Kimberley Dilley

Identification of overweight status is associated with higher rates of screening for comorbidities of overweight in pediatric primary care practice

OBJECTIVES. The goals were to determine whether primary care provider identification of children as overweight was associated with additional screening or referrals and whether the types and numbers of visits to primary care differed for overweight and nonoverweight children. METHODS. Sequential parents/guardians at 13 diverse pediatric practices completed an in-office survey addressing health habits and demographic features. Medical records of each child from a sample of families were reviewed. Data were abstracted from the first visit and from all visits in the 14-month period before study enrollment. Analyses were limited to children ≥2 years of age for whom BMI percentile could be calculated. RESULTS. The analytic sample included 1216 children (mean age: 7.9 years; 51% male) from 777 families (parents were 43% white, 18% black, 34% Hispanic, and 5% other; 49% of families had a child receiving Medicaid/uninsured). Among overweight children (BMI of ≥95th percentile; n = 248), 28% had been identified as such in the record. Screening or referral for evaluation of comorbidities was more likely among overweight children who were identified in the record (54%) than among overweight children who were not identified (17%). Among children at risk of overweight (BMI of 85th to 94th percentile; n = 186), 5% had been identified as such in the record and overall 15% were screened/referred. In logistic regression modeling, the children identified as overweight/at risk of overweight had 6 times greater odds of receiving any management for overweight. CONCLUSIONS. Low rates of identification of overweight status and evaluation or referrals for comorbidities were found. Identification of overweight status was associated with a greatly increased rate of screening for comorbidities.

Heritability and Environmental Factors Affecting Vitamin D Status in Rural Chinese Adolescent Twins

CONTEXT Factors associated with the high prevalence of vitamin D deficiency in China are not well described, especially among Chinese adolescents. OBJECTIVES The aim of the study was to examine important environmental or sociodemographic factors influencing 25-hydroxyvitamin D [25(OH)D] levels and estimate its heritability. DESIGN A sample of 226 male and female adolescent twins aged 13-20 yr from a large prospective twin cohort of rural Chinese children and adolescents that has been followed for 6 yr were evaluated. MAIN OUTCOME MEASURE(S) Blood level of 25(OH)D was measured using tandem mass spectrometry methodology. RESULTS The overall mean (SD) 25(OH)D level was 18.0 (9.4) ng/ml, with wide variation by gender and season. In males (47.4% of subjects), the mean (SD) 25(OH)D level was 12.1 (4.2) ng/ml in non-summer and 27.4 (8.8) ng/ml in summer; in females, it was 10.1 (4.1) ng/ml in non-summer and 19.5 (6.3) ng/ml in summer. A multivariate model that included gender, age, season, physical activity, and student status demonstrated that male gender, summer season, and high physical activity significantly increased 25(OH)D levels. Summer season and male gender also significantly decreased the risk of being in the lowest 25(OH)D tertile. Overall, 68.9% of the variability in 25(OH)D level was attributable to additive genetic influence. Stratification by gender found that in males, 85.9% of the variability in 25(OH)D level was attributable to such influence, but in females, it was only 17%. CONCLUSION In this sample of rural Chinese adolescents, 25(OH)D level was influenced by gender, season, and physical activity level. There was a strong genetic influence on 25(OH)D level in males only.

Fertility Preservation and Adolescent Cancer Patients: Lessons from Adult Survivors of Childhood Cancer and Their Parents

Building on 40 years of progress in cancer detection and treatment, survival rates for childhood cancers have risen from 20 % to almost 80 % [1,2]. Approximately 270,000 Americans are childhood cancer survivors and, by 2010, an estimated 1 in every 250 adults will be living with a history of childhood cancer [2,3]. The early and late effects of treatment are beginning to take on greater importance for survivors, their families and providers [4]. Increasing numbers of childhood cancer survivors are beginning to face a new challenge in returning to normalcy after cancer. Infertility is one of the most common chronic medical problems reported by childhood cancer survivors [5] and can be a primary concern particularly among female survivors [6]. Female infertility has biological and psychosocial implications that cannot be easily addressed given the ethical and legal questions surrounding fertility preservation [7–9]. Recent advances in fertility preservation may soon offer potential methods for females of all ages to protect their reproductive capacity from damaging radiation and/or chemotherapy [10]. Current literature focuses on the further development of preservation techniques and the numerous ethical and legal questions, but little knowledge is available on the attitudes and opinions of childhood cancer patients and their parents regarding fertility preservation. Progress is being made in understanding the fertility issues that women may face after treatment. Infertility as an isolated health problem can be emotionally devastating for a woman [11] and is often viewed as a loss of one’s sense of femininity [12]. The risk of infertility touches on the most intimate aspects of a woman’s life after cancer, particularly her relationships, future plans for a family, and concerns about pregnancy and birth [4,12–16]. For cancer survivors who may be dealing with additional physical and emotional concerns, infertility may add yet another concern to an already lengthy list of fears and worries [17]. Some survivors describe that the loss of fertility can be as painful as facing cancer itself [15,18]. The situation is further complicated by the fact that female cancer survivors, particularly pediatric cancer patients, lack clear-cut options to address their fertility that are available to their male counterparts. Advancements in semen cryopreservation and intracytoplasmic sperm injection (ICSI) have revolutionized the reproductive outlook of male patients who have reached puberty [19]. Recent advances in reproductive science are beginning to change what is possible for female survivors as well. Traditionally, few options existed for female cancer patients who may want to have their own biological children in the future. The only two established techniques women have for fertility preservation are protecting the ovaries from radiation and emergency in vitro fertilization (IVF) [20,21]. While protecting a patient’s ovaries has become common practice, emergency IVF cannot be offered to patients diagnosed with cancer before puberty because mature oocytes cannot be collected [22]. The promise for female patients with childhood cancer lies in the strides made toward ovarian transplantation and in vitro follicle maturation. Ovarian transplantation involves the removal and cryopreservation of ovarian tissue before treatment and the reintroduction of tissue after treatment, either orthotopically or heterotopically, such as in muscle or subcutaneously [23]. Researchers have demonstrated that transplantation of cryopreserved ovarian tissue has led to human embryonic development when accomplished heterotopically [24] and to a live birth after orthotopic transplantation [25]. Another promising method of fertility preservation is in vitro maturation of immature oocytes. Similar to ovarian transplantation, ovarian tissue is removed and cryopreserved before fertility-threatening treatment. Once a woman is prepared to have a child, follicles can be isolated from the thawed tissue, matured in vitro in a three-dimensional culture system, and the mature oocyte can be fertilized through IVF. Murine oocytes have been collected from in vitro grown follicles, matured, and fertilized in vitro, which has resulted in live births [26]. Human trials, where one ovary is laparoscopically removed before treatment, are being conducted on adult patients in order to begin the experimental process of perhaps one day delivering this option to female cancer patients. As research begins to enter the clinical arena, a large number of unanswered questions remain regarding the application of the procedures, the legal and ethical considerations involved, and the receptiveness of patients and their families to fertility preservation. Thus far, very few studies have considered the viewpoints of childhood cancer patients and their parents [27]. Since decisions regarding fertility preservation must be made before treatment begins, parents, physicians, and patients are required to make a complex decision in a short amount of time during an extremely stressful situation, similar to the anxiety involved in the informed consent process of clinical cancer research trials [28]. In order for fertility preservation to become a realistic and valued addition to the treatment of childhood cancer patients, a better understanding of the decision-making process that parents and their children go through at the time of diagnosis and their interest in fertility preservation is needed. Further, a more thorough exploration of the patients’ and parents’ thoughts regarding the child’s fertility at the time of diagnosis as well as later in the patient’s life will be valuable in the continued advancement and eventual application of fertility preservation.

Second malignancies after autologous hematopoietic cell transplantation in children.

Childhood autologous hematopoietic cell transplant (auto-HCT) survivors can be at risk for secondary malignant neoplasms (SMNs). We assembled a cohort of 1487 pediatric auto-HCT recipients to investigate the incidence and risk factors for SMNs. Primary diagnoses included neuroblastoma (39%), lymphoma (26%), sarcoma (18%), central nervous system tumors (14%) and Wilms tumor (2%). Median follow-up was 8 years (range, <1–21 years). SMNs were reported in 35 patients (AML/myelodysplastic syndrome (MDS)=13, solid cancers=20, subtype missing=2). The overall cumulative incidence of SMNs at 10 years from auto-HCT was 2.60% (AML/MDS=1.06%, solid tumors=1.30%). We found no association between SMNs risk and age, gender, diagnosis, disease status, time since diagnosis or use of TBI or etoposide as part of conditioning. OS at 5-years from diagnosis of SMNs was 33% (95% confidence interval (CI), 16–52%). When compared with age- and gender-matched general population, auto-HCT recipients had 24 times higher risks of developing SMNs (95% CI, 16.0–33.0). Notable SMN sites included bone (N=5 SMNs, observed (O)/expected (E)=81), thyroid (N=5, O/E=53), breast (N=2, O/E=93), soft tissue (N=2, O/E=34), AML (N=6, O/E=266) and MDS (N=7, O/E=6603). Risks of SMNs increased with longer follow-up from auto-HCT. Pediatric auto-HCT recipients are at considerably increased risk for SMNs and need life-long surveillance for SMNs.

Fractures among long-term survivors of childhood cancer: A report from the Childhood Cancer Survivor Study

Although reductions in bone mineral density are well documented among children during treatment for cancer and among childhood cancer survivors, little is known about the long‐term risk of fracture. The objective of this study was to ascertain the prevalence of and risk factors for fractures among individuals participating in the Childhood Cancer Survivor Study (CCSS).

Secondary malignant neoplasms after high-dose chemotherapy and autologous stem cell rescue for high-risk neuroblastoma

Outcomes for high‐risk neuroblastoma remain poor. Modern treatment protocols utilizing intense induction followed by myeloablative consolidation chemotherapy with autologous stem cell rescue (ASCR) have improved survival rates, but the long‐term sequelae, including development of secondary malignant neoplasms (SMN), are just now surfacing.

Exostoses as a Long-Term Sequela After Pediatric Hematopoietic Progenitor Cell Transplantation: Potential Causes and Increase Risk of Secondary Malignancies from Ann & Robert H. Lurie Children's Hospital of Chicago

Allogeneic hematopoietic progenitor cell transplantation (HPCT) is a curative therapy for pediatric patients with both malignant and nonmalignant diseases. Single or multiple benign exostoses or osteochondromas have been reported after total body irradiation (TBI), as well as after focal irradiation. Patients exposed to TBI at a young age are at highest risk of developing exostoses. The objective of this institutional review board-approved study was to look at potential factors, besides radiation, that may play a role in development of exostoses. All patients who underwent allogeneic and autologous HPCT at a single institution between March 1992 and December 2003 and who developed an exostosis identified by clinical findings or as an incidental finding on a radiologic study were included. A case-control design matched patients with controls who had the same stem cell source.

Effectiveness of a Multicomponent Sun Protection Program for Young Children: A Randomized Clinical Trial.

IMPORTANCE Emphasizing sun protection behaviors among young children may minimize sun damage and foster lifelong sun protection behaviors that will reduce the likelihood of developing skin cancer, especially melanoma. OBJECTIVE To determine whether a multicomponent sun protection program delivered in pediatric clinics during the summer could increase summertime sun protection among young children. DESIGN, SETTING, AND PARTICIPANTS Randomized controlled clinical trial with 4-week follow-up that included 300 parents or relatives (hereafter simply referred to as caregivers [mean age, 36.0 years]) who brought the child (2-6 years of age) in their care to an Advocate Medical Group clinic during the period from May 15 to August 14, 2015. Of the 300 caregiver-child pairs, 153 (51.0%) were randomly assigned to receive a read-along book, swim shirt, and weekly text-message reminders related to sun protection behaviors (intervention group) and 147 (49.0%) were randomly assigned to receive the information usually provided at a well-child visit (control group). Data analysis was performed from August 20 to 30, 2015. INTERVENTION Multicomponent sun protection program composed of a read-along book, swim shirt, and weekly text-message reminders related to sun protection behaviors. MAIN OUTCOMES AND MEASURES Outcomes were caregiver-reported use of sun protection by the child (seeking shade and wearing sun-protective clothing and sunscreen) using a 5-point Likert scale, duration of outdoor activities, and number of children who had sunburn or skin irritation. The biologic measurement of the skin pigment of a childs arm was performed with a spectrophotometer at baseline and 4 weeks later. RESULTS Of the 300 caregiver-child pairs, the 153 children in the intervention group had significantly higher scores related to sun protection behaviors on both sunny (mean [SE], 15.748 [0.267] for the intervention group; mean [SE], 14.780 [0.282] for the control group; mean difference, 0.968) and cloudy days (mean [SE], 14.286 [0.282] for the intervention group; mean [SE], 12.850 [0.297] for the control group; mean difference, 1.436). Examination of pigmentary changes by spectrophotometry revealed that the children in the control group significantly increased their melanin levels, whereas the children in the intervention group did not have a significant change in melanin level on their protected upper arms (P < .001 for skin type 1, P = .008 for skin type 2, and P < .001 for skin types 4-6). CONCLUSIONS AND RELEVANCE A multicomponent intervention using text-message reminders and distribution of read-along books and swim shirts was associated with increased sun protection behaviors among young children. This was corroborated by a smaller change in skin pigment among children receiving the intervention. This implementable program can help augment anticipatory sun protection guidance in pediatric clinics and decrease childrens future skin cancer risk. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT02376517.

Anthracycline-induced cardiac toxicity more likely in underweight childhood cancer survivors.

Background We did a retrospective medical record and echocardiogram review of patients with history of anthracyclines and/or radiation seen in a long-term survivor clinic from 2000-2007. Observations Three hundred eight out of three hundred seventy (83.2%) patients had received at least 1 screening echocardiogram, and 24/308 (7.8%) patients had an abnormal echocardiogram. Observed risk factors for a future abnormal echocardiogram included anthracycline dose ≥250 mg/m2 and underweight status (BMI <5th%) at follow-up. Age, gender, radiation, anthracycline type, history of relapse, and history of stem cell transplant were not risk factors. Conclusions Our results confirm the dose-dependent risk of anthracyclines, and describe a novel association with underweight status.

Tobacco-related documentation in pediatric practice.

OBJECTIVE The goal of this study was to evaluate tobacco-related documentation in childrens medical records. METHOD A cross-sectional, consecutive sample of 4216 parents at 13 primary care practices was surveyed on demographics, health habits, and smoking status of household members. The medical records of 2085 children from a subsample of 1149 families (all households with smokers and a sample of nonsmoking households) were reviewed for tobacco-related documentation at the first visit to the practice and visits in the 14 months preceding recruitment. Relationships of documentations with visit type, household smoking status, and use of charting prompts were examined. RESULTS Most children (93%) had > or =1 visit during the reviewed period (77% had a health supervision visit), 23% were aged > or =11 years, 52% were Medicaid/uninsured, and 70% lived with smokers; 30.6% of children had family tobacco use status documented at a first visit to the practice and 15.4% had prenatal tobacco use status documented. Among children with a visit in the reviewed period, 39.3% with a health supervision visit and 9.6% without had a tobacco-related notation at a visit (P < .001). Overall, 15.2% of children living with a smoker had a visit notation indicating that someone in the household smoked. In households with smokers, documentation of household tobacco use status often disagreed with parent survey. Charting prompts significantly increased rates of identification of family tobacco use history and prenatal tobacco use history. CONCLUSIONS Correct identification of household smoking status was absent for most children living with smokers. Improved documentation systems may facilitate tobacco-related surveillance and counseling.