and carnitine levels over multiple cycles of chemotherapy in children and adolescents

PURPOSE

Fatigue in childhood cancer is a pervasive and distressing symptom described as a "lack of energy". Carnitine is a micronutrient used to transport long chain fatty acids into muscle mitochondria. Some chemotherapy drugs interfere with the carnitine network. Both carnitine and fatigue relate to physical energy and may be influenced by chemotherapy. Using a repeated measures design, change in carnitine levels and change in fatigue in childhood cancer patients receiving ifosfamide, cisplatin, or doxorubicin were examined over multiple chemotherapy cycles. The influence of carnitine levels on fatigue was evaluated.

METHODS AND SAMPLE

Fifty-eight patients, between ages 3 and 18 years, within two months from diagnosis and receiving cisplatin, doxorubicin, and/or ifosfamide chemotherapy drugs, participated. Measurements included carnitine plasma levels and self-reported fatigue using established child or adolescent fatigue scales and were collected during the 2nd cycle of chemotherapy, and repeated on alternating cycles up to cycle 8. The Parent Fatigue Scale was used for children under age 7.

KEY RESULTS

Total and free carnitine levels did not change significantly for the group. Fatigue decreased significantly in children age 7-12 (p = 0.04). Relationships between fatigue and carnitine were not significant.

CONCLUSIONS

Changes in carnitine plasma levels were not significant in this sample of patients. The carnitine levels remained within the reference values for children and were not associated with fatigue levels. School-age children may be more resilient to fatigue over the trajectory of treatment. Further research is needed into the biologic mechanisms of fatigue.

Standardization of health care provider competencies for intrathecal access procedures

INTRODUCTION

This quality improvement (QI) project addresses a method for experienced health care providers to maintain skill-based competence for intrathecal access procedures.

METHODS

A prospective QI design using intrathecal access simulation to assess, educate, and evaluate skill competency. Simulation was used as a strategy to promote patient safety and standardize practice patterns. Pretest and posttest methodology using paired t tests were performed to assess anxiety, confidence, and knowledge.

RESULTS

Fourteen pediatric providers participated in this QI project. There was a statistically significant improvement in confidence measuring intracranial pressure (ICP; t = -2.92, P = .013), performance-related overall anxiety (t = -2.132, P = .05) and administering intrathecal chemotherapy (t = -2.144, P = .053). Fifty percent of participants missed a medication error demonstrating confirmation bias.

CONCLUSION

This simulation strategy resulted in improved confidence in measuring ICP, performance-related overall anxiety, and confidence in administering chemotherapy. Confirmation bias occurred during simulation testing for a medication error. We propose this method for maintaining clinical competencies in health care providers and introducing new skills to existing practices.

Feasibility of a symptom management intervention for adolescents recovering from a hematopoietic stem cell transplant

BACKGROUND

Adolescents undergoing a hematopoietic stem cell transplantation (HSCT) experience a variety of adverse effects and eating difficulties. Few interventions exist to assist patients with self-care after HSCT hospitalization. The Eating After Transplant (EAT!) program is a mobile phone applications developed to assist adolescents with self-management of common eating-related issues during HSCT recovery.

OBJECTIVE

This study examined the acceptability and usability of the EAT! program among adolescents and assessed the competency of the participants using the program after hospital discharge through the first 100 days after HSCT.

METHODS

A repeated-measures design was used to evaluate the EAT! application with 16 adolescent patients recovering from an allogeneic HSCT. Participants provided verbal feedback and used a Likert scale to rate acceptability and usability of the application. In addition, a tracking device monitored use of the application. Competency was measured with orientation time and independent demonstration of use of the application.

RESULTS

Acceptability remained high throughout the study, but use significantly decreased over time. Patients reported familiarity with the program's content as the reason for the declining use. Competency was excellent with a short orientation period and independent demonstration throughout the study.

CONCLUSIONS

A mobile phone application is a feasible intervention to educate adolescents with symptom management strategies. Future research needs to examine factors affecting sustainability of use over time.

IMPLICATIONS FOR PRACTICE

Healthcare providers need to continue to develop and evaluate innovative methods to educate adolescents on effective self-care strategies throughout HSCT recovery.

F2-isoprostanes: a measure of oxidative stress in children receiving treatment for leukemia

Acute lymphoblastic leukemia (ALL) is the most prevalent and curable cancer among children and adolescents less than 15 years of age in the United States. Essential for cure of childhood ALL is prophylactic treatment of the central nervous system (CNS), with methotrexate (MTX) being the most widely used drug in this treatment. While CNS treatment has contributed to long-term disease-free survival, resulting declines in academic abilities have been reported. There is growing evidence that CNS treatment with MTX increases oxidative stress, a potential mechanism of CNS injury. This article reports changes in oxidative stress, measured by the biomarker F2-isoprostane (F2-IsoP), in the cerebrospinal fluid (CSF) in 47 children with ALL during the first 18 months of treatment. The number of CSF samples ranged from 5 to 14 during postinduction and from 1 to 9 during continuation. Total doses of intrathecal MTX during postinduction were significantly correlated with the mean and highest concentrations of F2-IsoP during postinduction and the mean concentration of F2-IsoP during continuation. F2-IsoP concentrations during postinduction and continuation were higher in children who received more than six doses of intrathecal MTX. New therapies for a highly curable disease such as childhood leukemia have the potential to be individualized in the future, requiring reliable molecular and biochemical markers, such as oxidative stress indicators. Innovative use of biomarkers has the potential to increase our understanding of treatment-related toxicities and associated symptoms and to inform future therapeutic approaches for optimizing cure and quality of life among children with leukemia.

An outpatient Urgent Care Bay within a pediatric cancer and hematology center

Time-sensitive medical care is essential for pediatric patients undergoing treatment for a hematologic or oncologic condition. Such patients commonly experience acute symptoms related to routine childhood illness and/or their underlying disease or therapy. An Urgent Care Bay (UCB) staffed by a designated nurse and medical provider was established within Texas Children's Cancer Center Outpatient Clinic to provide time-sensitive, same-day diagnostic and therapeutic medical care during clinic hours for patients with acute, non-life-threatening symptoms. The number of patients seen in UCB, chief complaint, underlying diagnosis, and disposition was reviewed. To establish timeliness of care, the authors reviewed the time of referral to the UCB provider or nurse, time of arrival to UCB, time evaluated by providers, and time of initiation of treatment. The addition of an UCB to Texas Children's Cancer Center Outpatient Clinic has shown to allow for rapid assessment and initiation of treatment while avoiding unnecessary emergency room care.

Chemotherapy-related changes in central nervous system phospholipids and neurocognitive function in childhood acute lymphoblastic leukemia

Long-term survivors of childhood leukemia are at risk for neurocognitive impairment, although the neurophysiological basis is not well understood. The purpose of this study was to explore associations between changes in cerebrospinal fluid (CSF) phospholipids and neurocognitive function in children undergoing chemotherapy for acute lymphoblastic leukemia. Seventy-six children were followed prospectively from diagnosis. CSF samples were collected during scheduled lumbar punctures and phospholipids were extracted. Neurocognitive evaluations were conducted annually beginning shortly after diagnosis. Concentrations of sphingomyelin (SM) increased following induction (p = 0.03) and consolidation (p = 0.04), while lysophosphatidylcholine (LPC) increased following induction (p = 0.003). Multivariable analyses demonstrated associations between post-induction SM and motor speed at 1 year (p < 0.001), 2 years (p = 0.001) and 3 years (p = 0.02) following diagnosis. Post-induction LPC was associated with verbal working memory (p = 0.007). Results indicate that early changes in phospholipids are related to neurocognitive decline and suggest a chemotherapy impact on white matter integrity.

Mathematics intervention for prevention of neurocognitive deficits in childhood leukemia

BACKGROUND

Despite evidence that CNS treatment is associated with cognitive and academic impairment, interventions to prevent or mitigate these problems are limited. The purpose was to determine if early intervention can prevent declines in mathematics abilities.

PROCEDURES

Fifty-seven children with ALL were enrolled and randomized to a Mathematics Intervention or Standard Care. Subjects completed neurocognitive assessments prior to the intervention, post-intervention, and 1 year later. Parents received written results and recommendations for use with their school. The Mathematics Intervention was based on Multiple Representation Theory and delivered individually over 1 year.

RESULTS

Thirty-two of 57 subjects completed the study and were included in data analyses. These 32 subjects completed all neurocognitive assessments and, for those in the Intervention Group, 40-50 hours of the Mathematics Intervention. There were no group differences on relevant demographic variables; risk stratification; number of intrathecal methotrexate injections; or high dose systemic methotrexate. Significant improvements in calculation and applied mathematics from Baseline to Post-Intervention (P = 0.003 and 0.002, respectively) and in visual working memory from Baseline to 1 year Follow-up (P = 0.02) were observed in the Intervention but not the Standard Care Group. Results from repeated measures ANOVA demonstrated significant between group differences for applied mathematics [F(2,29) = 12.47, P < 0.001] and visual working memory [F(2,29) = 5.53, P = 0.009].

CONCLUSIONS

The Mathematics Intervention improved mathematics abilities and visual working memory compared to standard care. Future studies are needed to translate the Mathematics Intervention into a "virtual" delivery method more readily available to parents and children.

Using Improvement Science to Promote Evidence-Based Practice in a Childhood Cancer and Hematology Center

A major children’s cancer and hematology center established a Quality Transformation (QT) Core to develop and monitor empirical outcomes that demonstrate excellence in clinical care. The QT Core, based on the Institute of Medicine’s domains of quality health care, aims to ensure that care is safe, effective, patient centered, timely, efficient, and equitable. Specific goals for the first year of the QT Core were to develop a team of improvement science experts, engage faculty and staff in QT initiatives, promote accountability for excellence in clinical care, and establish specific metrics to evaluate process, structure, and outcomes for QT Core projects. The purpose of this article is to discuss the successful development of a quality transformation core within a pediatric subspecialty and demonstrate the principles of improvement science through an actual quality transformation project designed to implement an evidence-based guideline for procedural sedation for children with cancer. The QT Core within this subspecialty was founded on principles of successful transformation of patient care that includes motivation to change, leaders committed to quality, active engagement of staff in meaningful problem-solving initiatives, alignment with organization goals with resource allocation, and integration to bridge boundaries throughout an organization. These key principles are demonstrated through the discussion of the development of the QT Core and implementation of an evidence-based procedure sedation guideline. Pediatric and pediatric subspecialty groups can be on the forefront of national initiatives that promote quality health care, exemplified by the QT Core developed within the cancer and hematology center.

Improving care for children with sickle cell disease/acute chest syndrome

BACKGROUND

Acute chest syndrome (ACS) is a leading cause of hospitalization and death of children with sickle cell disease (SCD). An evidence-based ACS/SCD guideline was established to standardize care throughout the institution in February 2008. However, by the summer of 2009 use of the guideline was inconsistent, and did not seem to have an impact on length of stay. As a result, an implementation program was developed.

OBJECTIVE

This quality-improvement project evaluated the influence of the development and implementation of a clinical practice guideline for children with SCD with ACS or at risk for ACS on clinical outcomes.

METHODS

Clinical outcomes of 139 patients with SCD were evaluated before and after the development of the implementation program. Outcomes included average length of stay, number of exchange transfusions, average cost per SCD admission, and documentation of the clinical respiratory score and pulmonary interventions.

RESULTS

Average length of stay decreased from 5.8 days before implementation of the guideline to 4.1 days after implementation (P = .033). No patients required an exchange transfusion. Average cost per SCD admission decreased from $30 359 before guideline implementation to $22 368. Documentation of the clinical respiratory score increased from 31.0% before implementation to 75.5%, which is an improvement of 44.5% (P < .001). Documentation of incentive spirometry and positive expiratory pressure increased from 23.3% before implementation to 50.4%, which is an improvement of 27.1% (P < .001).

CONCLUSIONS

Implementation of a guideline for children with SCD with ACS or at risk for ACS improved outcomes for patients with SCD.

Symptom clusters in children and adolescents receiving cisplatin, doxorubicin, or ifosfamide

PURPOSE/OBJECTIVES

To examine the influence of the proposed symptom cluster of fatigue, nausea and vomiting, and sleep disturbances on clinical outcomes defined as behavior changes, depression, and performance status in children and adolescents before and after receiving cisplatin, doxorubicin, or ifosfamide chemotherapy.

DESIGN

A prospective, descriptive, within-group, before-and-after-chemotherapy design was used.

SETTING

Two major childhood cancer treatment hospitals in the United States.

SAMPLE

67 patients aged 7-18 years who were receiving chemotherapy courses of cisplatin, doxorubicin, or ifosfamide.

METHODS

Fatigue, depression, behavior, and performance assessments were completed on the first day of cisplatin, doxorubicin, or ifosfamide therapy and one week later. Patients wore a wrist actigraph on the nondominant hand during the course of therapy and for 48 hours after discharge from the hospital. Nausea and vomiting were measured every 24 hours during the course of therapy and for 48 hours after discharge. A linear mixed model was used to evaluate the influence of the symptom cluster. Regression analysis was used to examine the associations between performance status and the symptom cluster. Principal component analysis with varimax rotation was used to produce the correlation of sleep symptoms.

MAIN RESEARCH VARIABLES

Fatigue, nausea and vomiting, sleep disturbances, behavior, depression, and performance.

FINDINGS

Adolescents with the cluster of increased fatigue and sleep disturbances experienced more depressive symptoms and behavior changes. Children with higher levels of fatigue had increased depressive symptoms. The more fatigue parents perceived in their children or adolescents, the more behavior and emotional difficulties were reported.

CONCLUSIONS

Fatigue, sleep disturbance, and nausea and vomiting, when clustered, impacted depressive symptoms and behavior changes in adolescents after chemotherapy. In children, fatigue alone impacted depressive symptoms and behavior changes.

IMPLICATIONS FOR NURSING

Symptom clusters can have a significant impact on children's and adolescents' quality of life during cancer treatment. Early recognition and intervention for these symptoms are an important nursing role.

Brief Report: Effect of Intravenous Methotrexate Dose and Infusion Rate on Neuropsychological Function One Year after Diagnosis of Acute Lymphoblastic Leukemia

OBJECTIVE

To compare the effects of two intravenous (IV) methotrexate (MTX) infusion protocols on cognitive function in children newly diagnosed with acute lymphoblastic leukemia (ALL).

METHODS

We compared 19 children treated with 1 g/m(2) of IV MTX over 24 hr (Group 1) to 13 children treated with 2 g/m(2) of IV MTX over 4 hr (Group 2) on measures of working memory, nonverbal, and verbal skills shortly after diagnosis (Time 1) and 1 year later (Time 2).

RESULTS

A significant GroupxTime interaction was found for a composite measure of working memory with Group 2 declining from Time 1 to Time 2. Group 2 performed significantly worse than Group 1 on a composite measure of nonverbal skills at both time points.

CONCLUSIONS

Findings suggest that difficulties in working memory and nonverbal skills may be evident during the first year of treatment for ALL and that severity may be dependent on IV MTX dose and/or infusion rate.

Pediatric oncology nursing

We are pleased to publish this special issue on pediatric oncology nursing. The articles in this issue provide readers with the most current clinical updates on the treatment and care of children and youth with childhood cancer. We thank Dr. Marilyn Hockenberry and the authors for their contributions to the pediatric nursing literature.

Three instruments to assess fatigue in children with cancer: the child, parent and staff perspectives

The purpose of this study was to develop and test three instruments to measure fatigue in children with cancer from the perspectives of the child, parents and staff. The study consisted of three phases: instrument development, content validation, and estimations of psychometric properties of the three fatigue instruments. One hundred forty-nine children between the ages of 7-12 years presently receiving chemotherapy for cancer, 147 parents and 124 staff participated in this study. The instruments demonstrated strong initial validity and reliability estimates. This study is the first to provide valid and reliable instruments to measure fatigue in children with cancer.

Incidence of anemia in children with solid tumors or Hodgkin disease

Anemia is a hematologic abnormality commonly discussed during the treatment of childhood cancer, but its incidence has not been previously reported. As the basis for determining the incidence of anemia, this retrospective review of medical records combined databases containing the records of all patients 1 to 18 years of age with newly diagnosed neuroblastoma, rhabdomyosarcoma, Hodgkin disease, Ewing sarcoma, or osteosarcoma from two pediatric oncology centers. Data from 405 patients were included in the analysis of hemoglobin at the time of diagnosis. Across diagnoses, 51% to 74% of patients were anemic using the Centers for Disease Control and Prevention age- and sex-specific values to define anemia. The long-term complications of anemia in children with cancer are unknown. Further investigation of the clinical significance of anemia, including its impact on quality of life, is warranted.

Childhood cancers: incidence, etiology, diagnosis, and treatment

Treatment advances over the last few decades have dramatically increased survival for children with cancer. More than half the children treated for cancer are now cured. Consequently, professionals working with these children are beginning to focus on minimizing the adverse effects of cancer and its treatment as well as helping families cope with a chronic, life-threatening illness. This article presents an overview of the incidence, etiology, diagnosis, and treatment of common childhood cancers. Approaches to care, efforts to prevent acute and late toxic effects, and nursing management of children with malignancies are discussed.

Systemic doxorubicin and intraarterial cisplatin preoperative chemotherapy plus postoperative adjuvant chemotherapy in patients with osteosarcoma

The role of adjuvant chemotherapy for osteosarcoma has been well defined. Recently, the use of preoperative chemotherapy has been further enhanced by the use of intraarterial cisplatin. The authors describe the use and results of systemic doxorubicin and intraarterial cisplatin as a preoperative regimen for eight pediatric patients with nonmetastatic osteosarcoma of an extremity. The therapy was well tolerated. Six patients achieved satisfactory local tumor control and were able to receive the surgical procedure to permit limb salvage. Two of these six patients subsequently developed metastatic disease. Of the two patients who did not achieve satisfactory local tumor control to permit a limb salvage procedure, both underwent amputation and one later developed metastatic disease. Five patients have remained continuously free of disease for a median of 18 months (range, 12-21 months). This report confirms the observations that intraarterial cisplatin and doxorubicin can be used as a safe and effective regimen preoperatively for pediatric patients with osteosarcoma of an extremity.