Cambridge hybrid closed-loop algorithm in children and adolescents with type 1 diabetes: a multicentre 6-month randomised controlled trial

BACKGROUND

Closed-loop insulin delivery systems have the potential to address suboptimal glucose control in children and adolescents with type 1 diabetes. We compared safety and efficacy of the Cambridge hybrid closed-loop algorithm with usual care over 6 months in this population.

METHODS

In a multicentre, multinational, parallel randomised controlled trial, participants aged 6-18 years using insulin pump therapy were recruited at seven UK and five US paediatric diabetes centres. Key inclusion criteria were diagnosis of type 1 diabetes for at least 12 months, insulin pump therapy for at least 3 months, and screening HbA1c levels between 53 and 86 mmol/mol (7·0-10·0%). Using block randomisation and central randomisation software, we randomly assigned participants to either closed-loop insulin delivery (closed-loop group) or to usual care with insulin pump therapy (control group) for 6 months. Randomisation was stratified at each centre by local baseline HbA1c. The Cambridge closed-loop algorithm running on a smartphone was used with either (1) a modified Medtronic 640G pump, Medtronic Guardian 3 sensor, and Medtronic prototype phone enclosure (FlorenceM configuration), or (2) a Sooil Dana RS pump and Dexcom G6 sensor (CamAPS FX configuration). The primary endpoint was change in HbA1c at 6 months combining data from both configurations. The primary analysis was done in all randomised patients (intention to treat). Trial registration ClinicalTrials.gov, NCT02925299.

FINDINGS

Of 147 people initially screened, 133 participants (mean age 13·0 years [SD 2·8]; 57% female, 43% male) were randomly assigned to either the closed-loop group (n=65) or the control group (n=68). Mean baseline HbA1c was 8·2% (SD 0·7) in the closed-loop group and 8·3% (0·7) in the control group. At 6 months, HbA1c was lower in the closed-loop group than in the control group (between-group difference -3·5 mmol/mol (95% CI -6·5 to -0·5 [-0·32 percentage points, -0·59 to -0·04]; p=0·023). Closed-loop usage was low with FlorenceM due to failing phone enclosures (median 40% [IQR 26-53]), but consistently high with CamAPS FX (93% [88-96]), impacting efficacy. A total of 155 adverse events occurred after randomisation (67 in the closed-loop group, 88 in the control group), including seven severe hypoglycaemia events (four in the closed-loop group, three in the control group), two diabetic ketoacidosis events (both in the closed-loop group), and two non-treatment-related serious adverse events. There were 23 reportable hyperglycaemia events (11 in the closed-loop group, 12 in the control group), which did not meet criteria for diabetic ketoacidosis.

INTERPRETATION

The Cambridge hybrid closed-loop algorithm had an acceptable safety profile, and improved glycaemic control in children and adolescents with type 1 diabetes. To ensure optimal efficacy of the closed-loop system, usage needs to be consistently high, as demonstrated with CamAPS FX.

FUNDING

National Institute of Diabetes and Digestive and Kidney Diseases.

Examining the effect of manganese on physiological processes: Invertebrate models

Manganese (Mn²⁺ as MnSO₄ &/or MnCl₂) is a common and essential element for maintaining life in plants and animals and is found in soil, fresh waters and marine waters; however, over exposure is toxic to organisms. MnSO₄ is added to soil for agricultural purposes and people are exposed to Mn²⁺ in the mining industry. Hypermanganesemia in mammals is associated with neurological issues mimicking Parkinson's disease (PD) and appears to target dopaminergic neural circuits. However, it also seems that hypermanganesemia can affect many aspects of health besides dopaminergic synapses. We examined the effect on development, behavior, survival, cardiac function, and glutamatergic synaptic transmission in the Drosophila melanogaster. In addition, we examined the effect of Mn²⁺ on a sensory proprioceptive organ and nerve conduction in a marine crustacean and synaptic transmission at glutamatergic neuromuscular junctions of freshwater crayfish. A dose-response effect of higher Mn²⁺ retards development, survival and cardiac function in larval Drosophila and survival in larvae and adults. MnSO₄ as well as MnCl₂ blocks stretch activated responses in primary proprioceptive neurons in a dose-response manner. Mn²⁺ blocks glutamatergic synaptic transmission in Drosophila as well as crayfish via presynaptic action. This study is relevant in demonstrating the effects of Mn²⁺ on various physiological functions in order to learn more about acute and long-term consequences Mn²⁺ exposure.

Canopy isotopic investigation reveals different water uptake dynamics of maples and oaks

Variations in drought responses exhibited by cohabiting tree species such as Acer sacharrum and Quercus alba have often been attributed to differences in rooting depth or water accessibility. A. sacharrum is thought to be a shallow rooted species, and is assumed to not have access to the deep and stable water resources available to Q. alba. As such, A. sacharrum conserves water by minimizing stomatal conductance under drought conditions whereas Q. alba does not. However, detailed records of sufficient temporal resolution which integrate water accessibility, meteorological drivers, and leaf level parameters (e.g., photosynthesis, stomatal conductance) are lacking, making such assumptions-though plausible- largely untested. In this study, we investigated the water accessibility of both maples (A. sacharrum) and oaks (Q. alba) during the late growing season using novel canopy stable isotope measurements. Our results showed that maples can draw from the same water pool as cohabitating oaks, but can also switch to a shallow water source in response to available moisture in the shallow soil profile. We also found that maples tended to use a deep water source under high vapor pressure deficit even when shallow soil water was available. On the other hand, oaks had consistent deep water access during our study period. It is noted that our measurements do not cover the whole growing season and should be extrapolated with caution. Such findings indicate that differences in leaf functions during drought between maples and oaks may be due to both soil water accessibility and atmospheric water demand.

The importance of cuticular permeance in assessing plant water-use strategies

Accurate understanding of plant responses to water stress is increasingly important for quantification of ecosystem carbon and water cycling under future climates. Plant water-use strategies can be characterized across a spectrum of water stress responses, from tight stomatal control (isohydric) to distinctly less stomatal control (anisohydric). A recent and popular classification method of plant water-use strategies utilizes the regression slope of predawn and midday leaf water potentials, σ, to reflect the coupling of soil water availability (predawn leaf water potential) and stomatal dynamics (daily decline in leaf water potential). This type of classification is important in predicting ecosystem drought response and resiliency. However, it fails to explain the relative stomatal responses to drought of Acer sacharrum and Quercus alba, improperly ranking them on the spectrum of isohydricity. We argue this inconsistency may be in part due to the cuticular conductance of different species. We used empirical and modeling evidence to show that plants with more permeable cuticles are more often classified as anisohydric; the σ values of those species were very well correlated with measured cuticular permeance. Furthermore, we found that midday leaf water potential in species with more permeable cuticles would continue to decrease as soils become drier, but not in those with less permeable cuticles. We devised a diagnostic parameter, Γ, to identify circumstances where the impact of cuticular conductance could cause species misclassification. The results suggest that cuticular conductance needs to be considered to better understand plant water-use strategies and to accurately predict forest responses to water stress under future climate scenarios.

Intensified vegetation water use under acid deposition

Despite the important role vegetation plays in the global water cycle, the exact controls of vegetation water use, especially the role of soil biogeochemistry, remain elusive. In this study, we reveal a new mechanism of soil biogeochemical control of large-scale vegetation water use. Nitrate and sulfate deposition from fossil fuel burning have caused substantial soil acidification, leading to the leaching of soil base cations. Of these, calcium has a unique role in plant cells by regulating stomatal aperture, thus affecting vegetation water use. We hypothesized that the leaching of the soil calcium supply, induced by acid deposition, would increase large-scale vegetation water use. We present evidence from a long-term whole watershed acidification experiment demonstrating that the alteration of the soil calcium supply by acid deposition can significantly intensify vegetation water use (~10% increase in evapotranspiration) and deplete available soil water. These results are critical to understanding future water availability, biogeochemical cycles, and surface energy flux and to help reduce uncertainties in terrestrial biosphere models.

A nonlinear contextually aware prompting system (N-CAPS) to assist workers with intellectual and developmental disabilities to perform factory assembly tasks: system overview and pilot testing

PURPOSE

This paper presents a new cognitive assistive technology, nonlinear contextually aware prompting system (N-CAPS) that uses advanced sensing and artificial intelligence to monitor and provide assistance to workers with cognitive disabilities during a factory assembly task.

METHODS

The N-CAPS system was designed through the application of various computer vision and artificial intelligence algorithms that allows the system to track a user during a specific assembly task, and then provide verbal and visual prompts to the worker as needed. A pilot study was completed with the N-CAPS solution in order to investigate whether it was an appropriate intervention. Four participants completed the required assembly task five different times, using the N-CAPS system.

RESULTS

The participants completed all of the trials that they attempted with 85.7% of the steps completed without assistance from the job coach. Of the 85.7% of steps completed independently, 32.5% of these were completed in response to prompts given by N-CAPS. Overall system accuracy was 83.3%, the overall sensitivity was 86.2% and the overall specificity was 82.4%.

CONCLUSIONS

The results from the study were positive in that they showed that this type of technology does have merit with this population. Implications for Rehabilitation It provides a concise summary of the importance of work in the lives of people with intellectual disabilities and how technology can support this life goal. It describes the first artificially intelligent system designed to support workers with intellectually disabilities. It provides evidence that individuals with intellectual disabilities can perform a work task in response to technology.

Evaluation of alloreactivity in kidney transplant recipients treated with antithymocyte globulin versus IL-2 receptor blocker

Induction therapy is used in kidney transplantation to inhibit the activation of donor-reactive T cells which are detrimental to transplant outcomes. The choice of induction therapy is decided based on perceived immunological risk rather than by direct measurement of donor T-cell reactivity. We hypothesized that immune cellular alloreactivity pretransplantation can be quantified and that blocking versus depleting therapies have differential effects on the level of donor and third-party cellular alloreactivity. We studied 31 kidney transplant recipients treated with either antithymocyte globulin (ATG) or an IL-2 receptor blocker. We tested pre- and posttransplant peripheral blood cells by flow cytometry to characterize T-cell populations and by IFN-γ ELISPOT assays to assess the level of cellular alloreactivity. CD8(+) T cells were more resistant to depletion by ATG than CD4(+) T cells. Posttransplantation, frequencies of donor-reactive T cells were markedly decreased in the ATG-treated group but not in the IL-2 receptor blocker group, whereas the frequencies of third-party alloreactivity remained nearly equivalent. In conclusion, when ATG is used, marked and prolonged donor hyporesponsiveness with minimal effects on nondonor responses is observed. In contrast, induction with the IL-2 receptor blocker is less effective at diminishing donor T-cell reactivity.

Outcome of children with high-risk acute lymphoblastic leukemia (HR-ALL): Nordic results on an intensive regimen with restricted central nervous system irradiation

BACKGROUND

Improvement in outcome of childhood high-risk (HR) ALL was sought with a very intensive Nordic protocol leaving most patients without CNS-RT.

METHODS

A total of 426 consecutive children entered the NOPHO-92 HR-ALL program. HR criteria included WBC > or =50 x 10(9)/L, CNS or testicular involvement, T-cell, lymphomatous features, t(9;22), t(4;11), or slow response. Of these, 152 children had very high risk (VHR) with special definitions. CNS consolidation was based on high-dose MTX (8 g/m2) and ARA-C (12 g/m2) alternating. VHR patients also received cranial RT.

RESULTS

The 9-year EFS was 61 +/- 3%, OS 74 +/- 2%, and EFS for T-ALL 62 +/- 4%. Cumulative incidence of isolated CNS relapse was 4.7 +/- 1%, and CNS relapse in total 9.9 +/- 2%. Poor prognostic factors were WBC > or =200 x 10(9)/L and a very slow response.

CONCLUSIONS

HR-ALL was successfully treated on the NOPHO-92 regimen, with a relatively low CNS relapse rate for non-irradiated children. WBC > or =200 x 10(9)/L and very slow response emerged as strong poor prognostic factors.

Chediak-Higashi syndrome: four cases from Northern Finland

Chediak-Higashi syndrome (CHS) is a rare multiorgan disease entity with autosomal recessive inheritance characterized by oculocutaneous albinism, bleeding tendency, recurrent bacterial infections and various neurological symptoms. Intracellular vesicle formation is deficient, resulting in giant granules in many cells, e.g. giant melanosomes in the melanocytes. Diagnosis has been based on morphological examination of peripheral blood and bone marrow, with giant granules seen in cells of the myeloid lineage and in lymphocytes. The ultimate diagnostic test is to look for a mutated LYST gene. Most patients develop an accelerated phase of the disease with deposition of lymphohistiocytes in the liver, spleen, lymph nodes and bone marrow, resulting in hepatosplenomegaly, bone marrow infiltration and haemophagocytosis. Peripheral blood neutropenia becomes more profound as anaemia and thrombocytopenia develop. Most patients succumb before the age of 10 years. Four patients with CHS are described, one of whom is a long-term survivor after successful allogeneic bone marrow transplantation, two succumbed during the accelerated phase and one is living with a chronic form of the disease.

CONCLUSION

Allogeneic bone marrow transplantation from an HLA-matched sibling is the therapy of choice and should be performed early. If there is no matched family donor, an unrelated donor or a placental blood graft is a good alternative. The clinical picture of CHS is heterogeneous and therapeutic decisions need to be made on an individual basis.

Cognitive functions of young adults who survived childhood cancer

Neuropsychological tests were used to determine the cognitive functioning of adult long-term survivors treatedfor childhood cancer Disease onset before the age of 5 was related to lower test scores in intelligence tests, several memory tests, and motor function tests. The cranial irradiated survivors displayed more difficulties, especially in short-term memory tests and the Wechsler Adult Intelligence Scale Digit Symbol Test as compared to nonradiated survivors. No statistically significant differences in test scores were observed between different forms of cancer The results of this study are consistent with the notion that those memory types that demand special attention and motor speed functions are especially vulnerable to cancer and its treatment.

Second malignant neoplasms after cancer in childhood and adolescence: a population-based case-control study in the 5 Nordic countries. The Nordic Society for Pediatric Hematology and Oncology. The Association of the Nordic Cancer Registries

Our purpose was to assess the risk of developing a second malignant neoplasm (SMN) after cancer in childhood and adolescence associated with different treatment modalities. Our investigation was performed as a nested case-control study within a Nordic cohort of 25,120 patients younger than 20 years old at first malignant neoplasm (FMN) diagnosed in 1960 through 1987. SMNs were diagnosed in 1960 through 1991. For each case of SMN, 3 controls were sampled, matched by sex, age, calendar year of diagnosis and length of follow-up. For the final analysis, there were 234 cases and 678 controls. Relative risks (RRs) of various exposures were estimated by means of conditional logistic regression, with non-exposed as the reference. The RR of developing SMN in the radiated volume was 4.3 (95% confidence interval 3.0-6.2). The risk was highest in children diagnosed before the age of 5 years; it increased with the dose of radiation and with increasing follow-up time after FMN. Chemotherapy alone was not associated with an increased RR, but it significantly potentiated the effect of radiotherapy. RRs were unchanged between the periods 1960-1973 and 1974-1987, and since the use of chemotherapy increased in the latter period, the number of SMNs may increase. Hereditary factors were important for the occurrence of SMN independently of therapy. We conclude that radiation was the most important treatment-related risk factor for the development of SMN. Chemotherapy appeared to play only an accessory role during the study period, potentiating the carcinogenic effect of radiotherapy.

White matter changes on MRI during treatment in children with acute lymphoblastic leukemia: correlation with neuropsychological findings

BACKGROUND

Treatment of childhood acute lymphoblastic leukemia (ALL) may cause structural and functional brain damage. To find out the incidence of white matter changes during therapy, a prospective MRI study was designed, and the findings were correlated with neuropsychological evaluation.

PROCEDURE

Thirty-three children with ALL underwent serial cranial MRI before, during, and after therapy. Twenty-eight of these children underwent also neuropsychological assessment at the end of treatment. They all received intravenous and intrathecal methotrexate for central nervous system (CNS) therapy, 15 patients received cranial irradiation in addition.

RESULTS

Transient high-intensity white matter changes were observed by MRI in three children 9% (95% CI, 2-24%) who received chemotherapy only. The high-intensity changes were most prominent in the frontal lobes in two of these children. The children with white matter changes were significantly younger than those with normal MRI (2.8 vs. 7.4 years; mean). There was no correlation between neuropsychological tests and white matter changes, except in attention and in tests referring to the frontal areas in general.

CONCLUSIONS

White matter changes are occasionally observed during therapy with the current Nordic protocols. Young children may be more susceptible to developing white matter changes after repeated intravenous methotrexate injections. There is no systematic correlation between neuropsychological deficits and MRI findings.

Granulocyte-macrophage colony-stimulating factor support in therapy of high-risk acute lymphoblastic leukemia in children

BACKGROUND

Our purpose was to increase the dose intensity of chemotherapy and reduce the days with neutropenic fever in childhood high-risk (HR) acute lymphoblastic leukemia (ALL) by systematic use of granulocyte-macrophage colony-stimulating factor (GM-CSF).

PROCEDURE

All children with HR-ALL in Finland during 1990-1996 were included. Two open-label study groups were formed: 1) 34 children diagnosed between January, 1992, and December, 1996, received seven or nine courses (depending on cranial RT or no cranial RT) of GM-CSF at 5 microg/kg s.c. daily until an absolute neutrophil count (ANC) of 1,000 x 10(6)/liter at scheduled places in the protocol and 2) 80 control children, those diagnosed between January, 1990, and December, 1991, plus all with significant coexpression of myeloid markers, did not receive GM-CSF.

RESULTS

Dose intensity increased in patients who received regular GM-CSF support. The intensive phase of therapy, including induction, consolidation courses, and delayed intensification, was 33 days shorter (P < 0.001) in children with seven courses and 26 days shorter (P < 0.01) in those with nine courses of GM-CSF compared to controls. The number of infections during the whole ALL therapy was reduced by use of GM-CSF in children aged >5 years (P < 0.001), but not in those aged <5 years. The mean total duration of intravenous antibiotics per child was 39 days in the GM-CSF group and 48 days in the control group (P < 0. 001). Systematic use of GM-CSF was cost-effective.

CONCLUSIONS

Systematic use of GM-CSF improved dose intensity by shortening the intensive treatment period by about 4 weeks. Use of GM-CSF reduced the days for inpatient antibiotics by about 1 week per child, which translates into reduced costs.

Military service of male survivors of childhood malignancies

BACKGROUND

The objective of this study was to assess the eligibility for and the course of compulsory military service of childhood cancer survivors.

METHODS

The medical, military recruitment, conscription, and military service data of male Finnish childhood cancer survivors were collected from manually filed records. Inclusion criteria were: survivors born 1977 or earlier, treated for a malignancy between birth and age 15 years, and followed by a pediatrician until at least age 18 years. The documents of 207 survivors from the Pediatric Clinics of Finnish University Hospitals were examined, and 130 of these survivors were considered eligible for military service. Demographic factors, the predictors of fitness for military service, factors associated with service interruption, the attained level of military training, and the health status of conscripts during service were evaluated. Comparisons were made with the Finnish male population of the same age and with conscripts serving at the corresponding time.

RESULTS

Approximately 60% of studied survivors were enlisted. Positive predictors of fitness for service were year of birth of 1973 or later (odds ratio [OR], 3.2), height at call-up age of 170-174.9 cm (OR, 3.6), and the man's own positive opinion of his fitness for service (OR, 62.3). Negative predictors were age at diagnosis > or = 11 years (OR, 0.5), central nervous system radiotherapy (OR, 0.3), limb defects (OR, 0.02), and the group of sequelae concerning neurologic, cardiopulmonary, and gastrointestinal systems, or secondary malignancies (OR, 0.3). Survivors interrupted their service more often (20%) (P < 0.001). Leukemia survivors were less likely to interrupt their service (7%) compared with other survivors (P = 0.04). Factors associated with service interruption were: diagnosis (P = 0.04), the man's own opinion of his fitness for service (P = 0.013), surgery (P = 0.003), and height (P = 0.049), weight (P = 0.019), and body mass index (P = 0.035) at the beginning of military service. The attained level of military training was equal to that of controls. The survivors visited the garrison physician less frequently in total (mean, 5.9 times) (P < 0.001), visited because of infections as much as controls, and were off duty more (mean, 11.9 days) (P = 0.012) than controls.

CONCLUSIONS

The current study found that childhood cancer survivors were less likely to meet the requirements set for military service in Finland. The causes of rejection usually were obvious, but approximately 30% were rejected merely on the basis of a former cancer diagnosis. However, enlisted survivors coped well with military service if their treatment sequelae were taken into consideration carefully at the time of enlistment. Vocational opportunities within the armed forces might be an appropriate career option even for survivors of childhood malignancies.

Osteonecrosis during the treatment of childhood acute lymphoblastic leukemia: a prospective MRI study

BACKGROUND

Since the survival rates of childhood leukemia have improved, attention is increasingly focused on the long-term effects of the treatment. Osteonecrosis may complicate the treatment of acute lymphoblastic leukemia (ALL). To have more information about the natural history and clinical course of the development of osteonecrosis, a prospective MRI study was designed.

PROCEDURE

The development of osteonecrosis was studied prospectively in 24 consecutive children with ALL who underwent T1-weighted magnetic resonance imaging (MRI) scanning of the lower extremities at the beginning of, during, and at the cessation of the chemotherapy. The general bone marrow signal intensity was assessed together with focal lesions. Circumscribed lesions with a rim of low signal intensity were considered typical of osteonecrosis.

RESULTS

Nine of the 24 patients (rate 38%) developed osteonecrosis during the treatment. Six of them were asymptomatic. MRI lesions regressed in size in six patients, and in three patients the MRI finding returned to normal. No operative treatment was needed. The osteonecroses appeared immediately or within a few months after the delayed intensification phase with intensive dexamethasone medication.

CONCLUSIONS

Corticosteroids have been considered to be the main pathogenetic factor in the development of osteonecrosis in children with malignancies, which was also suggested by our findings. However, there is a lack of systematic prospective studies concerning the natural history and long-term follow-up observations of the prognosis of osteonecrosis, especially in pediatric patients. Based on our results, the lesions are often asymptomatic and cause no disability, and spontaneous improvement or even resolution may occur.

Risk of cancer among offspring of childhood-cancer survivors. Association of the Nordic Cancer Registries and the Nordic Society of Paediatric Haematology and Oncology

BACKGROUND

Increasing numbers of children with cancer survive and reach reproductive age. However, the risk of cancer (other than retinoblastoma) in the offspring of survivors of childhood and adolescent cancer is uncertain.

METHODS

Using data from national cancer and birth registries, we assessed the risk of cancer among 5847 offspring of 14,652 survivors of cancer in childhood or adolescence diagnosed since the 1940s and 1950s in Denmark, Finland, Iceland, Norway, and Sweden. The offspring were followed up for a diagnosis of cancer for 86,780 person-years, and standardized incidence ratios were calculated.

RESULTS

Among the 5847 offspring, 44 malignant neoplasms were diagnosed (standardized incidence ratio, 2.6; 95 percent confidence interval, 1.9 to 3.5). There were 17 retinoblastomas, yielding a standardized incidence ratio of 37. There were 27 neoplasms other than retinoblastoma (standardized incidence ratio, 1.6; 95 percent confidence interval, 1.1 to 2.4). The second most common primary site of cancer among the offspring was the brain and nervous system, in which eight tumors were observed (standardized incidence ratio, 2.0; 95 percent confidence interval, 0.9 to 3.9.) There were between zero and four apparently sporadic cases of cancer in other primary sites among the offspring. Excluding 4 likely cases of hereditary cancer and 2 subsequent cancers among the offspring with hereditary retinoblastoma, there were 22 sporadic cancers, for a standardized incidence ratio of 1.3 (95 percent confidence interval, 0.8 to 2.0).

CONCLUSIONS

There is no evidence of a significantly increased risk of nonhereditary cancer among the offspring of survivors of cancer in childhood.

Growth impairment and growth hormone therapy in children treated for malignant brain tumours

Eighty-two children with malignant brain tumours were treated according to the "8 in 1" chemotherapy protocol in Finland during 1986 to 1993. Thirty-seven with brain tumours not involving the hypothalamic-pituitary region are still alive and tumour-free. The growth and response to growth hormone (GH) therapy in these children was analysed. Children who received craniospinal irradiation had the most severe loss of height SDS, being -1.07 within 3 years of the diagnosis. Even children with no irradiation to the hypothalamic-pituitary axis had a mean change in height SDS of -0.5 after 3 years. Fifteen of 23 children who received craniospinal irradiation and two out of eight children who received cranial irradiation have received GH therapy. A catch-up growth response to the daily GH therapy with the mean dose of 0.7 IU/kg per week was complete in 3 years (+1.87 SDS), irrespective of craniospinal irradiation, in children who were treated at prepubertal age but was seen in none of the children who had reached pubertal age.

CONCLUSION

Growth impairment and GH deficiency are common in children treated for malignant brain tumours. The response to GH therapy is good in prepubertal children in terms of increased growth velocity, although the final height is not yet known.

Improving outcome of malignant brain tumours in very young children: a population-based study in Finland during 1975-93

Sixty-four children with malignant brain tumours diagnosed at less than 3 years of age were reported to the Finnish Cancer Registry from 1975 to 1993. The survival rate has improved significantly: the 5-year survival rate was 26% for all children, 13% for children diagnosed during 1975-85 (n = 30) and 40% for those diagnosed during 1986-93 (n = 34). Of the surviving children in 1986-93, 43% were categorized in Bloom's group I or II and could lead active lives without major disabilities. The remaining children had severe neurologic late complications, such as hemiplegia, intractable seizures, and mental retardation.

Physical and psychosocial outcome for young adults with treated malignancy

We reexamined the physical, neurological, neuropsychological, social, and psychiatric circumstances of a group of 27 (10 females, 17 males) patients at the ages of 16-26 years who had survived a malignant disease during childhood. Twenty survivors had had leukemia and the rest different solid tumors. Only a third (31%) of the subjects were considered to be without any clinically significant physical health problems or functional symptoms, musculoskeletal and endocrinological disorders being the most common. In the neuropsychological test panel including verbal and performance IQ the survivors had significantly lower scores. Early onset of the disease and receiving radiotherapy correlated with impaired test results most significantly, especially on memory functions. One in five of the survivors reported having suffered from reading and writing problems that interfered with success in school and the subjects of the study group had progressed to high school less often than control subjects. The social indices indicated delayed development of sexuality and separation from parents. Overt mental problems appearing at a one-off interview were the same as in the control group. In conclusion, up to two thirds of the childhood cancer survivors as young adults still have physical or neuropsychological health problems and half showed delayed psychosexual maturation. This magnitude of various disorders indicates a long-term but individually oriented follow-up of this small group with the opportunity of physical, social, or psychological management of their main problem.

Chemotherapy for acute lymphoblastic leukemia may cause subtle changes of the spinal cord detectable by somatosensory evoked potentials

Intrathecal chemotherapy has been determined to cause transient or permanent paraparesis due to myelopathy in patients with leukemia or other malignancies. To systematically evaluate the effect of methotrexate on spinal cord function, somatosensory evoked potentials (SEP) were measured in children with acute lymphoblastic leukemia (ALL). A prospective evaluation was performed in 38 consecutive children aged 1.4-15.3 years with newly diagnosed ALL during treatment. Intrathecal methotrexate therapy was included in the therapy schedule of all patients as central nervous system (CNS) therapy in addition to intravenous chemotherapy in 19 standard risk patients and intravenous chemotherapy with cranial irradiation in 19 intermediate or high-risk patients. The measured conduction times were compared with those of 38 control children matched for age, height, and sex. A significant increase in the conduction time of the tibial nerve SEP was found between the Th12 level and the cortex in children with ALL after receiving intrathecal methotrexate therapy during the induction and CNS therapy phases when compared with their controls. The difference of the mean latencies was 1.45 ms (95% CI 0.39-2.51; P < 0.01). There was no significant delay in the median nerve SEP from the brain stem to the cortex, indicating that the conduction delay was in the area of the spinal cord exposed to intrathecal methotrexate. Moreover, the cortical amplitudes of the median nerve SEPs were significantly reduced when measured immediately after intravenous and intrathecal methotrexate and compared to the amplitudes measured after induction therapy in standard risk patients (P = 0.001). Intrathecal methotrexate with systemic chemotherapy causes a deterioration in the somatosensory pathways within the CNS, suggesting also spinal cord dysfunction in children with ALL in addition to the cerebral dysfunction described earlier.

In vivo purging of bone marrow in children with poor-risk neuroblastoma for marrow collection and autologous bone marrow transplantation

PURPOSE

To evaluate the following prospectively in poor-risk neuroblastoma (NBL) patients: (1) the feasibility and efficacy of in vivo purging of bone marrow; and (2) the outcome after autologous bone marrow transplantation (ABMT) when immunologically tumor-free, unpurged autografts were used.

PATIENTS AND METHODS

Twenty-three children with poor-risk NBL were evaluated during induction chemotherapy by repeat bone marrow examinations, including aspirate, biopsy, and an immunofluorescence method using the anti-GD2 monoclonal antibody 3A7. Nineteen patients completed the program with surgery with or without local irradiation followed by ABMT.

RESULTS

Autologous bone marrow grafts, both immunologically and cytologically clean, were obtained and used in 19 of 23 children. The overall 4-year disease-free survival of the 19 grafted children was 53%, with a toxic death rate of 16% and a posttransplant relapse rate of 37%. According to the in vivo purging efficacy of the 18 children with initial marrow disease, the following three groups were formed: patients with (1) perfect in vivo purging (n = 5); (2) eventually successful in vivo purging (n = 8); and (3) unsuccesful in vivo purging (n = 5). The 4-year DFS was 100%, 67%, and 0%, respectively (P < 0.001). The five patients with unsuccessful in vivo purging failed because of resistant/progressive bulky disease.

CONCLUSION

In patients with poor-risk NBL, in vivo purging of bone marrow by conventional chemotherapy is feasible, can be monitored, and the purging efficacy during the first 3 months after diagnosis is a strong prognostic factor reflecting tumor responsiveness to therapy. Autografting with immunologically clean, unpurged marrows gives a DFS well comparable to previous studies using ex vivo purging.

An increased loading dose of ondansetron: a north european, double-blind randomised study in children, comparing 5 mg/m2 with 10 mg/m2

A North European, randomised, double-blind study, comparing a loading-dose of ondansetron of 5 mg/m2 with 10 mg/m2, administered intravenously before highly emetogenic chemotherapy, was carried out in 187 chemotherapy-naïve children. In the first 24 h, both groups received further ondansetron intravenously at a dose of 5 mg/m2 8-hourly. Thereafter, ondansetron was given at an oral dose of 4 or 8 mg depending on the surface area of the child, three times a day and continued for at least 3 days after the last day of chemotherapy. There was no difference in the control of emesis between the two groups. Ondansetron provided good control of emesis and nausea on day 1 with 71-72% of patients experiencing two or fewer emetic episodes (complete or major responders) and 90-86% of patients reporting nausea as none or mild. There was also no difference in the efficacy of the treatment arms in the control of emesis and nausea on subsequent days of the study period. Both anti-emetic regimens were well-tolerated.

Long-term survivors of childhood cancer have an increased risk of manifesting the metabolic syndrome

Survivors of childhood cancer have been reported to have a severalfold increased risk of death from cardiovascular disease. A cluster of metabolic abnormalities, including obesity, insulin resistance, hyperinsulinemia, glucose intolerance, hypertension, and dyslipidemia, have been designated as forming a metabolic syndrome that is associated with increased cardiovascular mortality. We studied 50 survivors (23 males) of childhood cancer, aged 10.5-31.2 yr, an average of 12.6 yr (range, 7.9-21.3 yr) after their diagnosis and compared them with 50 age- and sex-matched controls for signs of the metabolic syndrome by examining clinical and anthropometric measures, serum lipid profile, and fasting plasma insulin and glucose concentrations. Spontaneous nocturnal GH secretion was also evaluated in the cancer survivors. The patients had increased relative weight (P = 0.03) and body fat mass (P < 0.001), decreased serum high density lipoprotein (HDL) cholesterol (P < 0.001), and a reduced ratio of HDL to total cholesterol (P = 0.01). Fasting plasma glucose and insulin levels were higher (P < 0.001 and P = 0.003, respectively) in the cancer survivors than in the controls. The patients had an increased risk [odds ratio (OR), 4.5; 95% confidence interval (CI), 1.3-15.8; P = 0.01] of obesity (relative weight, > 120%), fasting hyperinsulinemia ( > 111 pmol/L; OR, 3.0; 95% CI, 1.0-8.6; P = 0.04), and reduced HDL cholesterol ( < 1.07 mmol/L; OR, 7.9; 95% CI, 2.2 to 29.6; P < 0.001). A combination of obesity, hyperinsulinemia, and low HDL cholesterol was seen in eight cancer survivors (16%), but in none of the controls (P = 0.01). This high risk group was characterized by reduced spontaneous GH secretion (P = 0.02). Long term survivors of childhood cancer appear to have an increased risk of manifestations of the metabolic syndrome. Decreased GH secretion may contribute to these metabolic abnormalities.

Influence of antineoplastic therapy on function of the masticatory system, tooth development, and cariogenic status: a case report

Antineoplastic therapy causes developmental disturbances in the dental enamel and root if children are treated during tooth development. Increased caries activity has also been reported. The effect of anticancer therapy on the function of the masticatory system (i.e. jaws, dentition, masticatory muscles) is not well known. A case report of a 9-year-old girl with right auricular rhabdomyosarcoma is presented. She received irradiation of 50 Gy to the right auricular area and chemotherapy. A year and a half after cessation of cancer therapy, she was disease free and the clinical stomatognathic examination combined with electromyogram (EMG) registration of the masseter and temporal muscles and magnetic resonance imaging (MRI) examination of the temporomandibular joints (TMJ) revealed a strongly restricted mouth opening capacity, painful right TMJ, and flattened head of the right mandibular condyle. Muscle atrophy in the right masseter muscle was clearly visible but EMG activities of the masseter and temporal muscles, however, were higher on the right than on the left. More severe developmental defects, and worse gingival and cariological health were observed on the right side than on the left side. She developed 12 carious lesions and all the lesions were on the right maxilla or mandible or on anterior teeth. The left side was not affected. Intensive prophylactic dental care after cancer treatment is important in order to prevent caries and gingival inflammation. Stomatognathic treatment (i.e. management of occlusal and dysfunctional problems) may improve the mouth opening capacity and relieve pain.

Ototoxicity in children with malignant brain tumors treated with the "8 in 1" chemotherapy protocol

BACKGROUND

Adjuvant chemotherapy has improved the outcome of childhood malignant brain tumors in large randomized trials. With increasing survival rates, treatment toxicity has become a matter of concern. Radiation therapy and cisplatinum are known to be ototoxic.

METHODS

We evaluated the incidence and factors predisposing to ototoxicity in children treated with the "8 in 1" chemotherapy protocol in Finland during 1986--1993. Thirty-five of the 82 children survived for at least 1 year after diagnosis. Thirty of these children were old enough to have an audiogram.

RESULTS

Seventeen of the 30 children had normal hearing, seven had hearing loss at high frequencies, and six (20%) had severe hearing loss in the speech range. The risk factors for severe hearing loss were young age, a high cumulative dose of cisplatinum, and deteriorating renal function. In the presence of these factors, the risk of severe hearing loss was over 50%. Hearing loss at high frequencies could occur after low cumulative doses of cisplatinum, but severe hearing loss correlated with high cumulative doses.

CONCLUSIONS

Cisplatinum-induced hearing loss at high frequencies is common, but hearing loss in the speech range also occurs, particularly in children with predisposing factors, and may progress insidiously and rapidly. Therefore a hearing test before each "8 in 1" course is important.

Neuropsychologic late effects in children with malignant brain tumors treated with surgery, radiotherapy and "8 in 1" chemotherapy

Sixty-eight children with malignant brain tumors were treated with the "8 in 1" chemotherapy protocol from 1986 to 1993 in Finland. The overall 5-year survival rate was 43%. Thirty-one children are still alive and tumor-free, and have been evaluated in the present study. Of these 31 children, 26% had hemi- or tetraplegia, 13% intractable seizures, and 30% attend special schools. The mean full scale (FS) IQ was 85 (range 45-138), 24% had an FSIQ value less than 70, and 36% more than 90. One-half of the survivors were placed in Bloom's group I or II, are able to lead an active life, and have only mild neurologic disabilities. In the other, neurologic late complications accumulated and these children were relegated to Bloom's group III or IV, with major disabilities such as hemiplegia, intractable epilepsy, or mental retardation. The most important prognostic factors were severe perioperative complications, young age at diagnosis, and cranial irradiation.

Risk of subsequent malignant neoplasms among 1,641 Hodgkin's disease patients diagnosed in childhood and adolescence: a population-based cohort study in the five Nordic countries. Association of the Nordic Cancer Registries and the Nordic Society of Pediatric Hematology and Oncology

PURPOSE

To assess the risk of subsequent malignant neoplasms among Hodgkin's disease patients diagnosed before 20 years of age in the five Nordic countries (Denmark, Finland, Iceland, Norway, and Sweden).

PATIENTS AND METHODS

There were 1,641 Hodgkin's disease patients identified through the national cancer registries since the 1940s or 1950s. The patients were monitored for 17,000 person-years until the end of 1991. Expected figures were derived from the age-specific incidence rates in each country and standardized incidence ratios (SIR) were calculated.

RESULTS

A total of 62 subsequent neoplasms were diagnosed (SIR, 7.7; 95% confidence interval [CI], 5.9 to 9.9). The overall cumulative risk of subsequent neoplasms was 1.9% at the 10-year follow-up point, 6.9% at 20 years, and 18% at 30 years. There were 26 subsequent neoplasms among males (SIR, 6.5; 95% CI, 4.3 to 9.6) and 36 among females (SIR, 8.9; 95% CI, 6.2 to 12), of which 16 were breast cancers (SIR, 17; 95% CI, 9.9 to 28). High risks were seen for thyroid cancer (SIR, 33; 95% CI, 15 to 62), for secondary leukemia (SIR, 17; 95% CI, 6.9 to 35), and for non-Hodgkin's lymphoma (SIR, 15; 95% CI, 4.9 to 35). The relative risk increased from 3.3 (95% CI, 1.2 to 7.1) for Hodgkin's disease patients diagnosed in the 1940s and 1950s to 15 (95% CI, 7.4 to 27) in the 1980s. The highest risk of secondary leukemia (SIR, 68; 95% CI, 18 to 174) was seen among those diagnosed with Hodgkin's disease in the 1980s.

CONCLUSION

Patients who survive Hodgkin's disease at a young age are at very high relative risk of subsequent malignant neoplasms throughout their lives. In particular, the high relative risk of breast cancer following Hodgkin's disease in the teenage years calls for enhanced activity for early diagnosis.

Minor changes on cranial MRI during treatment in children with acute lymphoblastic leukaemia

Cranial MRI was used to study treatment-related changes in children undergoing therapy for acute lymphoblastic leukaemia (ALL) or lymphoma. Nineteen children (18 with ALL, 1 with lymphoma) underwent MRI at the beginning of treatment and at intervals during it, to a total of 105 imaging studies and a minimum of 3 per case. Nine patients had finished all therapy, all received consolidation treatment. No patient had central nervous system (CNS) leukaemia at diagnosis or developed a CNS relapse. Mild treatment-related white matter changes were observed in only 2 patients after consolidation therapy with three 5 g/m2 pulses of intravenous methotrexate. Transient enlargement of the ventricles and cortical sulci was observed in 13 patients, always temporally related to steroid treatment. These preliminary data suggest that treatment-related white matter changes are rare and no routine MRI follow-up is needed during treatment in asymptomatic children after a baseline assessment.

The importance of regular dental treatment in patients with cyclic neutropenia. Follow-up of 2 cases

Data on two patients with cyclic neutropenia are presented. They demonstrate that regular tooth care and professional dental treatment can prevent progressive periodontal breakdown but that neglecting oral hygiene soon leads to periodontal pathology. Regular, monthly professional removal of dental plaque and calculus, and rinsing with 0.2% chlorhexidine gluconate during neutropenia help maintain periodontal attachment level. The caries susceptibility and the apical periodontitis in the intact anterior tooth of the female patient indicate the possibility of cyclic neutropenia playing a role in caries and pulpal pathology.

Clinical characteristics and factors affecting growth in long-term survivors of cancer

We evaluated clinical characteristics and growth in 51 (24 males) long-term survivors of childhood cancer (median follow up 12.7 years). Patients were shorter, had a higher proportion of body fat and higher systolic blood pressure than their controls. The change in relative height during treatment was -0.83 standard deviation score (S.D.S.) in patients with cranial irradiation and -0.32 S.D.S. in patients without cranial irradiation; the figures after treatment were -0.56 and 0.20 S.D.S., respectively. Half (r2 = 0.50) of the variation in growth retardation during therapy could be explained by the cumulative doses of 6-mercaptopurine (6-MP) and vincristine and relative height at diagnosis. Cranial irradiation, increased relative height at diagnosis and young age at diagnosis were significant predictors of growth failure over the total observation period, explaining 43% of the variation. We conclude that long-term survivors of childhood cancer have impaired linear growth, increased body fat mass and elevated systolic blood pressure. Young children who are tall for their age at diagnosis and treated with cranial irradiation have the highest risk of impaired growth after the diagnosis. High doses of 6-MP seem to contribute significantly to growth retardation during therapy.

Chemotherapy with the "8 in 1" protocol for malignant brain tumors in children: a population-based study in Finland

We evaluated the outcome of 68 children with malignant brain tumors treated with the "8 in 1" chemotherapy protocol in Finland from 1986 to 1993, comparing 5-year survival rates with those for a historical control group (from 1975 to 1985). For all malignant brain tumors, overall survival was 43% (vs 28% in the control group; P <0.05), and progression-free survival (PFS) was 43% (vs 23%; P <0.05). For medulloblastoma and primitive neuroectodermal tumor, survival was 63% (vs 35%; P <0.05), and the corresponding PFS was 59% (vs 35%; P = 0.15). For high-grade glioma, both the survival rate and the PFS were 27% (vs 17%; P = NS). Thus the outcome was significantly better for our "8 in 1" -treated patients than for the historical controls, especially among the children with primitive neuroectodermal tumor and medulloblastoma. In contrast, those with high-grade gliomas and brain stem tumors seem to have received little benefit; different, more effective treatments are needed for these patients.

Decreased isokinetic trunk muscle strength and performance in long-term survivors of childhood malignancies: correlation with hormonal defects

OBJECTIVE

To evaluate trunk muscle strength and performance in long-term survivors of childhood malignancies relative to age and sex-matched controls, and to relate the muscle strength observations to the therapeutic agents used and possible hormonal disturbances.

DESIGN

Age and sex-matched cohort study.

SETTING

Referral center in the northern part of Finland.

PATIENTS

Forty-six long-term survivors of childhood cancer. Mean age at examination 19.1 years and median off-therapy time 9.4 years.

INTERVENTION

Isokinetic dynamometer testing.

MAIN OUTCOME MEASURES

Measurements of trunk muscle peak torque (PT) and total work done (TWD) were performed at angle speeds of 50 degrees/sec and 200 degrees/sec. The results were normalized relative to body fat-free weight (FFW).

RESULTS

PT in the trunk muscles was lower in the patients at both angle speeds (mean normalized PT = 5.7Nm/kgFFW vs 7.6Nm/kgFFW for controls at 50 degrees/sec), as also was TWD except for extension TWD at the higher angle speed (mean normalized TWD = 59.9J/kgFFW vs 84.6J/kgFFW for controls at 200 degrees/sec). The normalized PT at 50 degrees/sec and TWD at 200 degrees/sec were lower in the males with testicular damage; also, low age at diagnosis correlated positively with muscle strength and performance. There were no differences in normalized PTs or TWDs between cranial radiation and non-radiation cases, or between growth-hormone-deficient and non-deficient cases, and the patients without cranial radiation or with normal growth hormone secretion still had lower normalized PTs and TWDs than the controls.

CONCLUSIONS

Survivors of childhood malignancies have decreased maximal trunk muscle strength and performance. The etiology of this effect remains unclear, but young age at diagnosis, as well as serum testosterone levels in male survivors, evidently influence muscle strength and performance.

Vincristine therapy for children with acute lymphoblastic leukemia impairs conduction in the entire peripheral nerve

Somatosensory evoked potentials were measured prospectively in 38 children with acute lymphoblastic leukemia to evaluate the side effects of vincristine therapy on conduction of the peripheral nerves. Nineteen patients at standard risk received vincristine 12 mg/m2 during induction therapy and 19 patients at intermediate or high risk received 6 mg/m2 during induction therapy and an additional 6 mg/m2 during delayed intensification therapy. These latencies were compared with those of 38 age-, height-, and sex-matched controls. A prolongation in the peripheral conduction time of the posterior tibial nerve was found in the standard risk patients after induction compared with that of the controls, and a delay was found not only from the ankle to the popliteal fossa, but also from the popliteal fossa to the spinal cord (P < .01). The conduction times of the median nerve from the wrist to the plexus (P < .01) and from the wrist to the spinal cord (P < .01) were prolonged after delayed intensification therapy. There was a significant delay in the median and tibial nerve conduction between the intermediate and high risk patients and their controls after a total vincristine dose of 12 mg/m2. These delays were found along the entire length of the nerves, especially in the proximal part of the tibial nerve (P < .001).

Tumor markers CA 125 and CA 19-9 in cord blood and during infancy: developmental changes and use in pediatric germ cell tumors

Tumor markers CA 125 and CA 19-9 are elevated in a variety of malignancies in adult patients, but only little is known of their biology during gestation or infancy. We have addressed the developmental pattern of these carbohydrate antigens in pediatric patients by measuring their serum levels in 133 cord blood samples from the second through third trimester of gestation and in 39 infants aged less than 1.5 y. The serum concentrations of both markers revealed developmental changes, the levels being higher at earlier gestation (wk 24 through 37) than at term or during infancy. The clinical value of the markers was evaluated by monitoring 26 children with germ cell tumors; 14 benign and 2 immature teratomas, and 11 malignant germ cell tumors. Patients with immature sacrococcygeal teratomas showed constant and prolonged elevations of serum CA 125 and CA 19-9. In contrast, all but two children with mature teratomas had normal marker levels; these two patients with abnormally high serum CA 125 and CA 19-9 values for the first 4 postoperative weeks had a benign ovarian and ventricular teratoma, respectively. Of the 11 children with malignant germ cell tumors, serum CA 125 or CA 19-9 concentration was elevated in four patients at diagnosis and declined to normal within 2 wk after institution of therapy. Malignant recurrence in two patients was not associated with a reelevation of the CA 125 level. Taken together, our results demonstrate a developmentally regulated pattern of serum CA 125 and CA 19-9. The carbohydrate markers were usually inferior to alpha-fetoprotein in monitoring of germ cell tumors, but may be a useful adjunct in the follow-up of immature teratomas.

Is there a role for interleukin-3 in Diamond-Blackfan anaemia? Results of a European multicentre study

Forty patients (nine adults aged 20-54; 31 children aged 1-17) with Diamond-Blackfan anaemia (DBA) were treated with recombinant human interleukin-3 (IL-3) in a European multicentre compassionate-need study. IL-3 was given as a daily subcutaneous injection at a starting dose of 2.5 micrograms/kg, escalating at day 21 to 5 micrograms/kg, and then to 10 micrograms/kg if there was no response, for a total duration of 12 weeks. Three children achieved a significant response, achieving sustained remissions off all therapy. At the time of entry, one was steroid-responsive and transfusion-independent, and two were transfusion-dependent. Two adults had a transient reduction in transfusion requirements, but could not tolerate the complete course of therapy. Eosinophilia was common; neutrophil and platelet counts were unaffected except in three patients in whom previously noted mild thrombocytopenia was transiently exacerbated. Clinical response to IL-3 did not correlate with in vitro culture results. A comparison of individual patient characteristics of our study with previously reported series confirms earlier impressions that patients who have never achieved significant in vivo erythropoiesis in response to steroids or during a spontaneous remission are highly unlikely to respond to IL-3. In contrast, there may be a 50% chance of a sustained remission, off steroids, in children who are steroid-dependent and transfusion-independent at the time of IL-3 therapy, suggesting a possible role for a short course of IL-3 earlier in the treatment of children with steroid-responsive DBA.

Incidence of dental caries in children with acute lymphoblastic leukemia is related to the therapy used

Dental caries is an infectious disease and it may be harmful for children suffering from leukemia. DMFS, DMFT scores of forty-five children with acute lymphoblastic leukemia (ALL) were significantly higher than in healthy age-and-sex-matched controls after cessation of therapy. The children with CNS irradiation had higher DMFT (7.13 than children with only chemotherapy (3.4) and the controls (1.8). Lifelong caries incidence showed that children with ALL had 2.7 new caries lesions per year during the therapy compared to the 1.1 (p < 0.05) new lesions in controls. More detailed analysis of permanent anterior teeth at the age of twelve years showed that all patient groups had more filled anterior teeth than controls (p < 0.001); and children with bone marrow transplantation had significantly more fillings than the other two groups.

Developmental defects of teeth in survivors of childhood ALL are related to the therapy and age at diagnosis

The relation of the therapy used and age at diagnosis to developmental defects of dental enamel and root was analyzed in 45 survivors of childhood acute lymphoblastic leukemia (ALL) and compared to that of age- and sex-matched healthy controls. Chemotherapy alone increased the number of enamel defects, but it did not affect the roots. The scattered irradiation of 0.72-1.44 Gy to the dental arches during central nervous system (CNS) irradiation caused an increased number of developmental defects both in enamel and root. Age at diagnosis is an important factor and it showed that the irradiation of 10 Gy did not cause enamel defects if amelogenesis was complete. In conclusion, the therapy is related to developmental defects of the teeth but the most important factor is age, both at diagnosis and during the therapy.

Prospective controlled survey of viral infections in children with acute lymphoblastic leukemia during chemotherapy

BACKGROUND

Infections cause significant morbidity in children with acute lymphoblastic leukemia (ALL). The incidence of viral infections commonly occurring in children with ALL receiving chemotherapy was compared with viral infections in control children and the spread of infections in families was traced.

METHODS

Fifteen families of children with ALL receiving chemotherapy (62 members) and 26 matched control families (106 members) were monitored for a total of 36,197 and 36,583 days, respectively, from November/ 1987 to December/1989 for the occurrence of infections.

RESULTS

The children with ALL had more infections than their control counterparts (P < 0.01) with respiratory infections the most common in both groups. Viral etiology was verified for 47 episodes [5.2/1000 days at risk, 95% confidence interval (CI) 3.9-7.0] in the children with ALL and 22 (2.4/1000 days at risk, 95% CI 1.5-3.7) in the control subjects (P < 0.01 for the difference). Parainfluenza viruses, enteroviruses, and adenoviruses were the most common agents in both groups. The infections of the other members of the patients' families were similar to those of their controls. The children most commonly fell ill first, and although children with ALL had more infections, they did not appear to spread the infections to their family members.

CONCLUSIONS

The children with ALL had more infections than their controls, but they managed to recover well from viral infections caused by common respiratory viruses. The children with ALL did not change the spread of infections among family members.

Allogeneic bone marrow transplantation in Chédiak-Higashi syndrome

A boy with Chédiak-Higashi syndrome (CHS) treated by allogeneic bone marrow transplantation (BMT) is described. He had had several respiratory infections during his first 2 years of life, and at the age of 2.5 years he presented with an accelerated phase of CHS. Despite treatment with ascorbic acid and trimethoprim/sulfamethoxazole, he continued to experience recurrent bacterial infections. Allogeneic BMT was performed with his HLA- and mixed leukocyte culture-identical healthy brother as the donor. The preparative regimen consisted of busulfan and cyclophosphamide, and methotrexate and cyclosporine A were given as prophylaxis for graft-versus-host disease (GVHD). The patient engrafted well, and no symptoms or signs of acute GVHD developed. He then achieved chimerism status, in which half the peripheral blood neutrophils and some of the bone marrow myelopoietic cells displayed Chédiak-Higashi granules, and DNA analysis showed half the peripheral blood cells to be of donor origin and the other half to be of host origin. The boy is currently alive and well 24 months after transplant. Allogeneic BMT, even with mixed chimerism as a result, is a potentially curative therapy for CHS.

Late cranial MRI after cranial irradiation in survivors of childhood cancer

We carried out MRI on 43 survivors of childhood cancer after different treatment protocols with or without cranial radiotherapy. They were free of disease, therapy having been discontinued 2-20 years earlier. Treatment had been for various malignancies, excluding brain tumours; 27 had received cranial irradiation for acute lymphoblastic leukaemia (ALL) or lymphoma. Two asymptomatic young women treated for ALL had falx meningiomas. White matter changes, low intensity foci (representing calcification or old haemorrhage) and heterogeneous intensity focic old haemorrhages) were seen only in patients who had undergone radiotherapy. Because of the possibility of benign, potentially curable brain tumours occurring after cranial irradiation, it may be wise to carry out occasional cranial imaging in the follow-up of these patients. No routine imaging follow-up is needed after chemotherapy alone.

Pituitary size assessed with magnetic resonance imaging as a measure of growth hormone secretion in long term survivors of childhood cancer

We investigated 37 long term survivors of childhood cancer to study the relationship among growth, GH secretion, and pituitary size. The median follow-up time after diagnosis was 13.2 yr. The pituitary gland was visualized with magnetic resonance imaging. Radiated patients (n = 25) had a reduced relative height and showed a greater reduction in relative height after diagnosis than nonradiated patients (n = 12). The patients had lower spontaneous nocturnal GH secretion than controls due to a reduced peak amplitude. Spontaneous GH secretion was lower in radiated patients than in nonradiated subjects. The patients had lower plasma insulin-like growth factor-I (IGF-I) and serum IGF-binding protein-3 (IGFBP-3) concentrations than the controls. Radiated subjects had decreased IGF-I and IGFBP-3 concentrations compared to nonradiated subjects. Half of the patients (20 of 37) evaluated with magnetic resonance imaging had a reduced pituitary size (pituitary height, < -2 SD score). Radiated subjects had smaller pituitary glands than nonradiated ones. Seventeen of 20 patients (85%) with reduced pituitary size had decreased nocturnal GH release. There was a positive correlation between nocturnal GH secretion, plasma IGF-I, and serum IGFBP-3 levels, on the one hand, and pituitary height, on the other. These results indicate that cranial radiation may result in tissue damage, leading to decreased pituitary size, reduced spontaneous GH secretion, and impaired linear growth. The finding of reduced IGF-I levels in both radiated and nonradiated patients combined with decreased IGFBP-3 concentrations in radiated patients, indicates that cytotoxic chemotherapy may induce hepatic damage resulting in decreased IGF-I synthesis.

[Second cancer. Risk of a second malignant neoplasm in persons with cancer in childhood and adolescence]

Cancer treatments in early life have in previous studies been associated in with high risks of developing a second malignant neoplasm. This study reports on the relative and attributable risks of second malignant neoplasms among 30,880 people under the age of 20, who had been identified in the files of any of the five Nordic cancer registers, 1943-1987. Overall, 247 cases of second malignant neoplasms were observed in 238 patients, yielding a relative risk for cancer of 3.6 (95% confidence interval 3.1-4.1). The risk changed significantly from 2.6 in people first diagnosed during the 1940s and 1950s to 6.9 among cohort members included in the late 1970s and 1980s. Highest levels of the relative risk were seen during the ten years immediately after first malignant diagnosis. The incidence of second malignant neoplasms attributable to the first cancer and associated treatments, however, showed a consistent rise throughout the 45 years of follow up. It was concluded that the estimated risks for second malignant neoplasms were significantly lower than those found in most large hospital based studies but compatible with the results from a similar population based study in the United Kingdom. Extent of risk and cancer pattern were similar among the Nordic countries and are believed to be representative for a large part of the European population.

Decreased pituitary gland height after radiation treatment to the hypothalamic-pituitary axis evaluated by MR

PURPOSE

To evaluate treatment-related changes in pituitary gland morphology after childhood cancer and to compare these findings with growth data.

METHODS

Forty-three survivors of childhood cancer were evaluated by cranial MR imaging. Twenty-nine of the patients had received radiation therapy to the hypothalamic-pituitary axis with doses of 10 to 46 Gy. The height of the pituitary gland was measured from midline sagittal images and compared with age- and sex-matched controls. Pituitary gland heights were compared with body height standard deviation scores in patients.

RESULTS

The patients who had received radiation therapy to the hypothalamic-pituitary axis had significantly smaller pituitary glands than patients in the nonirradiated group or their age- and sex-matched controls (mean, 3.5 mm versus 5.9 and 5.8 mm, respectively). They were also significantly shorter than patients in the nonirradiated group.

CONCLUSION

Radiation therapy to the hypothalamic-pituitary area may lead to poor growth of the pituitary gland and short stature.

Second malignant neoplasms after cancer in childhood or adolescence. Nordic Society of Paediatric Haematology and Oncology Association of the Nordic Cancer Registries

OBJECTIVE

To assess the relative risk of developing a second malignant neoplasm in people with a diagnosis of cancer in childhood and adolescence.

DESIGN

Register based follow up study.

SETTING

Populations of Nordic countries.

SUBJECTS

30,880 people under the age of 20 with a first malignant neoplasm diagnosed during the period 1943-87.

MAIN OUTCOME MEASURES

Relative and attributable risks of second malignant neoplasms by type of first cancer, age at first diagnosis, calendar period, sex, and country. Expected figures were based on the appropriate national incidence rates for cancer.

RESULTS

247 cases of second malignant neoplasms were observed in 238 patients, yielding a relative risk for cancer of 3.6 (95% confidence interval 3.1 to 4.1). The risk changed significantly from 2.6 in people first diagnosed during the 1940s and 1950s to 6.9 among cohort members included in the late 1970s and 1980s. Increases were observed for most types of cancer. Highest levels of the relative risk were seen during the 10 years immediately after first malignant diagnosis. The incidence of second malignant neoplasms attributable to the first cancer and associated treatments, however, showed a consistent rise throughout the 45 years of follow up.

CONCLUSION

The estimated risks for a second malignant neoplasm were significantly lower than those found in most large hospital based studies but compatible with the results from a similar population based study in the United Kingdom. Extent of risk and cancer pattern were similar among the Nordic countries and are believed to be representative for a large part of the European population.

White matter changes in children treated for acute lymphoblastic leukemia

BACKGROUND AND METHODS

Twenty-seven children with acute lymphoblastic leukemia (ALL) were studied by magnetic resonance (MR) imaging after central nervous system (CNS) treatment. The children were followed by clinical evaluations and computed tomographic (CT) brain scans. Two CNS treatment techniques were used. Eleven patients received intravenous and intrathecal methotrexate; 16 patients received 18-30 Gy of cranial radiation therapy in addition to systemic chemotherapy. The time interval between the CNS treatment and MR scans varied from 9 months to 4 years 8 months.

RESULTS

Four of the 27 children (15%) showed white matter changes on the MR scans attributable to therapy, but only one had hypodensity on CT. Three of the 16 children (19%) receiving radiation therapy in addition to chemotherapy had white matter changes. One of the 11 patients (9%) from the group receiving only chemotherapy did so. The difference between the two treatment groups was not significant.

CONCLUSIONS

Radiation therapy or chemotherapy (alone or in combination) may have been responsible for the white matter changes. MR imaging is a sensitive detector of white matter changes in children with ALL, but its value and significance during follow-up should be assessed in well-designed longitudinal research studies.

Superior treatment results in females with high-risk acute lymphoblastic leukemia in childhood

In this population-based study, 808 children aged 1-15 years from Denmark, Finland, Iceland, Norway and Sweden, were diagnosed between July 1981 and June 1986 as suffering from non-B-cell acute lymphoblastic leukemia (ALL). The total population was 4.5 million children. Remission was achieved in 770/808 of the patients (95%). No sex difference in the remission rate was observed. The event free survival (EFS) at 102 months was 0.47 for males and 0.62 for females (p less than 0.001). There was no difference in EFS between males and females with standard-risk (0.58 and 0.60) or intermediate-risk (0.47 and 0.60) ALL, respectively. The EFS for females with high-risk ALL (0.68) was superior to that of males with high-risk ALL (0.31). Cox multivariant analysis showed that white blood cell count, sex, age and thrombocyte count were significant prognostic factors in all children. The intensified treatment according to the prognostic factors used in this study led to equal EFS for females with ALL from all risk groups. Males with high-risk ALL, however, did not benefit from the intensified treatment.

Cranial computed tomographic findings in children with newly diagnosed acute lymphoblastic leukemia: a prospective follow-up study during treatment

Cranial computed tomography (CT) was performed on 40 consecutive children with newly diagnosed acute lymphoblastic leukemia (ALL) on admission before any chemotherapy, 5 months after CNS therapy (n = 39) and after 2 to 3 years of therapy (n = 31). Changes related to leukemia were found in only 10% of the patients at the time of diagnosis (4/40). These initial changes, two intracranial hemorrhages, one dural thickening and one contrast enhancement, all disappeared during therapy. The findings which persisted unchanged in the next two CT scans were thought to be normal variations or caused by earlier disorders. CNS therapy consisted of intrathecally and intravenously administered methotrexate in 20 standard risk (SR) patients and cranial irradiation in addition to chemotherapy in 19 intermediate risk (IR) or high risk (HR) patients. Four SR patients developed changes during therapy. Three had enlarged cerebrospinal fluid (CSF) spaces and one developed a focal low density area suggesting disturbances in brain blood circulation and also experienced disturbances in level of consciousness. Of the 19 IR or HR patients, eight developed changes related to the therapy, including four with white matter hypodensity areas, of whom three also had enlarged CSF spaces, and four others who developed enlarged CSF spaces. The medians of the widths of the cortical sulci (P less than .001), insular cisterns (P less than .01), third ventricles (P less than .01), and frontal horns (P less than .05), and also of Evans' ratios (P less than .05) increased significantly after CNS therapy as compared with the findings at diagnosis in the patients who had received cranial irradiation. Most of these changes persisted during the follow-up. We conclude that the clinical value of CT scanning during therapy for ALL is restricted to patients with neurological symptoms or those who have undergone CNS irradiation.