Helen Kosmidis

Insulin-like growth factor-I and binding protein-3 in relation to childhood leukaemia

The aetiology of most cases of childhood leukaemia remains unknown, but several studies have indicated that increased birthweight and height are risk factors for the disease. Since insulin‐like growth factor‐I (IGF‐I) mediates the effect of growth hormone and has been positively associated with prostate cancer, we have evaluated the role of this hormone and its principal binding protein, IGFBP‐3, in the aetiology of childhood leukaemia. Incident cases of childhood leukaemia from those recorded by a national network of childhood oncologists were enrolled in our study. Controls were children hospitalised for acute conditions of no more than moderate severity with matching for gender, age and maternal place of residence. Blood measurements of IGF‐I and IGFBP‐3 were undertaken using commercially available radioimmunoassays. Serum IGF‐I values decreased by about 1.7% per month, and the rate of decline was higher, though not significantly so, among cases (2.1% per month) than among controls (1.4%). There was no significant association between IGF‐I and the likelihood of childhood leukaemia, but an increment of 1 μg/ml of IGFBP‐3 was associated with a substantial and statistically significant reduction of childhood leukaemia by 28% (95% confidence interval 7% to 45%). Because IGFBP‐3 is essentially a binding protein, we interpret our findings as indicating that bioavailable IGF‐I may play an important role in the aetiology of childhood leukaemia. The much smaller quantities and the inherent instability of IGF‐I in the blood in comparison to those of IGFBP‐3 are likely to hinder documentation of an underlying positive association of IGF‐I with the disease. Int. J. Cancer80:494–496, 1999.

Guidelines for a therapeutic alliance between families and staff: A report of the SIOP Working Committee on Psychosocial Issues in Pediatric Oncology

This, the fifth official document of the SIOP Working Committee on Psychosocial Issues in Pediatric Oncology, develops another important topic: the Therapeutic Alliance between families and staff. This is addressed to the Pediatric Oncology Community as Guidelines that could be followed. Every parent, medical staff member, and psychosocial professional involved in the care of the child should be responsible for cooperating in the childs best interest. Everyone must work together toward the common goal of curing the cancer and minimizing its medical and psychosocial side-effects.

Vincristine Overdose: Experience with 3 Patients

Vincristine overdose (7.5 mg/m2) was accidentally administered to 3 children with acute lymphoblastic leukemia. Treatment included double-volume exchange transfusion, phenobarbital administered prophylactically, and folinic acid rescue 18 mg every 3 hours for 16 doses. Vincristine levels were also assayed and showed a dramatic decline in postexchange levels in the 2 patients who survived and an almost unchanged value in the patient who succumbed. Early signs of toxicity in the 2 survivors were peripheral neuropathy (day 4), bone marrow toxicity (day 5), gastrointestinal toxicity (days 6 and 7), and hypertension (days 7 and 8). Marrow aplasia lasted for 4 and 10 days, peripheral neuropathy for 15 and 42 days, gastrointestinal toxicity for 3 and 5 days, and hypertension for 5 and 14 days. The 2 children were discharged on days 13 and 16 and cytostatic therapy was restarted on days 18 and 25. Both are alive without evidence of leukemia. The third patient developed liver and marrow toxicity on day 3 and died on day 9. Postmortem examination showed leukemia infiltration of the liver and spleen.

Optimal care for the child with cancer: A summary statement from the SIOP working committee on psychosocial issues in pediatric oncology†

Since its foundation in 1991, the SIOP Working Committee on Psychosocial Issues in Paediatric Oncology 1 has developed and published 12 sets of Guidelines for health‐care professionals treating children with cancer and their families. Those elements considered essential in the process of cure and care of children with cancer are summarized in this document as a formal statement, developed at the 2007 SIOP annual meeting in Mumbai. Elaboration of the concepts with detailed strategies for practice can be found in the referenced guidelines [1–12] and in a companion publication [13]. This article is a summary of what practitioners considered critical elements in the optimal care of the child with cancer, with the goal of stimulating a broader application of these elements throughout the SIOP membership. Pediatr Blood Cancer 2009;52:904–907.

ELECTRICAL POWER LINES AND CHILDHOOD LEUKEMIA: A STUDY FROM GREECE

Residential proximity to electrical power lines of different voltage in relation to childhood leukemia was investigated through a case-control study undertaken in Greece during 1993-1994. The study comprised 117 incident cases of childhood leukemia and 202 age-, gender- and place-of-residence-matched controls. Four measures of exposure to magnetic fields were developed, using data provided by the Public Power Corporation of Greece: Voltage (V) divided by the distance (d), V/d2, V/d3 and an adaptation of the Wertheimer-Leeper code. Conditional-logistic-regression modeling was used to adjust for potential confounding influences of 18 variables. No significant trends of childhood leukemia risk with increasing exposure levels were noted, nor were there statistically significant elevations of disease risk at the higher exposure levels in each measure of exposure. These results do not support a causal link between residential proximity to electrical high-voltage wires and childhood leukemia risk, but in themselves do not refute a weak empirical association.

Death of a child at home or in hospital: Experiences of greek mothers

The purpose of this study was to investigate the experiences of Greek mothers who cared for a child dying of cancer at home or in the hospital, and to highlight some of their major needs during the terminal period. Fifteen mothers were interviewed and both quantitative and qualitative procedures were used to analyze the findings. Ten families (67%) chose to care for the child at home without having access to home care services, while the remaining five sought hospital care. Their decision was primarily based upon the childs expressed wish and parental preference. The family network played a significant role in supporting the mother-child unit, especially when death occurred at home. Mothers assessed positively the services provided by nurses and social workers, and had expectations that physicians would support them on a psychological level during the terminal period. The care of the dying child is influenced by cultural factors predominant in Greek society and some of the findings are discussed in this light.

Aggregation of childhood leukemia in geographic areas of Greece

A total of 872 children aged up to 14 years, who were diagnosed withleukemia in Greece during the decade 1980-89, were allocated by place ofresidence to the 601 administrative districts of the country. Evaluation ofspatial clustering was done using the Potthoff-Whittinghill method, whichvalidly assesses heterogeneity of leukemia risk among districts with variableexpected numbers of cases. There was highly significant evidence for spatialclustering occurring particularly among children living in urban and, to alesser extent, semi-urban areas. The evidence was stronger for childrenyounger than 10 years old, applied also to children in different five-yearage groups, and persisted when cases of acute lymphoblastic leukemia wereanalyzed separately. These findings provide support to the hypothesis thatlocalized environmental exposures could contribute to the etiology ofchildhood leukemia, but they cannot distinguish between exposures of physicalor chemical nature, nor can they exclude socially conditioned patterns ofexposure to infectious agents.

Trends and geographical distribution of childhood leukemia in Greece in relation to the Chernobyl accident

Parts of Greece have been exposed to fallout radiation from the Chernobyl accident as much as any of the countries boardering with the former Soviet Union, because of the direction of the prevailing winds after the accident. Although fallout radiation did not reach levels expected to be associated with measurable effects, there is widespread concern in Greece that the incidence of childhood leukemia may be rising in the more heavily affected parts of Greece. Patient discharge data from all Greek hospitals treating childhood leukemia were used to calculate the annual incidence of the disease from January 1980 to June 1986 (preaccident period), from July 1986 to June 1988 (immediate postaccident period) and from July 1988 to June 1991 (“relevant” post-accident period, that accommodates the presumed latent period of the disease). Fallout radiation measurements (in Bq/kg Cs-137) were used to create 17 regions of similar (within regions) but highly variable (between regions) levels of fallout deposition. Background radiation (in Bq/kg Ra-226) and annual incidence of childhood leukemia by region were also estimated. There was no evidence of increased incidence of childhood leukemia during the immediate or the “relevant” post-Chemobyl period in any part of the country. Furthermore, regression analyses did not show any significant or suggestive association of childhood leukemia by region with either background or fallout radiation. These results indicate that the Chemobyl accident did not affect noticeably the incidence of childhood leukemia in Greece during the five-year post accident period.

Survival from Childhood Leukemia Depending on Socioeconomic Status in Athens

One hundred and twenty children first diagnosed as having acute leukemia between 1988 and 1992 in Athens, Greece, were followed until May 15, 1993. The socioeconomic status of the childrens families was assessed by means of paternal occupation, paternal schooling, maternal schooling, ownership of a car, ability to choose a private medical facility and freedom in the choice of the attending physician. The analysis was done by proportional-hazards modelling, controlling for age and gender. All six socioeconomic indicators, alternatively evaluated, showed that fatality rates were higher in the lower socioeconomic groups, although nominal statistical significance was reached for only one of them. With respect to family ownership of a private car, the fatality rate ratio between children of families who own a car and children of families who do not was 0.29 with a 95% confidence interval of 0.13-0.62 (p = 0.002). These results suggest that in Greece, socially disadvantaged children have a less favorable survival from childhood leukemia.

Communicating with the dying child: An invitation to listening—a report of the SIOP working committee on psychosocial issues in pediatric oncology

This is the twelfth official document of the SIOP W orking Committee on Psychosocial Issues in Pediatric Oncology since its creation in 1991. This twelfth document describes the use of direct statements from the children themselves, solicited from parents and physicians, on how children of various ages approached their final days. The pa r nts and professionals who submitted the verbatim case examples were asked to present the ch ildren’s statements at the seminar as a stimulus for discussion. The children were seeking reassurances from their parents as they faced their own death, talking about a journey to a faraw ay place where they were going to go after they died and where they would eventually be joined by their parents. The themes are presented, not as exclusive and complete nor as scientifically va id, but solely as a stimulus for SIOP members to pursue in their respective centers and i n the r own cultural milieus this active “listening” approach in learning from the children themselves the type of concerns they have and the kind of support they are looking for as they e nter the terminal phase of their illness. INTRODUCTION The previous eleven documents of the SIOP Working C ommittee on Psychosocial Issues in Pediatric Oncology, developed at the annual SIOP me etings were prescriptive in nature, offered as guidelines to be implemented internationally in the treatment of children with cancer (*). This twelfth document in the series was developed, not a s a guideline, but as a procedure, an approach to supporting the children after treatment has been judged to be no longer effective and the difficult decision is made to move from the curativ e to the palliative and terminal phases of care. What kind of support is the dying child looking for ? Research over the years has shown that the great majority of children who enter palliation com e to an understanding, from what they see and