Biomedical subjects

R K Mulhern

Publications and source records attributed to R K Mulhern.

At least 37 records · Page 2Linked to original sources

PubMed1998

Effectiveness of psychological intervention for children and adolescents with chronic medical illness: a meta-analysis.

Outcomes from 42 studies of psychological interventions for children and adolescents with chronic medical conditions were analyzed using meta-analysis. Studies were divided into the four intervention categories suggested by LaGreca and Varni (1993), Disease Management, Emotional/Behavioral Problems, Health Promotion, and Prevention. Results supported overall effectiveness of psychological interventions, with an effect size (ES) of 1.12, as well as maintenance of treatment gains for at least 12 months posttreatment. Psychological interventions directed at disease-related or emotional/behavioral problems were both found to be effective, although too few studies of health promotion or disease prevention interventions were identified to be included in the analysis. Effectiveness of behavioral interventions, which were most heavily represented in the sample, demonstrated similar effects for disease management (ES = 1.20) and emotional/behavioral (ES = 1.03) problems. Although disease type, severity, and duration did not affect intervention effectiveness, some influences of patient age and gender were noted across studies. Recommendations for further intervention studies and improvements in study design are discussed.

Child↗

PubMed1998

A hybrid neural network analysis of subtle brain volume differences in children surviving brain tumors.

In the treatment of children with brain tumors, balancing the efficacy of treatment against commonly observed side effects is difficult because of a lack of quantitative measures of brain damage that can be correlated with the intensity of treatment. We quantitatively assessed volumes of brain parenchyma on magnetic resonance (MR) images using a hybrid combination of the Kohonen self-organizing map for segmentation and a multilayer backpropagation neural network for tissue classification. Initially, we analyzed the relationship between volumetric differences and radiologists' grading of atrophy in 80 subjects. This investigation revealed that brain parenchyma and white matter volumes significantly decreased as atrophy increased, whereas gray matter volumes had no relationship with atrophy. Next, we compared 37 medulloblastoma patients treated with surgery, irradiation, and chemotherapy to 19 patients treated with surgery and irradiation alone. This study demonstrated that, in these patients, chemotherapy had no significant effect on brain parenchyma, white matter, or gray matter volumes. We then investigated volumetric differences due to cranial irradiation in 15 medulloblastoma patients treated with surgery and radiation therapy, and compared these with a group of 15 age-matched patients with low-grade astrocytoma treated with surgery alone. With a minimum follow-up of one year after irradiation, all radiation-treated patients demonstrated significantly reduced white matter volumes, whereas gray matter volumes were relatively unchanged compared with those of age-matched patients treated with surgery alone. These results indicate that reductions in cerebral white matter: 1) are correlated significantly with atrophy; 2) are not related to chemotherapy; and 3) are correlated significantly with irradiation. This hybrid neural network analysis of subtle brain volume differences with magnetic resonance may constitute a direct measure of treatment-induced brain damage.

Adolescent↗

PubMed1998

Neuropsychologic functioning of survivors of childhood medulloblastoma randomized to receive conventional or reduced-dose craniospinal irradiation: a Pediatric Oncology Group study.

PURPOSE: The purpose of this study was to test the hypothesis that survivors of medulloblastoma who were younger at diagnosis and those who received standard-dose cranial irradiation (SRT) of 36 Gy would have a lower performance on standardized tests of cognitive function and achievement than children who were older and those treated with reduced-dose cranial irradiation (RRT) of 23.4 Gy. PATIENTS AND METHODS: Eligible patients had been treated on Pediatric Oncology Group (POG) study 8631 for low-risk medulloblastoma that randomized patients to receive RRT or SRT after surgical resection. Those who were alive and free of progressive disease 6.1 to 9.9 years from completion of treatment were eligible for this study. Of the 35 eligible patients, 22 patients (13 SRT, nine RRT) participated in a battery of tests that included intellectual and academic development as well as ratings of health-related quality of life. RESULTS: Patients were stratified by treatment group (SRT v RRT) and into younger (Y) and older (O) groups by the median age at diagnosis (8.85 years), which resulted in four groups that we hypothesized would show neuropsychologic test scores in the following order: Y/SRT less than Y/RRT less than O/SRT less than O/RRT. Evidence to support the hypothesized ordering of groups in terms of neuropsychologic toxicity was obtained with regard to Performance Intelligence Quotient (IQ), Full Scale IQ, Attention, Reading, and Arithmetic. CONCLUSION: Children treated for medulloblastoma experienced less severe neuropsychologic toxicity when treated with 23.4 Gy instead of 36 Gy cranial irradiation. Older children experienced less toxicity than children who were younger at the time of irradiation.

Achievement↗

PubMed1997

Psychological functioning of adolescent and young adult survivors of pediatric malignancy.

OBJECTIVE: To assess the psychological functioning of adolescent and young adult survivors of pediatric malignancy, and identify risk factors for maladjustment. DESIGN: Patients age > or = 14.5 years (N = 161) receiving surveillance follow-up at a major pediatric cancer center completed the SCL-90-R, a self-report measure of psychological symptomatology. Comparisons were made with the normative standardization sample, and the relationship of selected demographic and medical variables with psychological distress was explored using logistic regression analyses. RESULTS: Survivors mean scores on all SCL-90-R subscales were lower than those of the standardization sample, and the distribution of scores on the Anxiety, Psychoticism, Global severity Index, and Positive Symptom Total scales were significantly below normative values. No SCL-90-R subscale displayed an excessive frequency of clinically elevated scores. For patients who displayed clinical elevations on the SCL-90-R, three factors were identified which were associated with increased risk of maladjustment; older patient age at follow-up, more frequent disease relapse, and more severe functional impairment. CONCLUSIONS: This cohort of childhood cancer survivors is characterized by very low levels of psychological distress and significantly better psychological health than would be expected according to normative data. These findings contrast with those of another study from the same institution in which a fourfold increase in social and behavioral problems was found amongst younger survivors, in the age range 7-15. The use of self-report vs. parent-report, and the potential influence of repressive adaptation on the self-reports of pediatric cancer survivors, are raised as possible explanations for these findings.

Adaptation, Psychological↗

PubMed1997

Variables associated with anticipatory nausea and vomiting in pediatric cancer patients receiving ondansetron antiemetic therapy.

Investigated the prevalence of anticipatory nausea and vomiting (ANV) among 59 pediatric cancer patients who had routinely received ondansetron (Zofran) antiemetic therapy and determined patient- and treatment-related factors associated with ANV. Of the sample, 59% indicated at least mild ANV symptoms, suggesting that a significant number of patients report ANV and are bothered by it, despite the use of Zofran. These children were compared to those reporting no ANV symptoms. Most ANV symptomatology was consistent with a traditional classical conditioning model although cognitive processes may also play a role. Children with greater expectations of severe postchemotherapy vomiting and those who were more distressed by nausea and vomiting were more likely to experience ANV symptoms. Implications for psychological and pharmacological treatments of ANV are discussed.

Adolescent↗

PubMed1997

Anticipatory nausea and vomiting in pediatric cancer patients: an analysis of conditioning and coping variables.

We examined the influence of cognitive factors and conditioning variables on anticipatory nausea and vomiting symptoms (ANV) in 32 pediatric cancer patients with postchemotherapy nausea and vomiting (PNV) who received ondansetron. The patients were compared with 18 patients without ANV (NANV). Age, gender, history of motion sickness, aggressiveness of the chemotherapy, PNV severity, number of chemotherapy treatments, number, type, and efficacy of self-reported coping strategies, and expectations of severity of postchemotherapy symptoms failed to differentiate the ANV and NANV groups. The amount of subjective distress associated with nausea and vomiting was significantly greater in the ANV group. Among patients in whom ANV developed, level of distress and expectations of severity of postchemotherapy symptoms were positively correlated with the severity of ANV and PNV symptoms. Therefore, greater distress might increase the likelihood of ANV conditioning. Once ANV is conditioned, cognitive factors might influence the severity of symptoms.

Adaptation, Psychological↗

PubMed1997

Sibling Adaptation to Childhood Cancer Collaborative Study: the association of sibling adaptation with maternal well-being, physical health, and resource use.

This multi-institutional study investigated the association of behavioral/emotional adaptation among siblings of children with cancer with maternal general well-being, physical health, and resource use. One hundred seventy siblings and mothers completed standardized interviews and self-report measures 6 to 42 months after the cancer was diagnosed. As a group, mothers of children with cancer reported significantly lower levels of well-being than matched controls. When stratified according to the level of the sibling's behavioral/emotional adaptation, mothers of siblings in the Dysfunctional group (1) reported the lowest levels of well-being; (2) during the preceding year, were more likely to have sought professional services than mothers of children in the Resilient group; and (3) were least likely to have found social support helpful. Our results support an association between maternal well-being and sibling adjustment but show it is unlikely that nonspecific social support will improve adjustment. The rationale for problem-solving training for mothers is provided.

Adaptation, Psychological↗

PubMed1996

Sibling adaptation to childhood cancer collaborative study: health outcomes of siblings of children with cancer.

OBJECTIVE: This seven-site study examined the overall health status, healthcare utilization, somatization, and health-risk behaviors of siblings of children with cancer compared to these factors in matched controls or normative data. The study also examined whether informants (i.e., siblings, parents, physicians) differed in their assessments of the above health domains. DESIGN: Subjects were 254 siblings of children with cancer from seven different pediatric oncology treatment centers that participated in the Sibling Adaptation to Childhood Cancer Collaborative study group. Predictors of the siblings' health status, healthcare utilization, somatization, and health-risk behaviors were identified, and the relationship between these health domains and the siblings' resiliency vs. dysfunctionality were explored via interviews. RESULTS: Overall, siblings were found to be moderately healthy, although siblings report significant problems with sleeping and eating. Healthcare utilization appears to be reduced for siblings. Most importantly, the parents of these siblings are less likely to seek medical help for a variety of conditions for which parents of control children would bring their children to a doctor. A pattern emerged of parental underreporting of sibling health variables when compared to what the siblings themselves reported. When the relationship between health outcomes and the siblings' adaptation to their sick sibling's illness was examined, the resilient and dysfunctional groups significantly differed from each other. It appears that health outcomes are related to sibling adaptation to the changes brought about by their sick sibling's cancer diagnosis and treatment. CONCLUSIONS: The focus of care for families of children with cancer is often limited to the child with cancer. As indicated in this study, the "healthy" siblings may be overlooked in the process. While parents appear to recognize that their "healthy" children are complaining more about aches and pains, they may have little energy or time to attend to the needs of these other family members. It is the intent of this study to document what clinicians may expect and to highlight the need for evaluation of this otherwise neglected group.

Adaptation, Psychological↗

PubMed1995

Survival outcome following isolated central nervous system relapse treated with additional chemotherapy and craniospinal irradiation in childhood acute lymphoblastic leukemia.

PURPOSE: An analysis of survival outcome following isolated central nervous system (CNS) relapse treated with craniospinal irradiation (CSI) and additional chemotherapy in children with acute lymphoblastic leukemia (ALL) was conducted. METHODS AND MATERIALS: Eighteen of 344 pediatric patients with ALL who attained initial complete remission on the St. Jude Children's Research Hospital "Study XI" prospective protocol (1984-1988) developed a CNS relapse as first adverse event. Median interval to isolated CNS relapse was 7.5 months (range = 2-40 months) after achieving initial complete remission. At diagnosis, 14 of the 18 children were categorized as "high risk" for subsequent leukemic relapse. Preventive cranial irradiation [PCI (18 Gy)] was delivered as planned to one of the 14 "high-risk" children. The other 13 "high-risk" patients experienced a CNS relapse during the first year of continuation therapy prior to week 52 of planned PCI. All four "low-risk" patients experienced a CNS relapse beyond the first year of continuation therapy; none were scheduled to receive PCI. Following isolated CNS relapse, all 18 patients were treated on a prospective contingency of "Study XI" trial consisting of intensified reinduction chemotherapy, weekly intrathecal methotrexate/hydrocortisone/Ara-C x 4-6 injections, craniospinal irradiation (cranium to 24.0 Gy and spine to 15.0 Gy at 1.5 Gy/fraction) and maintenance systemic therapy for a minimum of 1 year. RESULTS: Ten of 18 patients remain in continuous complete secondary remission at 17 to 50 months post-CNS relapse. Second sites of relapse in the remaining eight children were as follows: CNS in four, bone marrow in three, and bilateral testicular in one patient. Each of these eight patients died of progressive leukemia. At a median followup of 40 months post-initial CNS relapse, the 3-year secondary Kaplan-Meier survival and event-free survival are 72% and 56%, respectively. Minimal long-term neurotoxicity was associated with the treatment regimen. The most important prognostic factors predicting continuous secondary remission included white blood cell count at diagnosis (p = 0.05), and duration of initial remission (p = 0.04). CONCLUSION: This trial demonstrates that more than one-half of patients may be successfully salvaged with intensified chemotherapy and craniospinal irradiation without significant morbidity following an isolated CNS relapse, despite previous multiagent chemotherapy though virtually no prior PCI in childhood ALL.

Adolescent↗

PubMed1995

A prospective neurocognitive evaluation of children treated with additional chemotherapy and craniospinal irradiation following isolated central nervous system relapse in acute lymphoblastic leukemia.

PURPOSE: A prospective assessment of neurocognitive performance was conducted in children with acute lymphoblastic leukemia (ALL) following isolated central nervous system (CNS) relapse to evaluate the impact of additional systemic/intrathecal (IT) chemotherapy and craniospinal irradiation (CSI) upon long-term intellectual function. METHODS AND MATERIALS: Twenty-one children with ALL manifesting an isolated CNS relapse between 1984 through 1989 underwent serial evaluations of intellectual function. Neurocognitive function was measured by the full-scale intelligence quotient (FSIQ) as determined by the age-appropriate Wechsler Intelligence Scale and by achievement in reading, math, and spelling as assessed by the Wide Range Achievement Test (WRAT). Intelligence testing was initiated following isolated CNS relapse after clearance of cerebrospinal fluid (CSF) cytology but prior to CSI and continued at annual intervals for a minimum of 4 years postmeningeal failure. Protocol treatment for isolated CNS relapse consisted of reinduction and maintenance systemic therapy, intrathecal (IT) triple-agent chemotherapy, and early CSI (cranium to 24 Gy and spine to 15 Gy at 1.5 Gy/fraction) as outlined on the institutional "Total XI" trial. RESULTS: All 21 children attained secondary CNS remission and underwent the planned additional systemic/IT chemotherapy and CSI. Fourteen of the 21 children remain in secondary continuous remission, while the remaining 7 experienced a second relapse and were removed from further neurocognitive assessment. For the eight female and six male long-term survivors, mean ages at original diagnosis and at CSI were 5.7 years (range = 0.6-16.2) and 7.0 years (range = 1.8-17.0), respectively. At a median follow-up interval of 4.6 years (ranges 1.7-6.8) post-CNS relapse, comparison of group mean initial to final FSIQs revealed no statistically significant difference between the two measures (94.5 vs. 95.9, respectively, n = 11, p = 0.52). None of the children are functioning in the mentally retarded range. Final FSIQ outcome directly correlated with initial FSIQ (p = 0.00005, n = 11), age at diagnosis (p = 0.009, n = 14), and age at CSI (p = 0.011, n = 14). In addition, change between initial and final FSIQ scores inversely correlated with age at diagnosis (p = 0.009) and age at CSI (p = 0.018) but not with baseline IQ score (p = 0.41). Initial FSIQ scores were not influenced by either age at diagnosis (p = 0.12) or age at CSI (p = 0.14). Final group mean (range) WRAT scores in reading, math, and spelling were measured to be 94.7 (68-132), 95.6 (69-126), and 93.7 (77-122), respectively (n = 13). Final reading and math scores directly correlated with both age at diagnosis (p = 0.01) and age at CSI (p = 0.009). Spelling outcome did not correlate with either age at diagnosis (p = 0.25) or age at CSI (p = 0.24). Nine children are placed in regular classrooms, while the remaining five require a mixed classroom environment. CONCLUSION: In our study, children with ALL experiencing an isolated CNS relapse tolerated additional systemic/IT chemotherapy and CSI without apparent deterioration of group serial intellectual scores. However, longitudinal analyses of group intellectual measures obscured the independent impact of initial FSIQ, age at original diagnosis, and age at CSI upon individual neurocognitive outcome. Early and more intensive psychoeducational stimulation may be needed in very young children presenting with low initial FSIQ scores who are treated with CSI and additional chemotherapy following isolated CNS relapse in ALL.

Adolescent↗

PubMed1995

Health-related behaviors of survivors of childhood cancer.

The health-related beliefs and behaviors of long-term survivors of childhood cancer are important because of vulnerability to adverse late effects from their primary malignancy and its therapy. A health behavior survey was completed by 110 parents of long-term survivors ranging in age from 11-17 years, and by 40 adult long-term survivors of childhood cancer ranging in age from 18-29 years. The survey included questions on the former patient's frequency of alcohol and tobacco use, as well as diet, exercise, sleep, dental, and seatbelt habits. The reported prevalence of tobacco and alcohol use was less than 10% among those less than 18 years old. Among the adults, tobacco (17.5%) and alcohol (72.5%) use was greater, but problem drinking was infrequently reported. In order to assess their perceived vulnerability, we asked the parents and the young adult patients to rate the strength of their belief that it is more important for the patient to keep healthy compared to most other children or young adults. Contrary to our expectation, demographic factors such as the patient's gender, socioeconomic level, or time elapsed since completion of therapy exerted minimal influence on their responses. Over 80% of parents and 60% of young adult survivors believed that it was more important for the former patient to remain healthy compared to most other people. However, this shared belief in increased vulnerability was inconsistently expressed in the patient's health behaviors. These results suggest that specific changes are needed in the health assessment and education of long-term survivors of childhood cancer.

Adolescent↗

PubMed1995

Nutritional and treatment-related characteristics of pediatric oncology patients referred or not referred for nutritional support.

Nutritional problems often result from malignancies and aggressive multimodal treatment. Early identification of reliable risk factors associated with malnutrition and need for nutritional support is necessary for development of preventative approaches. Nutritional and treatment-related characteristics were examined for 173 pediatric oncology patients referred for nutritional support and a comparison sample of 43 patients matched on treatment protocol and/or diagnosis who had never been referred for nutritional support. Abnormally low serum albumin levels, poor oral intake, mucositis, prior radiation therapy, and increased gastrointestinal toxicity were significantly more frequent among referred than non-referred patients. A discriminant function analysis indicated that poor oral intake was the single best predictor of need for nutritional support. Patients with solid tumors were more nutritionally depleted at the time of referral; all bone marrow transplant patients received nutritional support. Patients with central nervous system (CNS) tumors required nutritional support for longer time periods. We conclude that routine documentation of poor oral intake (i.e., observation of change in a child's eating patterns) is the most reliable indicator of children who eventually require nutritional support and who may benefit from interventions that could delay or prevent nutritional problems. Prophylactic interventions should be tailored to meet the specific needs of individual diagnostic groups.

Adolescent↗

PubMed1995

Chemotherapy-induced nausea and emesis in pediatric cancer patients: an analysis of coping strategies.

We investigated the preference and perceived efficacy of coping strategies used to manage chemotherapy-induced nausea and emesis in 57 pediatric oncology patients. Over 85% of children preferred "Wishful Thinking," "Emotional Regulation," and "Distraction" to cope with nausea, and "Emotional Regulation" to manage emesis. Stepwise logistic regression analyses revealed that the coping strategy used and its perceived efficacy depended upon patient age and gender, severity of symptom distress, time elapsed from last chemotherapy, experience, and whether nausea or emesis was the identified problem. Successful copers, defined as those reporting high coping efficacy and minimal distress, composed only 25% of the sample. These children most often used "Problem Solving" combined with "Social Support" for symptom management. Successful coping was also associated with lower emetogenic potential of chemotherapy. The significance of these results is discussed for identifying high-risk children who may benefit from coping interventions.

Adaptation, Psychological↗

PubMed1995

Sibling adaptation to childhood cancer collaborative study: siblings' perceptions of the cancer experience.

Investigated responses of siblings (N = 254) of children with cancer to structured interviews designed to elicit thoughts and feelings about effects of cancer on self and family. Siblings indicated distress about family separations and disruptions, lack of attention, focus of family on the ill child, negative feelings in themselves and family members, cancer treatments and their effects, and fear of death. Siblings also reported becoming more compassionate, families becoming closer, and having experiences they otherwise would not have had. Age and gender differences in responses indicated distinctive perceptions of and vulnerability to the cancer experience. Older siblings were far more likely to report positive effects than younger siblings suggesting that level of maturity can moderate the stress of an ill child within the family.

Adaptation, Psychological↗

PubMed1995

Avoidant coping in children with cancer.

Compared coping styles in children with cancer (n = 66) and a normative control group of healthy children (n = 414), using a newly designed instrument, the Children's Behavioral Style Scale (CBSS). We hypothesized that children in the oncology group would make greater use of an avoidant coping style (blunting) than controls. Results confirmed the primary hypothesis; children with cancer endorsed greater use of blunting or avoidant coping than did healthy children. A new conceptual model of coping style was introduced utilizing CBSS scores to identify children as Monitors, Blunters, Active, or Passive copers. Using this model, a similar proportion of Active and Passive copers were found in both groups, while the shift towards Blunting in the oncology group was accentuated. Within the oncology group, a positive relationship between Blunting scores and time elapsed since diagnosis was observed, suggesting that the increased Blunting in children with cancer is a reactive phenomenon, at least partly a response to the contingencies of cancer and its' treatment. These findings may provide an alternative interpretation to previous reports of increased defensiveness and repression in children with cancer.

Adaptation, Psychological↗

PubMed1995

Postoperative chemotherapy and delayed radiation in infants and very young children with choroid plexus carcinomas. The Pediatric Oncology Group.

Eight infants with choroid plexus carcinomas were treated with surgery, prolonged postoperative chemotherapy and delayed radiation. The results suggest that some infants with choroid plexus carcinomas can be successfully treated with multimodality therapy, even allowing children with less than a gross total resection to have prolonged disease-free intervals.

Antineoplastic Combined Chemotherapy Protocols↗

PubMed1995

An intensive re-treatment protocol for children with an isolated CNS relapse of acute lymphoblastic leukemia.

PURPOSE: To assess the salvage rate and long-term complications among children treated with an intensive regimen for isolated CNS relapse during first remission of acute lymphoblastic leukemia (ALL). PATIENTS AND METHODS: Twelve boys and eight girls, diagnosed at a median age of 4 years, had CNS relapse at a median age of 7 years. Five had CNS leukemia at presentation, while five completed treatment before relapse. First complete remission lasted a median of 22.5 months. Ten patients had received cranial irradiation plus intrathecal (IT) therapy, and the remainder had received high-dose intravenous and/or IT methotrexate (MTX) as CNS-directed treatment. Retrieval therapy consisted of a five-agent intensive reinduction regimen followed by continuation therapy with four rotating drug pairs. Triple-IT therapy was administered weekly for 4 to 5 weeks, then every 6 weeks until craniospinal radiation (cranium, 24 Gy; spine, 15 Gy; both sites, 1.5 Gy per fraction) was administered. RESULTS: All 20 children achieved a second complete remission. The 5-year estimate of disease-free survival (mean +/- SE) was 70% +/- 11%. Thirteen patients remain in remission at 71+ to 126+ months (median, 104+), and 10 of 13 patients tested have normal IQ scores. Four patients have had a second relapse (one CNS and three non-CNS), and three have developed other malignancies. Prior cranial irradiation was associated with subsequent failure; only three of 10 patients who previously received radiotherapy, compared with all of the other 10 patients, remained in second remission. CONCLUSION: This intensive retrieval therapy is effective and well tolerated by children with an isolated CNS relapse of ALL, especially those who have not received prior cranial irradiation. Most patients have no significant neuropsychologic impairment.

Adolescent↗

PubMed1995

Children's distress during magnetic resonance imaging procedures.

We investigated the epidemiology of pediatric anxiety and distress associated with magnetic resonance imaging procedures (MRIPs). Scores on the State-Trait Anxiety Inventory (Spielberger, Gorsuch, Lushene, Vagg, & Jacobs, 1983) and the State-Trait Anxiety Inventory for Children (Spielberger, Edwards, Lushene, Montuori, & Platzek, 1973), and subjective ratings of distress associated with MRIP were obtained from 55 pediatric oncology patients and their parents. Approximately 30% of children and their parents reported that MRIP produced significant distress. However, parents' ratings of their child's distress were significantly higher than children's self-ratings, and agreement between child and parent pairs was poor. Insertion of an intravenous line was identified as the most aversive component of MRIP by both parents (55%) and children (38%). The selective application of cognitive-behavioral interventions for noninvasive diagnostic procedures is suggested.

Adolescent↗