Daniela Caprino

Childhood Cancer Survivors in the Dark

In October 2002, the families of 1,360 longterm survivors of childhood leukemia or cancer were invited to a gala dinner commemorating the 30th anniversary of the Unit of Pediatric Hematology and Oncology of the Giannina Gaslini Children’s Hospital and Research Institute (Genova, Italy). The invitation was confidential and made no mention of past disease. Among the many families who answered, four long-term survivors declined, primarily because they had never known they had ever had cancer or did not remember. Confused about their health status and wanting to learn more about the disease they had endured, these four survivors asked to meet with the pediatrician-inchief who had cared for them more than 25 years ago. We report our findings on the experiences and distress of these four adults, who only recently learned they had cancer in early childhood. These cases provide telling examples of situations that might have been prevented if reflective communication had transpired among the patient, family, and caregivers during the original illness. The four individuals had learned from their parents only recently that they had a severe debilitating disease during early childhood and that they had to undergo regular follow-up for the following 5 years. None of them knew the exact diagnosis or name of the disease. Here are the details of each person’s story. A 36-year-old woman had abdominal Hodgkin’s lymphoma when she was 8 years old. She earned her college degree and is now a high school teacher. She was accompanied to the meeting by her husband. They concurred that theirs was a “perfect marriage.” They said the woman’s sterility was not a problem for either of them and that they had forgone adopting a child. The invitation to the gala aroused the woman’s suspicion about her past as a child patient and motivated her to request clarification. The account of her experience and the memory of some particulars, such as radiotherapy and intravenous chemotherapy sessions, together with her teaching background, induced a process of internalization and an awareness through which she reached the conclusion that she had indeed suffered from cancer early in her life. Her husband’s presence during the encounter was conducive to this realization, which both reached simultaneously. At the end of the meeting, they said they were glad to know about her past disease and to have discovered that her sterility was a late effect of the treatment. A 35-year-old woman had nonHodgkin’s lymphoma when she was 6 years old. She studied with no difficulties until age 19, when she married. She had two healthy children. When she received the invitation to the ceremony, her husband was astonished and then angry, convinced that she knew all about her disease but had, out of a lack of trust in him, hidden everything from him. During the couple’s meeting with us, she adamantly vowed she had known nothing about her disease. Dialogue was difficult at the outset of the conversation, due to each person’s unyielding stand. The compelling request for assistance was driven, above all, by the need to re-establish the trust that the couple seemed to have lost. The recollection of events occurring 25 years earlier proved From the Department of Pediatric Hematology and Oncology, G. Gaslini Scientific Children’s Hospital, Genova, Italy.

Rituximab‐based immunosuppression for autoimmune haemolytic anaemia in infants

We report a case series of four infants with severe autoimmune haemolytic anaemia (AIHA) who responded to treatment with rituximab and cyclosporine after having failed first line therapy with high‐dose steroid (prednisolone 4–8 mg/kg/d). Rituximab was started at 11–90 d from onset due to continued haemolysis; three infants also received cyclosporine A. Three of four infants reached complete response, defined as normal haemoglobin, reticulocytes and negative indices of haemolysis, at 7–21 months from diagnosis. In long‐term follow‐up two infants remained disease‐free with normal immunology, one had undefined immunodeficiency and one had autoimmune lymphoproliferative syndrome.

Ciprofloxacin prophylaxis in children with acute leukemia in an era of increasing antibiotic resistance.

W read with great interest the results of the randomized placebo-controlled trial from Laoprasopwattana and coworkers regarding the effectiveness of ciproflaxacin prophylaxis for preventing fever in neutropenic children with acute leukemia or lymphoma. In this study, there was a 23% reduction of febrile episodes in patients receiving ciprofloxacin, with a consequent decrease in the number of patients who needed to be treated to prevent 1 febrile episode to 4. In a similar, multicenter study comparing amoxicillin–clavulanate with placebo in a homologous patient population, we observed a 21% reduction of febrile events, with a number needed to be treated of 5. What becomes apparent from both studies is that for every 100 neutropenic patients receiving prophylaxis, 75–80 of them are treated unnecessarily to prevent the remaining 20–25 from developing fever and neutropenia. If we consider that the incidence of Gram-negative bacteremia, the most feared complication because of high mortality, generally represents no more than 10–15% of all febrile neutropenic episodes, we estimate that we would administer unnecessarily prophylaxis in 96–97 patients to prevent Gram-negative bacteremia in 3–4 patients. This number could still be considered as acceptable, if antibiotic resistance was not an emerging problem. In the Laoprasopwattana study, the proportion of ciprofloxacin resistant Gram-negatives colonizing patients after 2 weeks of intervention was 95%, whereas it was 27% in those randomized to receive placebo. To the contrary, in our institution where ciprofloxacin is not administered for prophylaxis, resistance to ciprofloxacin is 17% (25/145) of Gram-negative organisms causing bacteremia in children with cancer during an 8-year period (2004 to 2011). We consider this proportion as worrisome and worth strictly monitoring. The prolonged use of fluoroquinolone prophylaxis is associated with appearance of resistant strains, with the emergence of bacteria displaying cross-resistance to β-lactams, and aminoglycosides. This limits its use for empirical therapy, at least in low-risk conditions. Moreover, there is no proof of its efficacy in repeated episodes of neutropenia. We believe that now is the time when antibacterial prophylaxis in neutropenic children with cancer should be abandoned at least during chemotherapeutic regimens.

Health migration and care disparities

To the Editor: Pediatricians realize that there is variability in the treatment of children with cancer, as highlighted by Bhatia in her excellent review [1]. There is widespread agreement that in the US these disparities are deep-rooted and historical [2]. For some countries, however, tackling this problem is a relatively new issue due in large part to the increase in health migration [3,4] over the past several years. Nearly 30% of the children with cancer currently treated in our Department come from Eastern Europe, North Africa, and Latin America, that is, regions where conditions and standards, especially for rare and complex cases, limit regular access to appropriate care [5,6]. However, immigration trends of foreign patients without medical assistance have been stable over the last few years, but the percentage of severely ill patients that are admitted to our department is on the rise (Fig. 1). Most of them come in order to undergo SCT for congenital hematologic diseases, immunodeficiency or second/third line cancer therapy. They arrive with support from the Italian Army, Non-Governmental Organizations (NGOs), Parents’ Associations, or are directly sent by their local hospitals. Only a few families can afford the full cost of stay and treatment. Moreover, approximately 9.7% of the pediatric population between 0 and 2 years of age in Italy is made up of children of immigrant workers [7] for whom coverage is provided by the National Health Service, as it is for Italian citizens. This flow of foreign patients has brought with it noteworthy difficulties that have forced our physicians and nurses to adopt different approaches towards patients and their families who often have different perceptions of health and health care. Cultural and language barriers may impede empathic dialogue between the healthcare team and families, sometime jeopardizing compliance with, and control of treatment. In extreme cases, the lack of mutual understanding can engender anger and mistrust. Beyond the medical issues, the migration of patients and their families entails countless other difficulties including financial, administrative, logistic, psychological, spiritual, and cultural ones. Furthermore, it involves numerous individuals, both inside and outside the hospital, including embassies, patients’ organizations, and NGOs. Nevertheless, cancer treatment outcomes among our foreign patients hardly parallel those of Italian children, and do not exceed 50%. There may be several reasons for this discrepancy, such as the fact that most children reach our Unit with advanced disease, severe infections, misunderstandings about medical explanations, and less compliance with therapy and rules of hygiene. Only by raising healthcare standards in those countries from which patients tend to leave can the above challenges be overcome [8]. In the meantime, medical teams having to care for culturally diverse patients must be adequately trained and supported in order to properly and sensitively deliver the necessary care. At our center we have made attempts to improve patient/health team communication by increasing the presence of cultural mediators, and we are currently looking into other strategies.

Needs and expectations of adolescent in-patients: the experience of Gaslini Children's Hospital.

Abstract Background: Adolescents affected by a severe disease who undergo high-risk treatment may experience stress, pain, extreme frustration, depression, and anger. In this large spectrum of emotions, several situations must be considered carefully. To improve coping and quality of services offered to adolescents in paediatric hospitals, we elaborated a semi-structured interview and a short questionnaire (Quality of life-adolescent-Istituto Giannina Gaslini, QoL-adol-IGG scale) to investigate the quality of life, the needs and expectations of adolescent in-patients. Methods: The study sample includes 117 in-patients aged between 10 and 20 years coming from several Italian regions who were admitted to the G. Gaslini Research Children’s Hospital for a period of 10 days or more, regardless of the disease. The QoL-adol-IGG scale was administered – after obtaining informed consent from the children and their parents – in one single encounter by trained psychologist. The distribution of the answers was evaluated after stratification by patient’s age, gender, area of residence, and clinical diagnosis. Continuous data were compared using the Kruskal-Wallis, while the χ2-test was used for categorical data. Results: Seventy-two percent had difficulty practicing normal daily activities during their stay in the hospital, not only because of the disease (40%), but also because of the poor organization within the hospital, the lack of proposals/activities and space for spare time, and the limited access to technologies. Adolescents ≥15 years were more frequently dissatisfied than youngsters concerning the access to Internet and other technologies, the possibility to make new friends and to take part in social activities. Conclusion: The results of this study, which evaluated the hospital’s organization, but also psychological functioning in a representative sample of patients, may contribute to optimize internal procedures of clinical departments where adolescent in-patients are present, on the basis of their requests and taking into account their age.

A new strategy for prenatal diagnosis in a sporadic haemophilia B family: A RAPID PRENATAL DIAGNOSIS IN A HAEMOPHILIA B FAMILY

Although the quality of life for haemophiliacs has clearly improved in the last few years, haemophilia still remains a serious disorder justifying prenatal diagnosis (PD) and, if necessary, termination. Because chorionic villus sampling (CVS) is performed in the first trimester of pregnancy, an increasing number of carriers are interested in this test. It has been shown that waiting for the results is particularly distressing for pregnant women, therefore decreasing the diagnostic procedure time can be psychologically helpful. Here we report on PD in a sporadic haemophilia B family based on the direct identification of the pathogenic mutation in a CVS taken at the 12th gestational week. In order to hasten the results, we recovered DNA from a single villus fragment boiled in water and used it directly for PCR reaction. Conformation‐sensitive gel electrophoresis (CSGE) was used to detect the mutation in the haemophilia carrier and in the foetus. This approach allowed us to obtain a diagnosis within 24 h of CVS, thus avoiding the long‐term psychological effects on the pregnant woman.

Identification of mutations in exon 14 including five novelties in 13 Italian patients with haemophilia A

Haemophilia A (HA) is the most common X-linked, recessive bleeding disorder which affects from one in 5000 to one in 10 000 males. The disorder is caused by mutations within the FVIII gene (FVIII), which is located at Xq28 and consists of a 9 kb coding region. Other than the inversion of intron 22, reported with a prevalence of 40–50% of patients with severe HA [1], and the inversion of intron 1, reported with a prevalence of about 2–5% [2–4], the gene alterations causing HA are spread all over the gene [5] and include mostly point mutations, small insertions and deletions. In a series of HA, unrelated, Italian patients, referred to our centre for genetic counselling, we have identified 13 mutations in exon 14. Briefly, following informed consent, genomic DNA was extracted from citratated peripheral blood samples, and amplified for FVIII coding regions, promoter and splicing sequences, as described elsewhere [6,7]. Amplified fragments showing an abnormal peak pattern in denaturing high-performance liquid chromatography (DHPLC Helix Varian system; Varian Analytical Instruments, Palo Alto, CA, USA) were sequenced using a fluorescent ABI Prism BigDye terminator kit (Applied Biosystem, Warrington, UK), and the mutations were characterised. Each mutation was confirmed on a second, independent, amplified polymerase chain reaction (PCR) sample. For each of the novel mutations, 50 control samples were analysed and evidence for polymorphisms was ruled out. As shown in Table 1, six of 13 mutations were nonsense alterations and were found to be associated with a severe phenotype, consistently with the premature truncation of the factor VIII protein in the reading translation. Seven mutations were frameshift, all but one was associated with the severe form of the disease. History of neutralizing antibodies to FVIII was negative in all patients.

PSYCHOLOGICAL AND SOCIAL COMMITMENT IN GENETIC COUNSELLING AND IN PRENATAL DIAGNOSIS OF HEMOPHILIA 190

PSYCHOLOGICAL AND SOCIAL COMMITMENT IN GENETIC COUNSELLING AND IN PRENATAL DIAGNOSIS OF HEMOPHILIA 190

2 ANALYSIS OF METHYLATION PATTERN IN FEMALES WITH LOW FACTOR VIII: C LEVEL

The analysis of X chromosome activation through the metilation pattern could be useful in the study of affected females for X-linked recessive diseases, such as Hemophilia A (HA). Low FVIII;C level in female can be due to: acquired inhibitors to FVIII, X chromosome abnormalities, homozygosity at the hemophilia locus, extreme lyonization in an heterozygote. It is possible to reveal a non random inactivation of X chromosomes by hybridization of genomic DNA with M27ß probe (locus DXS 255). We analyzed with this probe 3 females with low FVIII:C levels (range 2%-5%). G.V. is a 33 year old female (FVIIhC 5%, FVIIIvW:Ag 80%) born from a HA carrier and a normal man. Karyotype was 46,XX and no inhibitors against FVIII were detected. The study with M27ß probe showed that only the paternal X chromosome was inactive. HA in this female is probably due to a non random X-inactivation. P.M. is a 48 year old female (FVIII:C 12%; FVIIIvW:Ag 100%) born from first cousins parents. Her father and brother are hemophilics (FVIII:C 11%) and her mother was a carrier. Cytogenetic studies revealed no abnormalities. M27ß analysis showed a balanced lyonization. An homozygosity for the HA defective gene, was demonstrated by the aplotype analysis with RFLPs. P.T. is a 19 year old female (FVIII:C 2.2%; FVIIIvW:Ag 73%) with Turner Syndrome (46,X,-idic(X)) born from healthy unrelated parents without history of bleeding disorders. The RFLP studies showed the maternal origin of idic(X). The methylation pattern obtained by M27ß probe confirmed the whole inactivation of the abnormal X therefore we hypothesized a mutation in FVIII gene in the normal X coming from her healthy father. In conclusion, the possibility to demonstrate the degree of X-chromosome activation is a very important and useful tool in understanding the pattern of HA carriers.

44 ASPECTS OF PRENATAL DIAGNOSIS IN HEMOPHILIA A (HA) AND B (HB)

Prenatal diagnosis (PD) of genetic diseases is the accepted preventive medical application of clinical genetics in many severe diseases such as HA and HB. We observed 408 women at risk for HA and 77 for HB coming respectively from 223 and 58 families. From 1987 we performed 72 PD out of 60 women on chorionic villus sampling (CVS) by transabdominal approach, free hand under continuous ultrasound guidance, at 10 weeks gestation. Even if earlier sampling is possible, a delaied procedure allowed to cut down the risks of miscarriage and of fetal limb abnormalities. In our hands the fetal loss risk is about 1.5%. We diagnosed 12 affected males, 24 healthy males and 28 female fetuses. At the beginning in 3 cases the sample was not sufficient for DNA analysis and, after CVS, in 2 cases the mother was uninformative and in 3 cases the mother was diagnosed as non carrier. We did not observe any malformation or pregnancy loss in the patients analyzed for hemophilia, probably related to the absence of other risk factors. The use of PCR for DNA analysis, allowed us to improve the carrier detection and PD of HA and HB reducing the time of analysis, increasing the informativity with the detection of sequence polymorphisms and using less chorionic tissue. The last 15 PD were performed by PCR. We gave a genetic counselling to 13 pregnant women at risk, avoiding the CVS in non carrier females. Therefore the acceptance of antenatal diagnosis increased: 8/60 women performed more then one PD (5/8 two CVS and 3/8 three CVS). On 10 pregnancies we analyzed the fetal sex by PCR obtaining the sex diagnosis in few hours. In 9/10 the result was confirmed by chromosomal analysis and only in 1 case we missed the diagnosis.