The Effect of Fatigue-Related Education on Pediatric Oncology Patients' Fatigue and Quality of Life.

The identification of cancer-related fatigue as a clinical problem in pediatric oncology is an important phenomenon, and there are limited number of studies about raising the awareness of pediatric oncology patients and their parents. Fatigue-related education for patients and their parents before and during cancer treatment reduces the fatigue levels of patients. This study aims to analyze the effect of fatigue-related education for pediatric oncology patients aged 7-12 and their parents on their fatigue and quality of life. This study was conducted with 80 children with cancer and their parents who were assigned to either the control group (n = 40) or the experimental group (n = 40). The experimental group received a fatigue-related educational program. The data were collected three times: prior to the program, 3 months later, and 6 months afterwards. Multidimensional variance analysis, the Bonferroni adjusted t test and regression analysis were used to analyze the data. A significant difference was found among the experimental and the control group for total mean scores and the mean scores of subdimensions of the Scale for the Assessment of Fatigue-Child Form in terms of the interactions of group, time, and group*time (p < 0.05). Significant differences were found among the experimental and control groups' mean scores on the Scale for the Quality of Life-Child and Parents Form in terms of the interactions of group, time, and group*time (p < 0.05). Fatigue-related education is an effective education model as a way to reduce fatigue and increase the quality of life of children with cancer. The use of fatigue-related education by nurses in pediatric oncology clinics will have positive effects on children and their parents.

Child with RET proto-oncogene codon 634 mutation.

Ince D, Demirag B, Ataseven E, Oymak Y, Tuhan H, Karakus OZ, Hazan F, Abaci A, Özer E, Mutafoglu K, Olgun N. Child with RET proto-oncogene codon 634 mutation. Turk J Pediatr 2017; 59: 590-593. Herein we reported a 7-year-old child with RET proto-oncogene c634 mutation. Her mother had been diagnosed with medullary thyroid carcinoma (MTC), and treated six years ago. Heterozygous mutation of the RET proto-oncogene at c634 had been detected in her mother. Genetic analysis showed the presence of the same mutation in our patient. Thyroid functions were normal. Serum calcitonin level was found mildly elevated. Parathormone (PTH) and carcinoembrionic antigen (CEA) levels were normal. Prophylactic thyroidectomy and sampling of cervical lymph nodes were performed. Histopathologic examination revealed hyperplasia in thyroid C cells, and reactive lymphadenopathy. The risk of MTC has been reported 100% through the life of patients with RET proto-oncogene mutation. It has been reported that particularly patients with c634 mutation have more risk of occurence of metastatic and progressive/recurrent MTC. Prophylactic `thyroidectomy, cervical lymph node dissection` before 5-years-of-age should be considered for these patients.

Analysis of genetic and non genetic risk factors for cisplatin ototoxicity in pediatric patients.

OBJECTIVE: The aim of this study was to analyse the genetic and non genetic risk factors for cisplatin ototoxicity. METHODS: This study was conducted on 72 children who received cisplatin based chemotherapy. Brock and Muenster classifications were used to evaluate ototoxicity seen in these children. 6 single nucleotide polymorphisms (SNP); ERCC1 rs 11615, GSTP1 rs1138272, GSTP1 rs1695, LRP2 rs 2075252, TPMT rs 12201199, COMT rs 9332377, were evaluated as genetic factors by real time PCR. Non genetic factors such as cranial irradiation, cumulative doses of cisplatin, age, gender, administration of other ototoxic drugs were analysed as well. By using Chi-square test, risk factors were matched with the ototoxicity classifications. Significant risk factors were reevaluated using logistic regression modelling. RESULTS: According to univariate analyses, male gender, co-treatment with aminoglycosides and mutant genotype of GSTP1 rs1695 were significantly related with cisplatin ototoxicity. Logistic regression modelling analyses also showed that male gender, co-treatment with aminoglycosides were found to be significantly related with cisplatin ototoxicity. Mutant genotype of GSTP1 rs1695 was not found to be significant, but close to the level of statistical significance. CONCLUSION: Male gender, co-treatment with aminoglycosides are significant risk factors for cisplatin ototoxicity in pediatric patients. Mutant genotype of GSTP1 rs1695 seems to be a genetic risk factor in univariate analyses, although not confirmed by multivariate analyses. Therefore, GSTP1 rs1695 SNP needs to be studied in larger series.

Communication and integration: a qualitative analysis of perspectives among Middle Eastern oncology healthcare professionals on the integration of complementary medicine in supportive cancer care.

CONTEXT AND OBJECTIVES: The use of complementary and traditional medicine (CTM ) in Middle Eastern countries is widespread, including among patients with cancer. Perspectives of oncology healthcare professionals (HCPs) in this region regarding the integration of CTM within conventional supportive cancer care were explored. METHODS: An 11-item questionnaire with an open-ended question asking respondents to comment about the integration of CTM within supportive cancer care was sent to Middle Eastern oncology HCPs, using snowball sampling methodology. The narratives provided were examined using thematic analysis. RESULTS: A total of 339 oncology HCPs completed and returned the study tool (80.3 % response rate ), of which 178 from 15 Middle Eastern countries responded to the open-ended question. The majority of respondents are in favor of the integration of CTM within supportive cancer care, though ideas on how this should be implemented varied. Thematic analysis identified multifactorial barriers to integration, which focused on HCPs' perspectives (e.g., a lack of knowledge and training; a skeptical approach to CTM), attitudes of patients and caregivers (e.g., unrealistic expectations regarding the outcomes of CTM treatments) and HCP-patient communication. In order to overcome these barriers, respondents suggested education and training programs for oncology HCPs which would focus on improving patients' quality-of-life-related outcomes. CONCLUSIONS: Middle Eastern oncology HCPs support the integration of CTM within supportive cancer care, while recognizing the need for education and training in this field. A better understanding of CTM would provide the knowledge and skills which would promote a non-judgmental, evidence-based approach, fostering better communication with patients.

Potential risks associated with traditional herbal medicine use in cancer care: A study of Middle Eastern oncology health care professionals.

BACKGROUND: The authors assessed the use of herbal medicine by Middle Eastern patients with cancer, as reported by their oncology health care professionals (HCPs). Herbal products identified by the study HCPs were evaluated for potential negative effects. METHODS: Oncology HCPs from 16 Middle Eastern countries received a 17-item questionnaire asking them to list 5 herbal products in use by their patients with cancer. A literature search (PubMed, Micromedex, AltMedDex, and the Natural Medicine Comprehensive Database) was conducted to identify safety-related concerns associated with the products listed. RESULTS: A total of 339 HCPs completed the study questionnaire (response rate of 80.3%), identifying 44 herbal and 3 nonherbal nutritional supplements. Safety-related concerns were associated with 29 products, including herb-drug interactions with altered pharmacodynamics (15 herbs), direct toxic effects (18 herbs), and increased in vitro response of cancer cells to chemotherapy (7 herbs). CONCLUSIONS: Herbal medicine use, which is prevalent in Middle Eastern countries, has several potentially negative effects that include direct toxic effects, negative interactions with anticancer drugs, and increased chemosensitivity of cancer cells, requiring a reduction in dose-density. Oncology HCPs working in countries in which herbal medicine use is prevalent need to better understand the implications of this practice. The presence of integrative physicians with training in complementary and traditional medicine can help patients and their HCPs reach an informed decision regarding the safety and effective use of these products.

Protective Effect of Acetyl-L-Carnitine Against Doxorubicin-induced Cardiotoxicity in Wistar Albino Rats.

BACKGROUND AND AIMS: Anthracyclines are one of the most preferred agents in practical pediatric oncology despite their dose-dependent cardiotoxic effects. The aim of this study was to investigate whether or not acetyl-L-carnitine (ALCAR) has protective effects on doxorubicin (DOX)-induced cardiotoxicity. METHODS: Wistar rats were divided into four groups; control, DOX, ALCAR and ALCAR+DOX. Rats in the first group were given saline on study days, whereas those in the second group were given a single dose of DOX on the 5th day and saline on the other days. Rats in the third group were given ALCAR and those in the fourth group were given ALCAR on study days but also given only a single dose of DOX on the fifth day of the study. Ejection fractions (EF) were measured by echocardiography before and after drug administration. Heart tissues were evaluated by light and electron microscopy. Apoptotic cells were determined with TUNEL and caspase-3 staining. RESULTS: DOX significantly decreased the EF values, whereas ALCAR did not. Cardiac functions were higher in the ALCAR+DOX group when compared to the DOX group. DOX administration caused a cardiac injury not only functionally, but also structurally, whereas ALCAR prevented it. CONCLUSIONS: ALCAR has a capacity of preventing DOX-induced cardiac injury at both functional and structural levels.

Integration of complementary medicine in supportive cancer care: survey of health-care providers' perspectives from 16 countries in the Middle East.

INTRODUCTION: In this multinational Middle-Eastern study, we assessed health-care providers' (HCPs) perspectives on their patients' use of complementary and traditional medicine (CTM) and identified the leading barriers to CTM integration in supportive cancer care. METHODS: A 17-item questionnaire was developed and administered to HCPs attending palliative medicine workshops conducted across the Middle East by the Middle East Cancer Consortium. RESULTS: 339 HCPs from 16 countries across the Middle East completed the questionnaire (80.3 % response rate). Respondents perceived their patients' reasons for CTM use primarily in the context of cancer cure (63 %) and quality of life (QOL) improvement (57 %). Expectation regarding CTM's role in cancer cure/survival was more pronounced in Turkey, Jordan, the Palestinian Authority, and the Persian Gulf area. In contrast, the expectation that CTM would improve QOL was more emphasized in Israel. A mid-position between the cure/survival and QOL poles was observed in Cyprus, Lebanon, and the North African countries. Leading barriers to CTM integration in supportive cancer care included oncologists' skepticism and a gap between patients' expectations and HCP's objectives. Respondents' leading recommendation to HCPs was to communicate integrative care emphasizing well-being and improved functioning in accordance with their patients' health beliefs. CONCLUSION: CTM integration in supportive cancer care can be facilitated by implementing a platform for Middle Eastern clinical collaborations. HCPs' expectations and experiences with CTM have been positive in the oncology setting. These data need to be corroborated with information of patients' expectations on the provision of CTM over all phases of the oncology treatment.

Evaluating palliative care needs in Middle Eastern countries.

BACKGROUND: Cancer incidence in Middle Eastern countries, most categorized as low- and middle-income, is predicted to double in the next 10 years, greater than in any other part of the world. While progress has been made in cancer diagnosis/treatment, much remains to be done to improve palliative care for the majority of patients with cancer who present with advanced disease. OBJECTIVE: To determine knowledge, beliefs, barriers, and resources regarding palliative care services in Middle Eastern countries and use findings to inform future educational and training activities. DESIGN: Descriptive survey. SETTING/SUBJECTS: Fifteen Middle Eastern countries; convenience sample of 776 nurses (44.3%), physicians (38.3%) and psychosocial, academic, and other health care professionals (17.4%) employed in varied settings. MEASUREMENTS: Palliative care needs assessment. RESULTS: Improved pain management services are key facilitators. Top barriers include lack of designated palliative care beds/services, community awareness, staff training, access to hospice services, and personnel/time. The nonexistence of functioning home-based and hospice services leaves families/providers unable to honor patient wishes. Respondents were least satisfied with discussions around advance directives and wish to learn more about palliative care focusing on communication techniques. Populations requiring special consideration comprise: patients with ethnic diversity, language barriers, and low literacy; pediatric and young adults; and the elderly. CONCLUSIONS: The majority of Middle Eastern patients with cancer are treated in outlying regions; the community is pivotal and must be incorporated into future plans for developing palliative care services. Promoting palliative care education and certification for physicians and nurses is crucial; home-based and hospice services must be sustained.

A case of central precocious puberty due to concomitant hypothalamic hamartoma and juvenile pilocytic astrocytoma.

Central precocious puberty (CPP) is caused by premature activation of the hypothalamo-pituitary-gonadal axis. More than 50% of boys with CPP have an identifiable etiology. Hypothalamic hamartoma (HH), hydrocephalus, tumors, infections, congenital defects, ischemia, radiation, or injury of the brain are the most common causes of secondary CPP. In this report, we present the case of a 2 years and 9 months old male patient who had a 30x40 mm contrast-enhancing suprasellar mass and was histopathologically diagnosed with giant HH. However, since HHs are designated as non-enhancing masses, considering the possibility of an incomplete diagnosis of a glial tumor, the patient was followed up. Clinical and radiological follow-up revealed stable findings with no evidence of tumor growth until the third year after surgery when he presented with neurological deficit due to the rapid growth of the suprasellar mass. After the second surgery, histopathological examination of the biopsy specimen revealed the lesion to be a juvenile pilocytic astrocytoma (PA). The concomitance of HH and juvenile PA is very rare. To our knowledge, this is the first report of a patient with concomitant juvenile PA and HH who developed CPP and did not have gelastic epilepsy despite the rapidly growing giant mass.

Pediatric laryngeal cancer with 5-year follow up: case report.

Larynx cancer is the commonest malignancy of upper aerodigestive tract. However, laryngeal cancer is extremely rare in childhood since these tumors are generally not suspected in the differential diagnosis of hoarseness, dysphagia and/or progressive airway obstruction in children; diagnosis can be made relatively late. In this report we would like to present a case of advanced stage pediatric laryngeal carcinoma who was treated with chemoradiotherapy and remained well on her 5-year follow-up.

A case of rapid-onset obesity with hypothalamic dysfunction, hypoventilation, autonomic dysregulation, and neural crest tumor: ROHHADNET syndrome.

OBJECTIVE: Rapid-onset obesity with hypoventilation, hypothalamic dysfunction, and autonomic dysregulation (ROHHAD) is a rare disorder that mimics both common obesity and genetic obesity syndromes along with several endocrine disorders during early childhood. We aim to present the clinical features, laboratory and imaging results, and treatment outcomes of a patient with ROHHAD syndrome. METHODS: In this case report, we describe a 26-month-old boy who was admitted to our emergency department with dyspnea and cyanosis and was suspected to have ROHHAD syndrome due to his rapid-onset obesity and alveolar hypoventilation. RESULTS: A thoracal and abdominal magnetic resonance imaging was performed to demonstrate a possible accompanying neural crest tumor and it provided a yet asymptomatic retroperitoneal ganglioneuroblastoma. Based on these findings, the patient was diagnosed as ROHHADNET syndrome. CONCLUSION: Because of the high prevalence of cardiorespiratory arrest and probability of accompanying tumors, early recognition of ROHHAD syndrome is important. To prevent presumptive mortality and morbidity, ROHHAD syndrome should be considered in all cases of rapid and early-onset obesity associated with hypothalamic-pituitary endocrine dysfunctions.

Integrative oncology research in the Middle East: weaving traditional and complementary medicine in supportive care.

INTRODUCTION: Complementary and alternative medicine (CAM) has an important role in supportive cancer care in the Middle East and is often used in association with traditional medicine. This article provides a comprehensive review of published data on CAM research in supportive cancer care in the Middle East. METHODS AND RESULTS: A multi-disciplinary Middle-Eastern Research Group in Integrative Oncology (MERGIO) was established in six countries. Authors independently searched Medline database for articles in Arabic, Hebrew, French, and Turkish using oncology and CAM-related keywords. Articles were recorded according to the first author's affiliation with an academic or clinical institution in the Middle East. RESULTS: We identified 143 articles on CAM and cancer care that had been published in 12 Middle-Eastern countries. Eighty-five articles were directly related to cancer supportive care. The latter included studies on the prevalence of CAM use by patients with cancer, aspects related to of doctor-patient communication, ethics and regulation, psychosocial aspects of CAM, CAM safety and quality assurance, studies of CAM education for health care providers, and ethno-botanical studies and reviews. Twenty-eight articles referred to clinical research on supportive care, and the use of specific CAM modalities that included acupuncture, anthroposophic medicine, dietary and nutritional therapies herbal medicine, homeopathy, mind-body medicine, shiatsu, therapeutic touch, and yoga. CONCLUSIONS: CAM-related supportive care research is prevalent in the Middle East, a fact that may serve as a basis for future multinational-multidisciplinary research work in supportive care in oncology.

Evaluation of the effect of acetyl L-carnitine on experimental cisplatin ototoxicity and neurotoxicity.

INTRODUCTION: Cisplatin (CDDP) is an effective and widely used chemotherapeutic agent for pediatric tumors, and ototoxicity is one of the dose-limiting side effects. OBJECTIVE: It was the aim of our study to investigate the effect of acetyl L-carnitine (ALCAR) on experimental CDDP ototoxicity by audiologic tests, histomorphologic, immunohistochemical and ultrastructural examinations and to investigate the apoptotic pathways. MATERIALS AND METHODS: Wistar albino rats (n = 28) were studied. Baseline audiological tests were performed in 4 groups: group 1, control; group 2, ALCAR; group 3, CDDP; group 4, CDDP + ALCAR-administered rats. Control audiological tests were performed on the 3rd day, and then the rats were sacrificed. Ear and brain specimens were examined by transmission electron microscopy, and caspase 3, 8 and 9 activities were investigated. RESULTS: The CDDP-administered rats showed significant auditory brainstem response threshold shifts using all stimuli (clicks, 6-kHz and 8-kHz tone burst) compared with the control groups. The CDDP + ALCAR-administered rats showed significant auditory brainstem response threshold shifts by only click stimuli compared with the control groups. In the brain, spiral ganglion and organ of Corti, ultrastructural damage was prominent in group 3; the number of TUNEL (terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling)-positive cells and caspase 3, 8 and 9 immunostaining cells was significantly high in group 3. CONCLUSION: ALCAR improves CDDP-induced auditory impairment, and also antioxidative and antiapoptotic properties of ALCAR on CDDP ototoxicity were supported by the findings.

The time to diagnosis in childhood lymphomas and other solid tumors.

BACKGROUND: There are few reports from developing countries on the factors that influence the time to diagnosis (TD) in childhood cancer. The purpose of this study was to investigate the determinants of the TD in Turkish cancer patients. PROCEDURE: A retrospective analysis was performed on 329 children diagnosed with cancer, excluding leukemia. The TD, including parent/patient time and physician time, was defined as the interval between the onset of symptoms and the final diagnosis. RESULTS: The median times for parent/patient, physician, and TD were 3, 28, and 53 days, respectively. For patient in the 1-9 years age group, physician time and TD were significantly shorter than in infants and those over 10 years. The longest median TD was recorded for children with germ cell tumors and retinoblastoma; the shortest was in children with renal tumors. When the first point of contact was a pediatrician, a private hospital or physician's office, a governmental educational hospital or a university hospital physician time was short. The longest TD was noted in patients who first contacted a non-pediatric specialist. The most significant predictors of parent/patient, physician time, and TD were metastases at diagnosis, first medical center, and first health professional contacted, respectively. CONCLUSIONS: The TD for childhood lymphomas and solid tumors was related to patient age, tumor type and location, the presence of distance metastases, first health professional, and center contacted. All physicians, especially other specialists seeing pediatric patients, need to be further sensitized to the signs and symptoms of childhood cancer.

Nurses' perceived barriers to assessment and management of pain in a university hospital.

A self-report questionnaire was answered by 114 nurses working at the internal medicine, oncology, and surgery clinics. The most commonly perceived barriers to pain management were system-related barriers. Lack of psychosocial support services and patient-to-nurse ratio received the highest ratings. Institutional and governmental attempts are needed to increase the number of nurses in the clinics and to establish support services. Nurse-related barriers were less perceived as an obstacle when compared with the other barriers. A small percentage of the nurses agreed that nurses' inadequate knowledge of pain management (10%) and nurses' indifference (8%) were barriers to pain management. Inadequate time for health teaching with patients was agreed on by 65% of the nurses. Most commonly rated physician-related barriers were inadequate assessment of pain and pain relief by doctors (63%) and physicians' indifference (47%). Patients' difficulty with completing pain scales (56%) and consumers not demanding results (53%) were the most commonly reported patient-related barriers. A significant percentage of the participating nurses indicated that they have no idea about patient-related barriers. Regular and continuous pain education programs may help to establish a supportive team spirit between doctors and nurses.

A palliative care initiative in Dokuz Eylul University Hospital.

Turkey is among the countries with only "capacity building activity"" in terms of palliative care development according to the mapping levels reported by the International Observatory on End of Life Care (http://www.eolc-observatory.net/global/pdf/world_map.pdf). Palliative care units are lacking even in major hospitals. Although some medical oncologists and pain specialists have been providing pain control and symptom relief to some extend, all these interventions remain a fragmented approach to care since there are no palliative care programs. Establishing palliative care services should be a priority in the development of comprehensive cancer care, particularly in a country where more than 60% of the cancer patients present with advanced stage disease. Like all the other university hospitals in the country, palliative care services have not been established so far in Dokuz Eylul University Hospital for several reasons although almost all the modern cancer treatment modalities have been provided to cancer patients. A group of health professionals have recently started a palliative care initiative in the hospital with an aim to raise awareness and to implement basic palliative care interventions to the current cancer care. This paper aims to tell the story of how this initiative get started and which step were taken so far.

Isolated hemihyperplasia in an infant: an overlooked sign for wilms tumor development.

BACKGROUND: Children with overgrowth syndromes including isolated hemihyperplasia have an increased risk for developing embryonal tumors, particularly Wilms' tumor and hepatoblastoma. Screening with sonography has been suggested as a method of identifying these tumors while they are still at an early stage. CASE PRESENTATION: We describe an infant diagnosed with Wilms tumor in whom isolated hemihyperplasia had been overlooked by several physicians prior to the tumor diagnosis. CONCLUSION: We recommend tumor surveillance for all patients with Beckwith-Wiedemann syndrome and isolated hemihyperplasia at least for the first six years of life since full molecular characterization of every patient is not readily available.

Evaluation of the effect of acetyl L-carnitine on experimental cisplatin nephrotoxicity.

BACKGROUND/AIMS: To evaluate the protective effects of acetyl L-carnitine (ALCAR) on cisplatin-induced nephrotoxicity in rats, and to gain insights into the possible protective mechanisms of ALCAR against nephrotoxicity. METHODS: Twenty-eight Wistar rats were divided into four groups. Group 1 was administered saline only, group 2 was administered ALCAR, group 3 was administered cisplatin, and group 4 was administered ALCAR prior to cisplatin. Rats were sacrificed after 72 h of cisplatin/saline infusion. Serum creatinine and glomerular filtration rate values were obtained, and kidney samples were examined by light and electron microscopy. Apoptotic cell death and caspase-3, 8 and 9 activities were studied immunohistochemically. RESULTS: In group 4, ALCAR administration resulted in an improvement in kidney function tests. Histopathological findings confirmed the biochemical data. Whilst the fusion of the foot processes of podocytes was observed in group 3, they were intact in group 4 on electron-microscopic examination. Apoptotic cell death and caspase-3, 8 and 9 activities were also decreased in group 4 compared to group 3. CONCLUSIONS: Antioxidative, antiapoptotic and anti-inflammatory properties of ALCAR were supported by the findings that this agent improves kidney function tests and has the effects of tissue protection and inhibition of apoptosis in cisplatin-induced nephrotoxicity.