Utilization of Thiopurine Metabolites and Allopurinol in Pediatric Acute Lymphoblastic Leukemia: Consideration for an Algorithmic Approach.

Persistently elevated absolute neutrophil counts during maintenance for acute lymphoblastic leukemia is a risk factor for relapse and may be related to wild-type thiopurine methyltransferase activity and overly efficient shunting of 6-mercaptopurine to hepatotoxic metabolites (6-methylmercaptopurine nucleotides), leading to low 6-thioguanine nucleotides. 6-mercaptopurine is also metabolized by xanthine oxidase, and therefore allopurinol, an inhibitor of xanthine oxidase, allows for increased 6-thioguanine nucleotides and decreased 6-methylmercaptopurine nucleotide. Here, we report our experience with allopurinol for persistently elevated absolute neutrophil count or hepatotoxicity and suggest an algorithmic approach for checking thiopurine metabolites and initiating allopurinol in acute lymphoblastic leukemia maintenance.

Pilot of a screening, brief intervention and referral to treatment process for symptoms of trauma among primary care patients.

BACKGROUND: For populations with high rates of trauma exposure yet low behavioural health service use, identifying and addressing trauma in the primary care setting could improve health outcomes, reduce disability and increase the efficiency of health system resources. OBJECTIVE: To assess the acceptability and feasibility of a screening, brief intervention and referral to treatment (SBIRT) process for trauma and symptoms of posttraumatic stress disorder (PTSD) among American Indian and Alaska Native people. We also examine the short-term effects on service utilization and the screening accuracy of the Primary Care Posttraumatic Stress Disorder Screen. METHODS: Cross-sectional pilot in two tribal primary care settings. Surveys and interviews measured acceptability among patients and providers. Health service utilization was used to examine impact. Structured clinical interview and a functional disability measure were used to assess screening accuracy. RESULTS: Over 90% of patient participants (N = 99) reported the screening time was acceptable, the questions were easily understood, the right staff were involved and the process satisfactory. Ninety-nine percent would recommend the process. Participants screening positive had higher behavioural health utilization in the 3 months after the process than those screening negative. The Primary Care Posttraumatic Stress Disorder Screen was 100% sensitive to detect current PTSD with 51% specificity. Providers and administrators reported satisfaction with the process. CONCLUSIONS: The SBIRT process shows promise for identifying and addressing trauma in primary care settings. Future research should explore site specific factors, cost analyses and utility compared to other behavioural health screenings.

An Internet-Based Therapeutic Tool for American Indian/Alaska Native Adults With Posttraumatic Stress Disorder: User Testing and Developmental Feasibility Study.

BACKGROUND: Posttraumatic stress disorder (PTSD) is a major public health concern among American Indian and Alaska Native populations. Primary care clinics are often the first point of contact for American Indian and Alaska Natives seeking health care and are feasible locations for trauma-focused interventions. OBJECTIVE: Web-based therapeutic interventions have the potential to reduce PTSD symptoms by offering psychoeducation and symptom self-management tools. We investigated the feasibility of a culturally adapted Web-based therapeutic intervention in two American Indian and Alaska Native-serving primary care sites. We developed and tested a self-guided Web-based therapeutic intervention aimed at improving knowledge and awareness of, and provision of guidance, support, and symptom-management for, PTSD symptoms. METHODS: A community-based participatory research process was used to refine adaptations to the veteran's administration's PTSD Coach Online, to develop new content, and to guide and interpret the results of the feasibility pilot. This process resulted in a 16-guide intervention "Health is Our Tradition: Balance and Harmony after Trauma" website. The feasibility pilot included 24 American Indian and Alaska Natives aged 18 years and older who scored positive on a primary care PTSD screener. Enrolled participants completed a demographic questionnaire, an experience with technology questionnaire, and baseline behavioral health measures. Once measures were complete, research staff described weekly text messages, minimum study expectations for website use, and demonstrated how to use the website. Feasibility measures included self-reported website use, ratings of satisfaction and perceived effectiveness, and website metrics. Feasibility of obtaining measures for an effectiveness trial was also assessed to include behavioral health symptoms and service utilization through self-report instruments and electronic health record queries. Self-reported measures were collected at enrollment and at 6 and 12 weeks post enrollment. Electronic health records were collected from 12 months before study enrollment to 3 months following study enrollment. Changes between enrollment and follow-up were examined with paired t tests, analysis of variance or logistic regression, or the Wilcoxon signed rank test for nonnormally distributed data. RESULTS: The culturally adapted website and associated text message reminders were perceived as satisfactory and effective by participants with no differences by age or gender. The majority of participants (86%, 19/24) reported use of the website at 6 weeks and nearly all (91%, 20/22) at 12 weeks. At 6 weeks, 55% (12/22) of participants reported using the website at the recommended intensity (at least three times weekly), dropping to 36% (8/22) at 12 weeks. Participant use of modules varied from 8% (2/24) to 100% (24/24), with guide completion rates being greater for guides that were only psychoeducational in nature compared with guides that were interactive. There were no significant changes in patterns of diagnoses, screening, medications, or service utilization during exposure to the website. CONCLUSIONS: "Health is Our Tradition: Balance and Harmony after Trauma" shows promise for an effectiveness pilot.

Disseminating Information on Trauma Screening, Brief Intervention, and Referral to Treatment in a Tribal Health Setting: A Case Study.

Exposure to trauma is consistently associated with co-occurrence of behavioral health disorders. Primary care settings are opportune places to screen for traumatic experiences and symptoms, as they are often the initial point of care for behavioral health concerns by the Alaska Native and American Indian (AN/AI) population. In this case study, we examine results dissemination activities at the SCF Research Department-hosted 2016 Alaska Native Health Research Forum (Forum) of a pilot study of a trauma-focused screening, brief intervention, and referral to treatment (T-SBIRT) process for AN/AI adults in primary care. Feedback included audience responses to the presentation delivered at the Forum and recommendations to guide future community dissemination of T-SBIRT results. Attendees (N = 31) found the presentation clear, interesting, and included the right amount of detail. Four broad dissemination themes were identified in discussion groups: 1) share results with everyone; 2) share results in ways that reach all AN audiences; 3) provide a summarized status update at each stage of the study; and 4) use results to improve care for trauma and related symptoms.

Development of a Screening and Brief Intervention Process for Symptoms of Psychological Trauma Among Primary Care Patients of Two American Indian and Alaska Native Health Systems.

American Indian and Alaska Native (AI/AN) people experience high rates of acute, chronic, and intergenerational trauma. Traumatic experiences often increase the risk of both medical and behavioral health problems making primary care settings opportune places to screen for trauma exposure or symptomology. The objective of this study was to determine considerations and recommendations provided by patients, health care providers, health care administrators, and tribal leaders in the development of an adult trauma screening, brief intervention, and referral for treatment process to pilot at two large AI/AN primary care systems. A qualitative and iterative data collection and analysis process was undertaken using a community-based participatory research approach guided by a cross-site steering committee. Twenty-four leaders and providers participated in individual interviews, and 13 patients participated in four focus groups. Data were thematically analyzed to select a trauma screening instrument, develop a screening process, and develop brief intervention materials. The nature of traumas experienced in the AI/AN community, the need to develop trusting patient-provider relationships, and the human resources available at each site drove the screening, brief intervention, and referral process decisions for a future trauma screening pilot in these health systems.

One facility's experience in reframing nonfeeding into a comprehensive palliative care model.

In Western culture, feeding is viewed as symbolic of life, and nonfeeding at the end of life is often considered unacceptable. This sentiment is magnified for infants. Reframing nonfeeding into comprehensive care can be achieved by anticipatory guidance, which can make the experience of infant death meaningful for parents. Since 2004, the George Mark Children's House, an inpatient pediatric palliative care center, has offered this model of care and supported families with challenging clinical experiences. A case study is provided.

Metastases to the breast: alveolar soft part sarcoma in adolescents.

Metastases to the breast comprise 0.5%-2% of breast neoplasms. This is a case report of an 18-year-old woman with an alveolar soft part sarcoma metastatic to the breast.

Evaluation of the Sunny Days, Healthy Ways sun safety curriculum for children in kindergarten through fifth grade.

Childhood sun protection is important to reduce the risk of developing skin cancer later in life. An evaluation of an expanded version of the Sunny Days, Healthy Ways sun safety instructional program was conducted with 744 students in 77 kindergarten to fifth grade classes in 10 elementary schools. Students in six schools received instruction twice over two school years. Students in four schools received it only once in a single school year or were enrolled in a no-treatment control group. A single presentation of the sun safety materials improved sun safety knowledge in students in grades 2-5 (p < 0.05). Repeated presentation over 2 years improved all outcomes, including increasing self-reported sun protection (p < 0.05) and decreasing skin darkening indicative of exposure to ultraviolet radiation (p < 0.05). The program did not improve children's knowledge or skin darkening in kindergarten and grade 1. These results highlight the need to provide sun protection education over several school years, not just one time, to produce changes in sun safety behavior.

Ewing sarcoma as a second malignant neoplasm after acute lymphoblastic leukemia.

Second malignant neoplasms (SMNs) are being increasingly recognized. This report describes a case of a 7-year-old girl with a history of acute lymphoblastic leukemia (ALL) who presented with a mass in her humerus that was diagnosed as Ewing sarcoma. Second malignant neoplasms are relatively rare in survivors of ALL treated without radiation. Even more unusual is the development of Ewing sarcoma as the SMN.

The pediatrician and medical care of the child with cancer.

The child's pediatrician is an important resource for families regarding a host of issues such as infections, complications and side effects of chemotherapy, school issues, and psychosocial stressors that are common in families of children with life-threatening illness. This article provides guidance for caring for children with malignancies in the primary care setting.