Caring for children with cancer evacuated from Ukraine: The patients' perception.

BACKGROUND AND AIMS: Since the beginning of the war in Ukraine on February 24, 2022, many pediatric oncology centers welcomed evacuated patients. To better understanding the needs of patients and families arriving at two Lombardy hospitals in the period March to November 2022, an anonymous questionnaire investigated the families' backgrounds, feelings, and impressions about hospitality and care. METHODS: Twenty questions investigated how patients had reached Italy, from whom they had received help (logistically/financially); the emotions regarding their status as war refugees; the knowledge, expectations, and opinions about Italy and Italians; the quality of medical care received and the relationships with the healthcare staff; lastly, suggestions to improve assistance. RESULTS: The questionnaires were completed by 19/32 patients/parents in November 2022 in two different pediatric-oncology centers. Most families had reached Italy (58%) and received medical care (95%) with the help of charities and the Italian Public Health Care System. A significant majority (69%) expressed satisfaction with the assistance provided. The Italian population demonstrated remarkable warmth, for 95% exhibiting friendliness and for 58% generosity. An improvement in their stay could be linked with the positive outcome of their children's cancer (15%), achieving complete family reunification (15%), the cessation of the conflict (10%), and the overcoming of language barriers (10%). CONCLUSIONS: Providing care for children from another country, not only grappling with the trauma of fleeing their homeland but also battling cancer, is an immense undertaking. It demands a diverse range of efforts and resources to ensure a positive and fulfilling outcome for this experience.

How ten-years of reirradiation for paediatric high-grade glioma may shed light on first line treatment.

PURPOSE: Recurrence incidence for paediatric/adolescent high-grade glioma (HGG) exceeds 80%. Reirradiation (reRT) palliates symptoms and delays further progression. Strategies for reRT are scarce: we retrospectively analysed our series to develop rational future approaches. METHODS: We re-evaluated MRI + RT plans of 21 relapsed HGG-patients, accrued 2010-2021, aged under 18 years. All underwent surgery and RT + chemotherapy at diagnosis. Pathologic/molecular re-evaluation allowed classification based on WHO 2021 criteria in 20/21 patients. Survival analyses and association with clinical parameters were performed. RESULTS: Relapse after 1st RT was local in 12 (7 marginal), 4 disseminated, 5 local + disseminated. Re-RT obtained 8 SD, 1 PR, 1PsPD, 1 mixed response, 10 PD; neurological signs/symptoms improved in 8. Local reRT was given to 12, followed again by 6 local (2 marginal) and 4 local + disseminated second relapses in 10/12 re-evaluated. The 4 with dissemination had 1 whole brain, 2 craniospinal irradiation (CSI), 1 spine reRT and further relapsed with dissemination and local + dissemination in 3/four assessed. Five local + disseminated tumours had 3 CSI, 1 spine reRT, further progressing locally (2), disseminated (1), n.a. (1). Three had a third RT; three were alive at 19.4, 29, 50.3 months after diagnosis. Median times to progression/survival after re-RT were 3.7 months (0.6-16.2 months)/6.9 months (0.6-17.9 months), improved for longer interval between 1st RT and re-RT (P = 0.017) and for non-PD after reRT (P < 0.001). First marginal relapse showed potential association with dissemination after re-RT (P = 0.081). CONCLUSIONS: This is the biggest series of re-RT in paediatric HGG. Considering the dissemination observed at relapse, our results could prompt the investigation of different first RT fields in a randomized trial.

The hidden side of Santiago Ramon y Cajal.

Alongside his anatomical studies, which laid the foundations of modern neuroanatomy, Santiago Ramón y Cajal also showed a lively interest in studying dreams, hypnosis, and the world of the paranormal. On his travels to worlds far removed from anatomy, Cajal sometimes strove to find potential neuroanatomical explanations for the phenomena he encountered, while at other times he simply allowed himself to be carried along by his curiosity, with no preconceptions. His investigations in such diverse spheres of knowledge and human behavior are an exceptional example of a scientific epoch that has since disappeared.

Age-appropriate multidisciplinary approach to young children with cancer undergoing radiotherapy: The SIESTA procedure.

A standardized multidisciplinary step-by-step approach to improve the compliance of young (or difficult) children having to undergo radiotherapy was described and applied. The procedure is called SIESTA, which stands for show-imagination-evaluation-support-treatment-anesthesia. Preliminary assessments suggest that the SIESTA approach was effective: the rate of young patients (≤6 years) requiring anesthesia decreased from 27% (14/52 cases) in 2011-2012 (before the procedure was adopted) to 13% (6/46) in 2018.

Customised pediatric palliative care: Integrating oncological and palliative care priorities.

AIM: To describe the experience involving the early introduction of palliative care (PC) in oncological patients treated within the paediatric oncology unit of the Istituto Nazionale Tumori of Milan and compare this cohort with a cohort of patients resident in the same area treated before the introduction of early palliative care. METHODS: A virtual team was assembled in 2015. The PC providers operate outside the hospital. Conference calls were scheduled to discuss patients' problems. This sample was compared with the clinical records of patients residing in the same area who died between 2009 and 2014. RESULTS: Between January 2015 and April 2019, 41 patients residing in the Milan area mainly with CNS tumours or sarcomas were referred to the team. Comparing the results with the previous cohort, there was a rise in the number of patients dying at home or in a hospice and the duration of PC increased over time. From 2015, none of the patients died in an intensive care unit. CONCLUSION: Patients managed by the virtual team were able to continue their cancer treatments, take part in Phase I trials and receive PC. All patients with a poor prognosis should have PC at an early stage.

Ugo Cerletti, Pathologica and electroconvulsive therapy.

Ugo Cerletti was the inventor of the electroconvulsive therapy (ECT) adopted in 1938 to treat schizophrenia. He had a robust education in anatomical pathology, which also left its mark on the journal Pathologica. Although his name is associated with several important moments and breakthroughs in the history of medicine, Ugo Cerletti's reputation has partly suffered from the same fate as his treatment. Electroshock was initially widely adopted, partly because of its low cost and relatively easy application, but with the advent of psychoactive drugs in the 1950s and 1960s, it subsequently came under ferocious criticism. Its fall from grace also affected to some extent the man who had invented it, though this seems hard to justify today.

On the clinical psychologist's role in the time of COVID-19, with particular reference to experience gained in pediatric oncology.

OBJECTIVE: The COVID-19 pandemic seems to be developing into a planetary-scale mental health experiment, undermining the foundations of our being human, obliging us to keep physically apart from one another, and inducing us to see other people as a potential threat. METHODS: In the world of pediatric oncology, we have found ourselves up against new challenges. In this article, we discuss the difficulties found in conducting psychological support sessions while complying with physical distancing rules, as well as wearing protective face masks, and even gloves; or while using modern remote communication telecommunications. RESULTS: The classic reasons behind requests for psychological support have been compounded by other, novel problems, such as: fewer relational resources for families at home, less chance to socialize, hospital stays with only one parent, the suspension of all teaching and group activities on the ward, economic difficulties caused by the pandemic, the rising levels of family conflictuality and generalized anxiety. CONCLUSIONS: It is essential to find new solutions that can be promptly implemented, reconfiguring the way we humanize our hospital wards.

How young patients with cancer perceive the COVID-19 (coronavirus) epidemic in Milan, Italy: Is there room for other fears?

The rapid spread of coronavirus disease 2019 epidemic in Italy, in particular in the Milan focal point, required drastic measures and led to panic in the population. While in our center we did not change our approach to the treatment of our young patients with cancer, we developed a qualitative survey to assess their perception of the risk and level of stress. The survey showed that a relatively large proportion of young patients felt personally at risk of severe complications. We believe that we need to adequately inform our patients, focusing on hygienic measures and personal protection and prompt reporting of any suspicious symptoms.

What Do We Know About the Do-It-Yourself Diets of Patients in Our Care?

This pilot study aimed to investigate dietary changes introduced after being diagnosed with cancer in a sample of 60 consecutive children and adolescents on the basis of a self-report questionnaire. The study showed that 53% of patients changed their diet, usually "to combat the tumor" (in 47% of cases). In 1 in 2 of these cases, the health care staff were not informed about any changes. This study underscores the fact that many patients and families chose to impose dietary changes that are not always discussed with their health care staff and that may risk interfering with the continuity of a patient's treatment. It is essential to have more opportunities to speak with patients and families about this issue.

Investigating sexuality in adolescents with cancer: patients talk of their experiences.

Objective. The aim of the present study is to understand which areas of sexuality were regarded as most important and/or problematic among adolescents with cancer.Methods. A questionnaire was administered to adolescent and young adult patients who had been receiving treatments at the Pediatric Oncology Unit of our Institution, for at least 2 months, and those in follow-up who had completed their treatments no more than two years previously. The questionnaire was devised to investigate patients' experiences in various areas, i.e. personal relations, sexual relations; functional aspects, body image, and communication.Results. Questionnaires were given to 70 patients and completed by 66. As main results, the survey showed that disease and treatment might negatively affect patients' way of relating with others (53% of cases) and their body image (56%), though their sexual desire remains unchanged (69.7%). Most patients (67%) reported not having the chance to talk to someone about having sex while receiving their treatments; 79% of patients felt this topic deserved more attention.Conclusion. This study promotes the discussion of an important topic for young people with cancer, which is inadequately addressed today. When establishing an age-specific model of care, aspects related to sexuality should be considered and managed.

"Summer is you": Adolescents and young adults with cancer sing about their desire for summer.

Creative spirit and art are used as part of the Youth Project in Milan, a program dedicated to adolescents and young adults (AYA) with cancer. The "Summer is you" music project involved 45 patients (15-26 years old): with professional help, the patients wrote music and lyrics, sang their song, and recorded a video clip, sharing with us not only their hopes and fears, but also their romantic encounters and their urge to travel (https://youtu.be/Q5FSCMUVg0E). This project exploited the power of music to bring young people with cancer together in a novel form of support that can complement the more conventional psychological approaches.

Correction to: Results of nimotuzumab and vinorelbine, radiation and re-irradiation for diffuse pontine glioma in childhood.

The therapeutic experience reported in the paper was conceived after the use of nimotuzumab and radiotherapy (BSCPED-05 international multicentric trial, EUDRACT 2005-003100-11) in 2009 when we decided to explore the activity of the same combination plus vinorelbine (see the paper for the rationale).

Proper use of social media by health operators in the pediatric oncohematological setting: Consensus statement from the Italian Pediatric Hematology and Oncology Association (AIEOP).

Social media are powerful means of communication that can also have an important role in the healthcare sector. They are sometimes seen with diffidence in the healthcare setting, partly because they risk blurring professional boundaries. This issue is particularly relevant to relations between caregivers and adolescent patients. The Italian Pediatric Hematology and Oncology Association created a multidisciplinary working group to develop some shared recommendations on this issue. After reviewing the literature, the working group prepared a consensus statement in an effort to suggest an analytical approach rather than restrictive rules.

Pilot guidelines for the use of bidirectional webcams with children suffering from advanced-stage oncological diseases.

This paper presents guidelines for school staff on the use of bidirectional webcams for the sake of school continuity with school children suffering from malignant tumors. These guidelines are designed to inform school staff about the interests of the main actors involved in the interaction (sick child, classmates, teachers). Repeated clinical observations were conducted after virtual school attendance (requested by parents) of children treated at the Pediatric Oncology Unit. During virtual school attendance, the school staff requested counseling from the psychological team of the National Cancer Institute and Foundation for Scientific Research regarding some difficulties which had arisen, namely: 1) the sick patient's difficulties due to functional impairment and fear of possible shame experiences resulting from physical changes; 2) classmates' difficulties due to emotional ties with the sick child and dynamics of identification; 3) professional and personal difficulties of teachers. This paper aims at introducing some guidelines to guide the principal and teachers at school in the adoption and use of webcams for children suffering from malignant tumors. The importance of acquiring information on the opinion of the sick child (to adopt the webcam) and of the classmates is highlighted. Another important point is the teachers' need to consider their own and other actors' emotional reactions, and the possible involvement and/or support of a clinical psychologist.

Adolescents' Health Awareness and Understanding of Cancer and Tumor Prevention: When and Why an Adolescent Decides to Consult a Physician.

BACKGROUND: A feature often seen in adolescent patients with cancer is a lengthy symptom interval, especially in comparison with children. It has been suggested that inadequate awareness of cancer risk among adolescents may play an important role in this study. METHODS: The Società Italiana Adolescenti con Malattie Onco-ematologiche and the Fondazione Umberto Veronesi conducted a survey to investigate health awareness among healthy adolescents and their understanding of cancer and its signs and symptoms by commissioning a specialized agency (AstraRicerche). A questionnaire was administered to 500 Italian adolescents from the age group of 15 to 19 years using the computer-aided web interviewing method. RESULTS: Approximately 80% of the adolescents interviewed claimed to be well informed about their own health, 85% said they were aware that some lifestyle habits could influence their health, and 80% reported that they know that cancer can develop in adolescence too. It was also noted that, while some adolescents were worried about a given symptom, 22% of them reportedly preferred a wait-and-see approach (either to avoid alarming their parents, or they hoped that the symptom would be temporary). CONCLUSIONS: This study showed that a majority of adolescents are concerned about their own health, but sometimes prefer not to report their symptoms to anyone. Hence, it is important to develop information campaigns tailored to raise awareness among this age group and help them interpret their symptoms.

Adolescents with Cancer in Italy: Improving Access to National Cooperative Pediatric Oncology Group (AIEOP) Centers.

This analysis compared the numbers of patients treated at Italian pediatric oncology group (Associazione Italiana Ematologia Oncologia Pediatrica [AIEOP]) centers with the numbers of cases predicted according to the population-based registry. It considered 32,431 patients registered in the AIEOP database (1989-2012). The ratio of observed (O) to expected (E) cases was 0.79 for children (0-14 years old) and 0.15 for adolescents (15-19 years old). The proportion of adolescents increased significantly over the years, however, from 0.05 in the earliest period to 0.10, 0.18, and then 0.28 in the latest period of observation, suggesting a greater efficacy of local/national programs dedicated to adolescents.

The Sooner the Better? How Symptom Interval Correlates With Outcome in Children and Adolescents With Solid Tumors: Regression Tree Analysis of the Findings of a Prospective Study.

BACKGROUND: The potential impact of diagnostic delays on patients' outcomes is a debated issue in pediatric oncology and discordant results have been published so far. We attempted to tackle this issue by analyzing a prospective series of 351 consecutive children and adolescents with solid malignancies using innovative statistical tools. METHODS: To address the nonlinear complexity of the association between symptom interval and overall survival (OS), a regression tree algorithm was constructed with sequential binary splitting rules and used to identify homogeneous patient groups vis-à-vis functional relationship between diagnostic delay and OS. RESULTS: Three different groups were identified: group A, with localized disease and good prognosis (5-year OS 85.4%); group B, with locally or regionally advanced, or metastatic disease and intermediate prognosis (5-year OS 72.9%), including neuroblastoma, Wilms tumor, non-rhabdomyosarcoma soft tissue sarcoma, and germ cell tumor; and group C, with locally or regionally advanced, or metastatic disease and poor prognosis (5-year OS 45%), including brain tumors, rhabdomyosarcoma, and bone sarcoma. The functional relationship between symptom interval and mortality risk differed between the three subgroups, there being no association in group A (hazard ratio [HR]: 0.96), a positive linear association in group B (HR: 1.48), and a negative linear association in group C (HR: 0.61). CONCLUSIONS: Our analysis suggests that at least a subset of patients can benefit from an earlier diagnosis in terms of survival. For others, intrinsic aggressiveness may mask the potential effect of diagnostic delays. Based on these findings, early diagnosis should remain a goal for pediatric cancer patients.

Measuring the efficacy of a project for adolescents and young adults with cancer: A study from the Milan Youth Project.

BACKGROUND: Various projects dedicated specifically to adolescents and young adults (AYA) with cancer have been developed in recent years. A critical aspect of such programs is the ability to demonstrate its value, and therefore how to measure desired outcomes. METHODS: A list of metrics to consider for demonstrating the advantages of an AYA program was identified and used to assess the activity of the Youth Project operating at the Pediatric Oncology Unit of the Istituto Nazionale Tumori in Milan. RESULTS: The number of newly diagnosed AYA patients seen at the Unit has increased since the formal launch of the Youth Project, from 65 to 81.2 cases/year. Concerning the 78 AYA patients presenting with malignant neoplasms in 2015, 82% were included in clinical trials (the other 18% in prospective observational studies). Fertility preservation measures were implemented for 59% of AYA patients considered at risk, and specific psychological support was provided in 70.6% of cases; 72.5% of patients actively participated in support activities. Other parameters considered were a preliminary satisfaction questionnaire administered to patients and the program's scientific recognition and acknowledgment by the community. CONCLUSIONS: The study proposed a number of potentially reproducible, practical parameters to consider in assessing the value of a program dedicated to AYA. These metrics were examined in terms of the activities of our Youth Project, and confirmed its efficacy. To be sustainable over time, AYA projects have to be accepted as a standard of care at the community and government levels.

An unusual case of homicide with a crossbow and a hunting knife.

Traumatic lethal injuries caused by crossbows are a rarity in forensic pathology. They occur as accidents, suicide and, more rarely, as murders. We report a case of murder received at the Institute of Legal Medicine in Milan carried out by two weapons - a crossbow and a hunting knife - that resulted in multiple thoraco-abdominal wounds. The case is also rare because of the unique circumstances involving the victim - a local service psychiatrist - and the perpetrator - a former medical specialist in psychiatry, suffering from a delusional psychotic disorder. The crossbow was the decisive instrument in the realization of the murder; it was chosen with premeditation for its high destructive capacity and the fact that it was easily obtainable, and it was used with darts that were specially modified to increase its harmful capacity. The presented case, as well as providing an opportunity to highlight the damaging effects of a rarely used weapon, stresses the problems inherent with access to tools such as the crossbow that are used in sport, and which are potentially dangerous but easily accessible, even to those with serious mental disorders, rendering them legally unfit for using firearms.