Evaluation of a transition to survivorship program for pediatric, adolescent, and young adult cancer patients and caregivers.

BACKGROUND: Survivorship education and anticipatory guidance represent an unmet need for pediatric, adolescent, and young adult (AYA) cancer survivors and their caregivers when treatment ends. This pilot study evaluated the feasibility, acceptability, and preliminary efficacy of a structured transition program, bridging treatment to survivorship, to reduce distress and anxiety and increase perceived preparedness for survivors and caregivers. PROCEDURE: Bridge to Next Steps is a two-visit program, within 8 weeks prior to treatment completion and 7 months post treatment, which provides survivorship education, psychosocial screening, and resources. Fifty survivors (age range 1-23 years) and 46 caregivers participated. Participants completed pre- and post-intervention measures: Distress Thermometer and Patient-Reported Outcomes Measurement Information System (PROMIS) anxiety/emotional distress (ages ≥8 years), and perceived preparedness survey (ages ≥14 years). AYA survivors and caregivers completed a post-intervention acceptability survey. RESULTS: Most participants (77.8%) completed both visits, and most AYA survivors (57.1%) and caregivers (76.5%) endorsed the program as helpful. Caregivers' distress and anxiety scores decreased from pre to post intervention (p < .01). Survivors' scores remained the same, which were low at baseline. Survivors and caregivers felt more prepared for survivorship from pre to post intervention (p = .02, <.01, respectively). CONCLUSIONS: Bridge to Next Steps was feasible and acceptable for most participants. AYA survivors and caregivers felt more prepared for survivorship care after participation. Caregivers reported decreased anxiety and distress from pre to post Bridge, whereas survivors remained at a low level for both. Effective transition programs that better prepare and support pediatric and AYA cancer survivors and families from active treatment to survivorship care can contribute to healthy adjustment.

Assessment of end-of-treatment transition needs for pediatric cancer and hematopoietic stem cell transplant patients and their families.

BACKGROUND/OBJECTIVES: The transition off active treatment is a time of significant stress for pediatric cancer patients and families. Providing information and support at this time is among the new psychosocial standards of care in pediatric oncology. This study sought to explore patient and family needs and concerns at the end of their active cancer treatment. DESIGN/METHODS: Forty-nine caregiver-child dyads completed semi-structured interviews and surveys 1-2 months before ending treatment, and again 3-7 months after treatment concluded. RESULTS: Patients and caregivers reported a moderate level of understanding of follow-up care needs, late effects, and perceived preparation. Altogether, child, adolescent, and young adult cancer patients and parents identified similar priorities for information needed during the transition off active treatment. The most essential pieces of information desired by patients and families across time points included reviews of late effects, schedules for follow-up care, health and physical restrictions, communication with the patient's primary care provider, and provision of a treatment summary. At Time 2, patients and families reported a greater retrospective desire for emotional health resources. Most patients and caregivers wanted information from a variety of sources, but the desired timing to receive this information varied and was dependent on disease group. CONCLUSIONS: There are many essential components to end-of-treatment care that are not consistently provided to pediatric cancer patients and families. Formalized programs offering education and support should be provided by multidisciplinary teams prior to the end of active treatment.

Fiber digestibility in royal antelope (Neotragus pygmaeus).

Royal antelope (Neotragus pygmaeus) are among the smallest ungulate species and are browsing ruminants. To date, their capacities for fiber fermentation and nutrient digestion have not been quantified. This study compared apparent digestibilities of a typical high-fiber herbivore pellet (ADF 25) and a low-starch, high-fiber diet (WHP) in royal antelope in a crossover design (seven subjects in the first period and four in the second). Animals on ADF 25 pellets had greater intake concentrations (P < 0.05) of dry matter, crude protein, lignin, and crude fat; however, animals fed the WHP diets had greater (P < 0.05) apparent digestibility of dry matter, acid detergent fiber, neutral detergent fiber, and crude fat. Identifying the capacity to which these smaller ruminants can degrade fiber will help to establish more appropriate feeding guidelines for small, browsing ruminants in captivity.

Fat-soluble vitamin and mineral comparisons between zoo-based and free-ranging koalas (Phascolarctos cinereus).

As part of a health investigation on koalas at San Diego Zoo, serum samples were analyzed from 18 free-ranging and 22 zoo-based koalas, Phascolarctos cinereus. Serum concentrations of calcium, chloride, cobalt, copper, iron, magnesium, manganese, molybdenum, phosphorus, potassium, selenium, sodium, zinc, and vitamins A, E, and 25(OH)D3 were quantified. Calcium, chloride, molybdenum, selenium, and vitamin E concentrations were significantly higher in zoo-based koalas than in free-ranging koalas, whereas magnesium, manganese, phosphorus, and zinc concentrations were significantly higher in the free-ranging koalas. No significant differences were found between genders. The results from this study will help to establish a starting point for determining target circulating nutrient concentrations in koalas.

Perspectives on Virtual Care for Childhood Cancer Survivors in Non-Metropolitan Areas during the COVID-19 Pandemic.

The COVID-19 pandemic paved the way for the widespread use of virtual care for childhood cancer survivors (CCSs). CCSs were virtual recipients of diverse care, including long-term follow-up (LTFU), primary care, mental health care, and several others. Virtual care comes with well-documented benefits and challenges. These are further magnified for CCSs living in rural or non-metropolitan areas. Here, we describe the virtual care of CCSs from two Upper Midwest cities with well-established childhood cancer survivor programs within large comprehensive cancer centers in the United States. CCSs from non-metropolitan areas, especially CCSs with two or more late effects, used virtual care more often during the COVID-19 pandemic compared to CCSs from metropolitan areas. A review of the related literature is also included and the identified challenges in providing virtual care, such as privacy concerns, technology-connectivity constraints, and medical license restrictions. Despite these limitations, the care of CCSs has evolved to leverage virtual care and its ability to increase access for patients and promote continuity of care for CCSs living in rural areas.

A multimethod assessment of psychosocial functioning and late effects in survivors of childhood cancer and hematopoietic cell transplant.

Previous research in childhood cancer and hematopoietic cell transplant (HCT) survivorship has relied on the use of standardized questionnaires that assess symptoms of psychological functioning but do not sufficiently capture the cancer survivorship experience. Study aims are to quantitatively and qualitatively assess the psychosocial functioning of pediatric cancer and HCT survivors seen in a multidisciplinary survivorship clinic, determine survivorship concerns, and assess potential demographic and medical correlates of psychosocial outcomes. Data were collected using a retrospective chart review of a parent-report questionnaire of the child's psychological functioning, responses to a semistructured interview that qualitatively assessed adjustment to life after treatment, and documented medical late effects. Results indicated the majority of survivors had healthy psychological adjustment based upon a parent-report questionnaire. However, nearly 72% of survivors reported 1 or more survivorship concerns during the interview, with the primary concerns being current and future health or physical functioning, including the possibility of cancer recurrence. A content analysis of the interview responses indicated HCT survivors had more school or cognitive functioning concerns compared with survivors who did not have an HCT. Further research should use survivorship-specific measures to better identify survivors at risk and determine the impact of late effects on their quality of life.

Evaluation of fatigue and related factors in survivors of pediatric cancer and hematopoietic stem cell transplant.

This study sought to better understand specific factors contributing to fatigue in survivors of pediatric cancer and hematopoietic stem cell transplant (HSCT). As part of a larger study evaluating long-term psychosocial functioning of pediatric cancer survivors, N = 87 participants completed measures assessing fatigue and emotional and behavioral functioning. Chart abstraction was used to catalog diagnosis, treatments received, treatment intensity, and late effects. Results suggest clinically significant fatigue in n = 4 (4.6%) of survivors participating in this study. Fatigue was greater for participants with more recent diagnoses and who were more recently off treatment and was positively associated with parent and self-report of internalizing (emotional) and externalizing (behavioral) symptoms. Participants with more severe late effects suffered greater fatigue; however, fatigue was not associated with treatment intensity or therapy type. Fatigue is an important variable to consider in evaluating the social, emotional, behavioral, and physical well-being of cancer and HSCT survivors. Interventions are needed to address fatigue directly, while also addressing both contributing factors to fatigue and potential negative outcomes that result from fatigue in survivorship.

Serum chemistry comparisons between captive and free-ranging giraffes (Giraffa camelopardalis).

Serum chemistry analyses were compared between captive and free-ranging giraffes (Giraffa camelopardalis) in an attempt to better understand some of the medical issues seen with captive giraffes. Illnesses, including peracute mortality, energy malnutrition, pancreatic disease, urolithiasis, hoof disease, and severe intestinal parasitism, may be related to zoo nutrition and management issues. Serum samples were collected from 20 captive giraffes at 10 United States institutions. Thirteen of the captive animal samples were collected from animals trained for blood collection; seven were banked samples obtained from a previous serum collection. These samples were compared with serum samples collected from 24 free-ranging giraffes in South Africa. Differences between captive and free-ranging giraffes, males and females, and adults and subadults were analyzed by using a 2 x 2 x 2 factorial and Fisher's least significant difference for mean separation; when necessary variables were ranked and analyzed via analysis of variance. Potassium and bilirubin concentrations and alanine aminotransferase (ALT) activities were different between captive and free-ranging giraffes, but all fell within normal bovid reference ranges. The average glucose concentration was significantly elevated in free-ranging giraffes (161 mg/dl) compared with captive giraffes (113 mg/dl). All giraffes in this study had glucose concentrations higher than bovine (42-75 mg/ dl) and caprine (48-76 mg/dl) reference ranges. Differences were also seen in lipase, chloride, and magnesium though these findings are likely not clinically significant. There were no differences detected between sexes. Adults had higher concentrations of potassium, total protein, globulins, and chloride and higher gamma glutamyltransferase activities, whereas subadults had higher concentrations of phosphorus. Within the captive group, nonimmobilized animals had higher concentrations of total protein and globulins. Captive giraffe diets need further investigation to determine if the differences seen in this study, especially glucose and bilirubin concentrations and ALT activities, may result in some health problems often seen in captive giraffes.

Late effects in adult survivors of childhood cancer: considerations for the general practitioner.

Childhood cancer survivorship is a national public health priority, with an increasing number of survivors who face late effects from both disease and treatment. As childhood cancer survivors are living into adulthood, care of the late effects associated with their diagnosis and treatment can become complex. Often these patients no longer have follow-up with the treating pediatric hospital and seek medical care from an adult primary care professional. Combining the results of current survivorship research with clinical experience, we describe common late effects that general internists and primary care professionals may encounter during routine visits with adult survivors of childhood cancer. Recommendations and resources are provided for identifying and managing late effects.

Quantifying the vitamin D3 synthesizing potential of UVB lamps at specific distances over time.

The purpose of this study was to quantify the ultraviolet B (UVB) output and in vitro previtamin D(3) synthesis over time from various artificial light sources. Three incandescent lamps, T-Rex Active UVHeat 160 watt spot, T-Rex Active UVHeat 160 watt flood, and ZooMed PowerSun 160 watt flood, and two 1.2 m fluorescent lamps, Sylvania Blacklight 350 BL and ZooMed Reptisun 5.0, were studied. Total UVB irradiance and concentration of previtamin D synthesized using an in vitro ampoule model were quantified initially and at monthly intervals for 1 year. Incandescent lamps were measured at distances of 0.9 and 1.5 m while fluorescent lamps were measured at distances of 30.5 and 45.7 cm at the lamp's center, using both the radiometer and ampoules. Fluorescent lamp irradiance was also measured at the lamp's ends. Data were analyzed as a repeated measures split-plot in time using SAS with all mean differences determined using Least Squares Means. Incandescent lamp irradiance differences were seen at various distances. The UVHeat lamps had consistently higher previtamin D(3) production and irradiance readings compared with the PowerSun lamp. Reptisun 5.0 was consistently higher in UVB irradiance over Sylvania BL 350 at both 30.5 and 45.7 cm. However, there were no differences when comparing conversion of 7-dehydrocholesterol to previtamin D(3). Irradiance differences were detected between the centers and ends of the fluorescent lamps. Until UVB requirements for vitamin D(3) synthesis in animals are determined, it is impossible to state that one light is superior to another.

Nutrient composition of plants consumed by black and white ruffed lemurs, Varecia variegata, in the Betampona Natural Reserve, Madagascar.

The purpose of this study was to quantify the concentrations of crude protein, fat, ash, neutral detergent fiber, acid detergent fiber, lignin, nonstructural carbohydrates, and gross energy in plant foods consumed by wild black and white ruffed lemurs (Varecia variegata). Calcium, phosphorous, magnesium, potassium, sodium, iron, zinc, copper, manganese, molybdenum, and selenium concentrations were also determined. A total of 122 samples from 33 plant families and more than 60 species were collected and analyzed for their nutritional content. The specific nutrient needs of black and white ruffed lemurs are unknown, but quantifying the nutritional composition of the foods they consume in the wild will help nutritionists and veterinarians formulate more appropriate diets for captive ruffed lemurs. This information will also supply information on how man-induced habitat changes affect the nutritional composition of foods consumed by free-ranging lemurs.

Serum concentration comparisons of amino acids, fatty acids, lipoproteins, vitamins A and E, and minerals between zoo and free-ranging giraffes (Giraffa camelopardalis).

Serum concentrations of amino acids, fatty acids, lipoproteins, vitamins A and E, and minerals in zoo giraffes (Giraffa camelopardalis) were compared to values obtained from free-ranging giraffes in an effort to identify potential nutritional differences in the zoo population. Zoo giraffes have a specific set of maladies that may be nutritionally related, including peracute mortality, energy malnutrition, pancreatic disease, urolithiasis, hoof disease, and severe intestinal parasitism. Dietary requirements for giraffes are not known; invasive studies used with domestic animals cannot be performed on zoo animals. Though domestic animal standards are often used to evaluate nutritional health of exotic animals, they may not be the most appropriate standards to use. Serum samples from 20 zoo giraffes at 10 zoological institutions in the United States were compared to previously collected samples from 24 free-ranging giraffes in South Africa. Thirteen of the zoo animal samples were collected from animals trained for blood collection, and seven were banked samples obtained from a previous serum collection. Dietary information was also collected on each zoo giraffe; most zoo giraffe diets consisted of alfalfa-based pellets (acid detergent fiber-16), alfalfa hay, and browse in varying quantities. Differences between zoo and free-ranging giraffes, males and females, and adults and subadults were analyzed with the use of a 2 x 2 x 2 factorial and Fisher's Least Significant Difference (LSD) for mean separation. Of the 84 parameters measured, 54 (60%) were significantly different (P < or = 0.05) between zoo and free-ranging giraffes. Nine (11%) items were significantly different (P < or = 0.05) between adult and subadult animals. Only one parameter, sodium concentration, was found to be significantly different (P < or = 0.05) between genders. Further investigation in zoo giraffe diets is needed to address the differences seen in this study and the potentially related health problems.

Serum concentrations of amino acids, fatty acids, lipoproteins, vitamins A and E, and minerals in apparently healthy, free-ranging southern giraffe (Giraffa camelopardalis giraffe).

This pilot project began establishing a nutritional profile for free-ranging giraffe. The results will be used as a tool to begin assessing the nutritional status of captive giraffe. In October 2004 serum samples were collected opportunistically from seven adult and 17 sub-adult giraffe being anesthetized for different studies. Seventeen animals were from Double Drift Game Reserve and seven animals were from Kariega Private Game Reserve. The serum samples were analyzed for circulating concentrations of amino acids, fatty acids, lipoproteins, vitamins, and minerals. Information from 15 serum samples collected from anesthetized giraffe in Kruger National Park during April and August 2003 was included in the calcium and phosphorus concentration data. No significant differences were identified between genders. Significant differences between locations were identified for concentrations of certain amino acids, fatty acids, and lipoproteins. Differences between locations are likely due to different nutrient concentrations of foods and possibly the result of different animal densities forcing different food choices among locations. This pilot project may expand to include changes in circulating nutrient concentrations for free-ranging giraffe as is influenced by other locations, seasonal food availability, and different giraffe subspecies. Zoo Biol 0:1-13, 2007. (c) 2006 Wiley-Liss, Inc.

Cholesterol values in free-ranging gorillas (Gorilla gorilla gorilla and Gorilla beringei) and Bornean orangutans (Pongo pygmaeus).

Cholesterol concentrations in captive gorillas and orangutans vary widely within species and average approximately 244 mg/dl for gorillas and 169 mg/dl for orangutans as published previously. The International Species Inventory System reports higher concentrations of 275 and 199 mg/dl for gorillas and orangutans, respectively. It is unknown whether these values were typical, influenced by captive management, or both. To answer this question, banked serum samples from free-ranging mountain gorillas (Gorilla beringei), western lowland gorillas (Gorilla gorilla gorilla), and Bornean orangutans (Pongo pygmaeus) were analyzed for total cholesterol, triglyceride, high-density lipoprotein cholesterol, and low-density lipoprotein cholesterol concentrations. Mountain gorillas did not differ significantly from free-ranging western lowland gorillas in cholesterol, triglyceride, high-density lipoprotein cholesterol, or low-density lipoprotein cholesterol concentrations, indicating mountain gorilla values could be a model for western lowland gorillas. Captive gorilla total cholesterol and low-density lipoprotein cholesterol concentrations were significantly higher (P < 0.05) than in free-ranging groups. Triglyceride concentrations for captive gorillas were significantly higher (P < 0.05) than the male mountain and western lowland gorillas, but they were not significantly different from the female mountain gorillas. Captive orangutan total cholesterol concentrations were only higher (P < 0.05) than the free-ranging female orangutans, whereas captive orangutan low-density lipoprotein cholesterol concentrations were significantly higher (P < 0.05) than both free-ranging male and female orangutans. Calculated and measured low-density lipoprotein cholesterol concentrations were compared for all free-ranging animals and were significantly different (P < 0.05) for all groups, indicating Friedewald's equation for calculating low-density lipoprotein cholesterol is not appropriate for use with nonfasted apes. The higher total cholesterol and low-density lipoprotein cholesterol concentrations in captive apes may predispose them to cardiovascular disease and might be attributed to diets, limited energy expenditure, and genetics.

Fiber digestibility by the orangutan (Pongo abelii): in vitro and in vivo.

Limited nutritional information exists on diets of free-ranging orangutans, Pongo abelii and P. pygmaeus. Although they are classified as frugivores, the chemical composition of their diet and their gastrointestinal anatomy suggest that they rely on fiber fermentation for a substantial portion of energy. However, the extent to which they can ferment fiber is not known. Continuous culture systems, inoculated with orangutan fecal bacteria, were established to determine the fiber-digesting capacity of orangutan hindgut microflora. The cultures received one of four treatments: soybean hulls, ground corncobs, corn starch, or no food. Neither dry matter nor neutral detergent fiber digestibilities differed significantly among treatments. However, neutral detergent fiber digestibilities were high for both the soybean hull (88.4%) and ground corncob (86.1%) treatments, indicating that the microflora had a strong fibrolytic capability. To determine whether the same fiber-degrading capacity occurred in vivo, two adult orangutans and one juvenile were fed four gel-matrix diets containing soybean hulls, ground corncobs, or ground primate biscuits. Neutral detergent fiber concentrations (dry matter basis) of the gel matrices were 52.9% with soybean hulls, 46.8% and 63.7% with ground corncobs, and 31.3% with ground primate biscuits. A fifth diet consisted of primate biscuits with 27.3% neutral detergent fiber (dry matter basis) and was considered the baseline diet. Neutral detergent fiber digestibility (74.5%) was greatest (P < 0.05) for the soybean hull gel diet and least (57.5% and 45.0%, respectively; P < 0.05) for the 63.7% neutral detergent fiber (dry matter basis) corncob gel diet and the baseline primate biscuit diet. Total volatile fatty acid concentrations in orangutan feces were not significantly different among diets; however, molar proportions of acetic, propionic, and butyric acid differed (P < 0.05) among diets. The results from both studies indicated that orangutans are capable of extensive fiber fermentation.

Fiber digestibility by black lemurs (Eulemur macaco macaco).

Black lemurs, Eulemur macaco, are classified as generalist feeders, consuming a proportion of fruits and leaves that varies with seasonal availability. It is hypothesized that black lemurs are capable of using neutral detergent fiber (NDF) as a source of energy through fiber fermentation in the cecum and large intestine. In captivity, they are typically fed a diet of commercially available primate biscuits and readily available produce, both of which are limited in NDE Digestibility trials were conducted on 14 black lemurs; 12 were housed in groups (four, three, three, and two) and 2 were individually housed. The lemurs were fed four manufactured feeds differing in fiber form and content. A commercially available primate biscuit, containing approximately 27% NDF, served as the control diet. The second diet contained the same primate biscuits, which were ground and then incorporated into a fiber-based gel matrix. The third and fourth diets were formulated using soybean hulls or ground corncobs as the fiber source, resulting in 53% and 47% NDF, respectively. Produce was added to the diet at 36% (dry matter basis). Dry matter digestibility differed significantly among all diets. Neutral detergent fiber digestibility was highest for the ground biscuit in gel and lowest for the two high-fiber gel diets, with biscuit digestibility values falling between the two extremes. The high-fiber gel diets were successful in increasing the NDF concentrations of the primate diets; however, black lemurs were capable of only limited fiber digestion.

Interdisciplinary preceptor teams to improve the clinical nurse leader student experience.

The Clinical Nurse Leader (CNL) role was introduced by the American Association of Colleges of Nursing (AACN) in 2003 (AACN, 2003). There are now over 2,500 certified CNLs in the United States. Still some areas of the country have no CNLs in practice; this was true of north central Texas until May 2010 when Texas Christian University (TCU) had its first graduating class. Lack of CNLs to serve as preceptors for the practicum courses in the CNL program was one concern, although AACN does offer options when CNLs are not available. TCU's CNL teaching team developed the interdisciplinary preceptor team (IPT) model to strengthen the practicum component of CNL education at TCU. One advantage of the IPT model is the match it provides with several CNL competencies: lateral integration of care via interdisciplinary teams, member and leader of health care teams, skillful communication within teams, and implementation of an interdisciplinary approach to safe, quality, patient care. Components of the IPT model are discussed with specific information about preceptor selection, team development, and examples of feedback from preceptors and students.

Growth velocity in pediatric bone marrow transplantation: significance of donor type and treatment factors.

Children who have undergone bone marrow transplantation (BMT) often have decreased growth. Growth is a multifactorial process, and the factors that influence growth after BMT are not completely understood. The authors hypothesized that donor type may be a factor influencing growth. Sixty-five children and adolescents who underwent BMT (32 related matched, 33 unrelated matched) were evaluated. Growth velocity (height standard deviation) was assessed prior to and 2 years following BMT. The results indicated that children and adolescents who underwent unrelated matched transplants had lower growth velocity (P < .059) than those with related matched transplants. Those who received the standard conditioning regimen that included total body irradiation (TBI) had a significantly lower growth velocity (P < .045) than those with chemotherapy-only regimens. Significant correlates of growth velocity included younger age at BMT and pre-BMT growth velocity. Thus, donor type, age at BMT, prior treatment, and BMT conditioning regimens that include TBI may all affect growth post-BMT. Careful monitoring of growth velocity is required for patients who have received an unrelated donor BMT.