Publications by authors named "Zhaohua Lu"

64 Publications

Excellent Outcome for Pediatric Patients With High-Risk Hodgkin Lymphoma Treated With Brentuximab Vedotin and Risk-Adapted Residual Node Radiation.

J Clin Oncol 2021 Apr 7:JCO2003286. Epub 2021 Apr 7.

Department of Radiation Oncology, St Jude Children's Research Hospital, Memphis, TN.

Purpose: Brentuximab vedotin, an effective anti-CD30 antibody-drug conjugate approved for use in adults with classical Hodgkin lymphoma (HL), was introduced in this frontline trial to reduce prescribed radiation in children and adolescents with classical HL.

Methods: Open-label, single-arm, multicenter trial for patients (age ≤ 18 years) with stage IIB, IIIB, or IV classical HL was conducted. Brentuximab vedotin replaced each vincristine in the OEPA/COPDac (vincristine, etoposide, prednisone, and doxorubicin/cyclophosphamide, vincristine, prednisone, and dacarbazine) regimen according to GPOH-HD2002 treatment group 3 (TG3); two cycles of AEPA and four cycles of CAPDac. Residual node radiotherapy (25.5 Gy) was given at the end of all chemotherapy only to nodal sites that did not achieve a complete response (CR) at the early response assessment (ERA) after two cycles of therapy. Primary objectives were to evaluate the safety and efficacy (complete remission at ERA) of this combination and the 3-year event-free (EFS) and overall survival (OS). The trials are registered at ClinicalTrials.gov identifier: NCT01920932.

Results: Of the 77 patients enrolled in the study, 27 (35%) achieved complete remission at ERA and were spared radiation. Patients who were irradiated received radiation to individual residual nodal tissue. At a median follow-up of 3.4 years, the 3-year EFS was 97.4% (SE 2.3%) and the OS was 98.7% (SE 1.6%). One irradiated patient experienced disease progression at the end of therapy and now remains disease free more than 6 years following salvage therapy, and one unexpected death occurred. Only 4% of patients experienced grade 3 neuropathy.

Conclusion: The integration of brentuximab vedotin in the frontline treatment of pediatric high-risk HL is highly tolerable, facilitated significant reduction in radiation exposure, and yielded excellent outcomes.
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http://dx.doi.org/10.1200/JCO.20.03286DOI Listing
April 2021

Never Enough Time: Mixed Methods Study Identifies Drivers of Temporal Demand That Contribute to Burnout Among Physicians Who Care for Pediatric Hematology-Oncology Patients.

JCO Oncol Pract 2021 Mar 15:OP2000754. Epub 2021 Mar 15.

Office of Quality and Patient Care, St Jude Children's Research Hospital, Memphis, TN.

Purpose: Burnout is a syndrome of emotional exhaustion, depersonalization, and reduced personal accomplishment because of chronic occupational stress. Approximately one third of pediatric hematology-oncology physicians experience burnout. The goal of this mixed methods study was to determine the prevalence and drivers of burnout among physicians caring for pediatric hematology-oncology patients at our institution.

Materials And Methods: This mixed methods, cross-sectional study was conducted at a large academic cancer center. Validated survey instruments were used to measure burnout, job demands, experience with patient safety events, and workplace culture. Quantitative data informed development of a semistructured interview guide, and physicians were randomly selected to participate in individual interviews. Interviews were transcribed and analyzed via content analysis based on a priori codes.

Results: The survey was distributed to 132 physicians, and 53 complete responses were received (response rate 40%). Of the 53 respondents, 15 (28%) met criteria for burnout. Experiencing burnout was associated with increased temporal demand. Twenty-six interviews were conducted. Qualitative themes revealed that frequent meetings, insufficient support staff, and workflow interruptions were key drivers of temporal demand and that temporal demand contributed to burnout through emotional exhaustion and reduced personal accomplishment.

Conclusion: Nearly one-third of participating physicians met criteria for burnout, and burnout was associated with increased temporal demand. Qualitative interviews identified specific drivers of temporal demand and burnout, which can be targeted for intervention. This methodology can be easily adapted for broad use and may represent an effective strategy for identifying and mitigating institution-specific drivers of burnout.
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http://dx.doi.org/10.1200/OP.20.00754DOI Listing
March 2021

Hope-Colored Glasses: Perceptions of Prognosis Among Pediatric Oncology Patients and Their Parents.

JCO Oncol Pract 2021 Mar 4:OP2000762. Epub 2021 Mar 4.

Division of Quality of Life and Palliative Care, Department of Oncology, St Jude Children's Research Hospital, Memphis, TN.

Purpose: Cancer patients' belief about prognosis can heavily influence medical decision making and goals of care. It is known that parents of children with cancer tend to be optimistic regarding their child's prognosis; however, little is known about pediatric patients' prognostic beliefs, how physicians' prognostic communication is perceived, and how these perceptions are compared with actual prognoses.

Patients And Methods: An original survey was administered to 100 pediatric oncology patients, age 10-18 years, and their parents from 2013 to 2015, at St Jude Children's Research Hospital. Patients were eligible for inclusion if they had an oncologic diagnosis, were between 1 month and 1 year from diagnosis, and were English speaking. Survey responses regarding perceived prognosis were compared with actual prognoses as determined from the medical record review and published literature. Analysis included descriptive statistics and association tests.

Results: Nearly half of participants (patients = 48.9%, parents = 50.5%) displayed prognostic optimism as compared with the determined objective estimate of curative potential. The majority of both patients (78%) and parents (85%) reported belief in a very high chance of cure, although fewer reported that their physician communicated a very high chance for cure (patients = 57%, parents = 70%), and only 43% were determined to have a very high probability of cure. Significant differences were noted in prognostic optimism by cancer type ( < .0001); patients with solid tumor were more often optimistic (n = 25, 83.3% optimistic; n = 5, 16.7% accurate), and patients with lymphoma were most often accurate (n = 2, 8.7% optimistic; n = 21, 91.3% accurate).

Conclusion: Pediatric oncology patients and parents tend to be optimistic about their chance of cure, as compared to both perceived prognostic communication from physicians and objective estimated prognosis. Understanding the nature of prognostic optimism among patients with cancer and caregivers may empower clinicians to guide realistic decision making while supporting hope.
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http://dx.doi.org/10.1200/OP.20.00762DOI Listing
March 2021

Perianesthetic neurological adverse events in children: A review of the Wake-Up Safe Database.

Paediatr Anaesth 2021 May 4;31(5):594-603. Epub 2021 Mar 4.

Division of Anesthesiology, St. Jude Children's Research Hospital, Memphis, TN, USA.

Background: Perianesthetic neurological adverse events are rare in children and have been studied in detail in the settings of cardiac surgery and regional anesthesia. Our study aims to characterize perianesthetic neurological adverse events in children in the setting of all types of surgery and diagnostic or interventional procedures, to evaluate anesthesia's role, and to identify factors amenable to prevention.

Methods: We conducted a retrospective study by reviewing all the anesthetic encounters reported in the Wake-Up Safe database between January 2010 and December 2017.

Results: The rate of perianesthetic neurological adverse events was 0.49 per 10 000 pediatric anesthetic encounters. The odds of NAE were significantly higher in children who were older than 6 months; had American Society of Anesthesiologists physical status (ASA PS) of 3, 4, or 5; or had American Society of Anesthesiologists Emergency (ASA E) status. Seizures were the most common NAE. Overall, 23 (18.1%) children with neurological adverse events died, and 33 (26%) experienced permanent or severe permanent harm. The risk of death was higher in infants and in children with ASA PS of 3, 4, or 5; ASA E status; preexisting neurological abnormality; or preexisting neurological deficit and in events associated with cardiac arrest or trauma. Anesthesia contributed to 24 (18.9%) events; patient disease was the primary causative factor in 95 (74.8%) adverse events, and 37 (29.1%) events were preventable, including 2 deaths. Preventable factors broadly included inadequate preoptimization, complications during airway management and central venous catheter placement, and suboptimal patient positioning.

Conclusion: Perianesthetic neurological adverse events are rare in children and have a poor outcome. Our study has described pediatric perianesthetic neurological injury in detail and identified contributing factors that can be optimized during various phases of perianesthetic care. This information can be utilized during the informed consent process and to enhance the quality of care in children receiving anesthesia.
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http://dx.doi.org/10.1111/pan.14165DOI Listing
May 2021

Creating a cancer genomics curriculum for pediatric hematology-oncology fellows: A national needs assessment.

Cancer Med 2021 Mar 23;10(6):2026-2034. Epub 2021 Feb 23.

Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA.

Background: With the advent of next generation sequencing, tumor and germline genomic testing are increasingly being used in the management of pediatric cancer patients. Despite this increase in testing, many pediatric hematology-oncology (PHO) providers are not confident interpreting or utilizing tumor or germline genomic results to care for their patients.

Methods: We developed and delivered a needs assessment survey to PHO program directors, attendings, and fellows in the United States to understand this deficiency, gather data on existing cancer genomics educational initiatives, and query preferences for creating a future curriculum.

Results: The survey includes 31 (41%) of 74 invited PHO program directors, 110 (11%) of 1032 invited attendings, and 79 fellows. The majority of attending physicians and fellows responding to the survey agree that understanding tumor (95% attending physicians; 95% fellows) and germline (86% attending physicians; 94% fellows) genomic information is essential for their practice. However, only 9 of 31 (29%) responding programs report that they have an existing cancer genomics curriculum. Most program directors indicated that the ideal genomics curriculum would occur during the first year of fellowship and incorporate direct patient care, online modules, and problem-based learning. Attending physicians and fellows identified that addressing indications for ordering tumor and germline genomic testing, counseling about the risks and benefits of such testing, and interpreting and individualizing clinical management based on tumor and germline results should be included in a future curriculum.

Conclusion: The results of this study reveal a great need to develop a curriculum that can be offered across PHO fellowship programs to expand knowledge in the area of cancer genomics.
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http://dx.doi.org/10.1002/cam4.3787DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7957159PMC
March 2021

Clinical and organizational risk factors for mortality during deterioration events among pediatric oncology patients in Latin America: A multicenter prospective cohort.

Cancer 2021 Feb 1. Epub 2021 Feb 1.

Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, Tennessee.

Background: Hospitalized pediatric hematology-oncology (PHO) patients have frequent clinical deterioration events (CDE) requiring intensive care unit (ICU) admission, particularly in resource-limited settings. The objective of this study was to describe CDEs in hospitalized PHO patients in Latin America and to identify event-level and center-level risk factors for mortality.

Methods: In 2017, the authors implemented a prospective registry of CDEs, defined as unplanned transfers to a higher level of care, use of ICU-level interventions on the floor, or nonpalliative floor deaths, in 16 PHO centers in 10 countries. PHO hospital admissions and hospital inpatient days were also reported. This study analyzes the first year of registry data (June 2017 to May 2018).

Results: Among 16 centers, 553 CDEs were reported in PHO patients during 11,536 admissions and 119,414 inpatient days (4.63 per 1000 inpatient days). Event mortality was 29% (1.33 per 1000 inpatient days) but ranged widely across centers (11%-79% or 0.36-5.80 per 1000 inpatient days). Significant risk factors for event mortality included requiring any ICU-level intervention on the floor and not being transferred to a higher level of care. Events with organ dysfunction, a higher severity of illness, and a requirement for ICU intervention had higher mortality. In center-level analysis, hospitals with a higher volume of PHO patients, less floor use of ICU intervention, lower severity of illness on transfer, and lower rates of floor cardiopulmonary arrest had lower event mortality.

Conclusions: Hospitalized PHO patients who experience CDEs in resource-limited settings frequently require floor-based ICU interventions and have high mortality. Modifiable hospital practices around the escalation of care for these high-risk patients may contribute to poor outcomes. Earlier recognition of critical illness and timely ICU transfer may improve survival in hospitalized children with cancer.
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http://dx.doi.org/10.1002/cncr.33411DOI Listing
February 2021

17-DMAG dually inhibits Hsp90 and histone lysine demethylases in alveolar rhabdomyosarcoma.

iScience 2021 Jan 28;24(1):101996. Epub 2020 Dec 28.

Department of Surgery, St Jude Children's Research Hospital, 262 Danny Thomas Place, Memphis TN 38105, USA.

Histone lysine demethylases (KDMs) play critical roles in oncogenesis and therefore may be effective targets for anticancer therapy. Using a time-resolved fluorescence resonance energy transfer demethylation screen assay, in combination with multiple orthogonal validation approaches, we identified geldanamycin and its analog 17-DMAG as KDM inhibitors. In addition, we found that these Hsp90 inhibitors increase degradation of the alveolar rhabdomyosarcoma (aRMS) driver oncoprotein PAX3-FOXO1 and induce the repressive epigenetic mark H3K9me3 and H3K36me3 at genomic loci of PAX3-FOXO1 targets. We found that as monotherapy 17-DMAG significantly inhibits expression of PAX3-FOXO1 target genes and multiple oncogenic pathways, induces a muscle differentiation signature, delays tumor growth and extends survival in aRMS xenograft mouse models. The combination of 17-DMAG with conventional chemotherapy significantly enhances therapeutic efficacy, indicating that targeting KDM in combination with chemotherapy may serve as a therapeutic approach to PAX3-FOXO1-positive aRMS.
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http://dx.doi.org/10.1016/j.isci.2020.101996DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7811140PMC
January 2021

A Spelling Paradigm With an Added Red Dot Improved the P300 Speller System Performance.

Front Neuroinform 2020 3;14:589169. Epub 2020 Dec 3.

School of Computer Science and Technology, Changchun University of Science and Technology, Changchun, China.

The traditional P300 speller system uses the flashing row or column spelling paradigm. However, the classification accuracy and information transfer rate of the P300 speller are not adequate for real-world application. To improve the performance of the P300 speller, we devised a new spelling paradigm in which the flashing row or column of a virtual character matrix is covered by a translucent green circle with a red dot in either the upper or lower half (GC-RD spelling paradigm). We compared the event-related potential (ERP) waveforms with a control paradigm (GC spelling paradigm), in which the flashing row or column of a virtual character matrix was covered by a translucent green circle only. Our experimental results showed that the amplitude of P3a at the parietal area and P3b at the frontal-central-parietal areas evoked by the GC-RD paradigm were significantly greater than those induced by the GC paradigm. Higher classification accuracy and information transmission rates were also obtained in the GC-RD system. Our results indicated that the added red dots increased attention and visuospatial information, resulting in an amplitude increase in both P3a and P3b, thereby improving the performance of the P300 speller system.
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http://dx.doi.org/10.3389/fninf.2020.589169DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7744603PMC
December 2020

Total Hip Arthroplasty in Adolescents and Young Adults for Management of Advanced Corticosteroid-Induced Osteonecrosis Secondary to Treatment for Hematologic Malignancies.

J Arthroplasty 2021 Apr 19;36(4):1352-1360. Epub 2020 Oct 19.

Division of Orthopaedics, Department of Surgery, St. Jude Children's Research Hospital, Memphis, TN.

Background: Osteonecrosis of the femoral head (ONFH) is a potentially severe toxicity associated with glucocorticoid treatment for pediatric hematologic malignancy. We examined clinical outcomes of THA in adolescents and young adults treated for hematologic malignancies who developed advanced ONFH.

Methods: In a single-institution cohort, we retrospectively reviewed medical records and imaging for perioperative complications, reoperations, functional assessment at last follow-up, and radiological outcomes. Twenty-seven patients (41 hips) underwent THA (bilateral in 14 patients). There were 11 males. Median (interquartile range [IQR]) age at primary diagnosis was 14.9 years [1.8-18.9]. The median (IQR) age at THA was 19.8 years [14.6-30.3]. Mean (range) post-THA follow-up was 111.5 months (65.4-165.8).

Results: Perioperative complications included one intraoperative calcar fracture that was secured with a cerclage wire and one posterior hip dislocation that occurred 6 days postoperatively, requiring closed reduction. One hip required a revision 21.1 months post-THA due to a fractured ceramic liner. The radiographic review was available for 38 of 41 hips and demonstrated none with loosening, subsidence, or osteolysis; nine developed periacetabular stress shielding. Incidence of stress shielding was associated with increased postoperative pain (P = .0130). There was a significant functional improvement in range of motion (ROM), pain, use of supports, participation in school, work, and sports, and use of pain medication from preoperative to postoperative clinical visits (P < .001).

Discussion: Total hip arthroplasty in adolescents and young adults offers symptomatic and functional improvement in patients with ONFH. We found it to be safe with low perioperative complication rates even in patients undergoing active treatment for malignancy.

Level Of Evidence: Level IV, case series study. See Instructions for authors for a complete description of levels of evidence.
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http://dx.doi.org/10.1016/j.arth.2020.10.019DOI Listing
April 2021

Barriers to the early integration of palliative care in pediatric oncology in 11 Eurasian countries.

Cancer 2020 Nov 19;126(22):4984-4993. Epub 2020 Aug 19.

Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, Tennessee.

Background: The early integration of palliative care significantly improves quality of life for children with cancer. However, cultural, structural, and socioeconomic barriers can delay the integration of palliative care into cancer care, particularly in low-income and middle-income countries. To date, little is known regarding the timing of and barriers to palliative care integration in Eurasia.

Methods: The Assessing Doctors' Attitudes on Palliative Treatment (ADAPT) survey evaluates physician perceptions regarding palliative care integration into pediatric oncology in Eurasia. This evidence-based survey was adapted to the regional context; iteratively reviewed by US and regional panelists; and piloted in English, Russian, and Mongolian. After distribution to physicians caring for children with cancer, statistical analysis was complemented by qualitative analysis of open-ended responses.

Results: A total of 424 physician responses were received from 11 countries in the Eurasian region. Study findings demonstrated wide variability in access to palliative care experts across countries (18%-96%), with the majority of providers (64%) reporting that the initial palliative care consultation typically occurs when curative options are no longer available. Providers desired an earlier initial palliative care consultation than what currently occurs in their setting (P < .001). Primary barriers to timely consultation included limited access to palliative care services and specialists, lack of physician education, and perceived family resistance.

Conclusions: The current study is the first to identify physician perceptions of the delayed timing of palliative care integration into childhood cancer care and associated barriers in Eurasia. These findings will inform the development of targeted interventions to mitigate local structural and cultural barriers to access and facilitate earlier palliative care integration in the region.
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http://dx.doi.org/10.1002/cncr.33151DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7981844PMC
November 2020

Investigation of Modifiable Variables to Increase Hospice Nurse Comfort With Care Provision to Children and Families in the Community: A Population-Level Study Across Tennessee, Mississippi, and Arkansas.

J Pain Symptom Manage 2020 12 2;60(6):1144-1153. Epub 2020 Jul 2.

St. Jude Children's Research Hospital, Memphis, Tennessee, USA.

Context: Most hospice nurses across Tennessee, Arkansas, and Mississippi report significant discomfort with provision of pediatric palliative and hospice care (PPHC). How best to target and modify variables to increase nurse comfort levels is not well understood.

Objectives: To determine whether modifiable variables are associated with increased hospice nurse comfort with PPHC provision in the community.

Methods: A cross-sectional survey was developed, pilot tested, and distributed to hospice nurses across a tristate region to assess nurse training experiences and comfort with PPHC provision. Targeted subanalyses were conducted to investigate associations between nurse comfort level and clinical, training, and patient frequency variables.

Results: A total of 551 respondents representing 71 hospices across Tennessee, Arkansas, and Mississippi completed surveys. Hospice nurse comfort with provision of care to children was statistically significantly associated with exposure to prior PPHC clinical experiences (P < 0.001), receipt of formal pediatric PPHC training (P < 0.001), and higher hospice-level (P = 0.01) and individual-level frequency of PPHC provision (P < 0.001). PPHC clinical experience was the most impactful variable with respect to comfort with overall and end-of-life PPHC provision; formal training was the most impactful variable with respect to comfort with management of severe symptoms at the end of life.

Conclusion: Modifiable variables exist that are readily targetable to improve hospice nurse comfort with PPHC provision. These findings should inform the development and investigation of clinical and educational interventions to empower both nurses and hospices to optimize the provision of quality care to children with serious illness and their families in the community.
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http://dx.doi.org/10.1016/j.jpainsymman.2020.06.036DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7680295PMC
December 2020

Time-varying networks of ERPs in P300-speller paradigms based on spatially and semantically congruent audiovisual bimodality.

J Neural Eng 2020 07 24;17(4):046015. Epub 2020 Jul 24.

School of Computer Science and Technology, Changchun University of Science and Technology, Changchun 130022, People's Republic of China.

Objective: In the P300-speller paradigm using spatially and semantically congruent audiovisual (AV) stimuli, AV stimuli elicited significantly higher event-related potential (ERP) amplitudes than those for a single visual (V) stimulus. Nevertheless, it remains unclear whether ERPs in AV and V spelling paradigms are generated with identical brain network architecture.

Approach: In this study, we constructed time-varying networks for ERPs in AV and V spelling paradigms based on adaptive directed transfer function to investigate the dynamic processes underpinning the processing of stimuli in the two spelling paradigms.

Main Results: Our analysis revealed that early AV integration, AV spatial and semantic information, and late AV integration enhanced activation in attention-related areas between 40–160 ms, areas associated with attention to target stimuli between 200–280 ms, and areas associated with decision-making between 320–520 ms, respectively. Left temporal areas were associated with AV spatial-semantic information-processing and late AV integration, the activation of which impacted the activation of brain areas associated with attention (P3a) and decision-making (P3b). In addition, the ability and efficiency of information transmission from brain networks in the AV spelling paradigm were significantly stronger than those in the V spelling paradigm between 40 and 160 ms, 200 and 280 ms, and 320 and 520 ms.

Significance: This work provides a theoretical basis for deepening our understanding of the neural mechanisms underscoring ERPs production in the AV P300-speller paradigm as well as a theoretical reference for further optimization of the induced paradigm based on AV stimuli and improves the performance of BCI system.
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http://dx.doi.org/10.1088/1741-2552/aba07fDOI Listing
July 2020

A multicountry assessment in Eurasia: Alignment of physician perspectives on palliative care integration in pediatric oncology with World Health Organization guidelines.

Cancer 2020 Aug 12;126(16):3777-3787. Epub 2020 Jun 12.

Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, Tennessee.

Background: The World Health Organization (WHO) advocates for early integration of palliative care for all children with life-threatening illness. Provider awareness and misperceptions, however, can impede this imperative. In the Eurasian region, little is known about physician knowledge and perspectives on palliative care.

Methods: The Assessing Doctors' Attitudes on Palliative Treatment survey was developed as an evidence-based and culturally relevant assessment of physician perceptions on palliative care integration into childhood cancer care in Eurasia. Iteratively tested by American and Eurasian palliative care experts, the survey was culturally adapted, translated, and piloted in English, Russian, and Mongolian. The survey was distributed to physicians caring for children with cancer. Fifteen statements were scored in accordance with WHO guidelines to evaluate provider knowledge. The statistical analysis was complemented by a qualitative analysis of open-ended responses.

Results: This study received 424 responses from 11 countries in Eurasia. The mean alignment between provider perspectives and WHO recommendations was 70% (range, 7%-100%). Significant independent predictors of higher alignment included country, prior palliative care education, and greater experience with patient death. Respondents primarily described palliative care as end-of-life care and symptom management. Two-thirds of respondents (67%) reported not feeling confident about delivering at least 1 component of palliative care.

Conclusions: This is the first study assessing physician perspectives and knowledge of palliative care in Eurasia and reveals wide variability in alignment with WHO guidelines and limited confidence in providing palliative care. Study findings will inform targeted educational interventions, which must be tailored to the local political, economic, and cultural context.
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http://dx.doi.org/10.1002/cncr.33001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7385991PMC
August 2020

Predictors of narcolepsy and hypersomnia due to medical disorder in pediatric craniopharyngioma.

J Neurooncol 2020 Jun 28;148(2):307-316. Epub 2020 Apr 28.

Department of Psychology, St. Jude Children's Research Hospital, Memphis, TN, 38105, USA.

Purpose: Several studies describe sleep-wake disturbances in pediatric craniopharyngioma, but none have determined the prevalence or associated predictors of excessive sleepiness in this group after diagnosis and prior to post-operative observation or adjuvant radiotherapy. In this study, we report sleep-wake disturbances in children and adolescents with craniopharyngioma and associated clinical and treatment variables.

Methods: After surgery and prior to radiotherapy or observation, pediatric patients (n = 110) with craniopharyngioma ≥ 3 years old completed a baseline sleep clinic evaluation by a pediatric sleep specialist, polysomnography (PSG) and next-day multiple sleep latency test (MSLT). MSLT was limited to those ≥ 6 years old. Logistic regression models were used to determine the relationship between patient characteristics and the presence and type of hypersomnia.

Results: Amongst patients completing PSG and MSLT, 80% had polygraphic evidence of excessive daytime sleepiness. Hypersomnia due to medical condition was diagnosed in 45% and narcolepsy in 35%. Overweight or obese patients were more likely to be diagnosed with hypersomnia (P = 0.012) or narcolepsy (P = 0.009). Grade 2 hypothalamic involvement (HI) at diagnosis was associated with the diagnosis of narcolepsy (P = 0.0008).

Conclusions: This study describes the prevalence and associated predictors of hypersomnia for patients with craniopharyngioma after surgical resection. HI was predictive of narcolepsy diagnosis, and a higher body mass index z-score was associated with hypersomnia due to medical condition and narcolepsy. We recommend that sleep assessment and intervention begin after surgical resection, especially in overweight or obese patients and those with extensive tumors.
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http://dx.doi.org/10.1007/s11060-020-03519-3DOI Listing
June 2020

The Self-Face Paradigm Improves the Performance of the P300-Speller System.

Front Comput Neurosci 2019 15;13:93. Epub 2020 Jan 15.

School of Computer Science and Technology, Changchun University of Science and Technology, Changchun, China.

Previous studies have shown that the performance of the famous face P300-speller was better than that of the classical row/column flashing P300-speller. Furthermore, in some studies, the brain was more active when responding to one's own face than to a famous face, and a self-face stimulus elicited larger amplitude event-related potentials (ERPs) than did a famous face. Thus, we aimed to study the role of the self-face paradigm on further improving the performance of the P300-speller system with the famous face P300-speller paradigm as the control paradigm. We designed two facial P300-speller paradigms based on the self-face and a famous face (Ming Yao, a sports star; the famous face spelling paradigm) with a neutral expression. ERP amplitudes were significantly greater in the self-face than in the famous face spelling paradigm at the parietal area from 340 to 480 ms (P300), from 480 to 600 ms (P600f), and at the fronto-central area from 700 to 800 ms. Offline and online classification results showed that the self-face spelling paradigm accuracies were significantly higher than those of the famous face spelling paradigm at superposing first two times ( < 0.05). Similar results were found for information transfer rates ( < 0.05). The self-face spelling paradigm significantly improved the performance of the P300-speller system. This has significant practical applications for brain-computer interfaces (BCIs) and could avoid infringement issues caused by using images of other people's faces.
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http://dx.doi.org/10.3389/fncom.2019.00093DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6974691PMC
January 2020

Happy emotion cognition of bimodal audiovisual stimuli optimizes the performance of the P300 speller.

Brain Behav 2019 12 15;9(12):e01479. Epub 2019 Nov 15.

Department of Electrical and Computer Engineering, Florida International University, Miami, FL, USA.

Objective: Prior studies of emotional cognition have found that emotion-based bimodal face and voice stimuli can elicit larger event-related potential (ERP) amplitudes and enhance neural responses compared with visual-only emotional face stimuli. Recent studies on brain-computer interface have shown that emotional face stimuli have significantly improved the performance of the traditional P300 speller system, but its performance needs to be further improved for practical applications. Therefore, we herein propose a novel audiovisual P300 speller based on bimodal emotional cognition to further improve the performance of the P300 system.

Methods: The audiovisual P300 speller we proposed is based on happy emotions, with visual and auditory stimuli that consist of several pairs of smiling faces and audible chuckles (E-AV spelling paradigm) of different ages and sexes. The control paradigm was the visual-only emotional face P300 speller (E-V spelling paradigm).

Results: We compared the ERP amplitudes, accuracy, and raw bit rate between the E-AV and E-V spelling paradigms. The target stimuli elicited significantly increased P300 amplitudes (p < .05) and P600 amplitudes (p < .05) in the E-AV spelling paradigm compared with those in the E-V paradigm. The E-AV spelling paradigm also significantly improved the spelling accuracy and the raw bit rate compared with those in the E-V paradigm at one superposition (p < .05) and at two superpositions (p < .05).

Significance: The proposed emotion-based audiovisual spelling paradigm not only significantly improves the performance of the P300 speller, but also provides a basis for the development of various bimodal P300 speller systems, which is a step forward in the clinical application of brain-computer interfaces.
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http://dx.doi.org/10.1002/brb3.1479DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6908870PMC
December 2019

Complications Following Nephron-Sparing Surgery for Wilms Tumor.

J Pediatr Surg 2020 Jan 26;55(1):126-129. Epub 2019 Oct 26.

Department of Surgery, St. Jude Children's Research Hospital, Memphis, TN; Division of Pediatric Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, TN. Electronic address:

Purpose: Because of the increasing use of nephron-sparing surgery (NSS) in bilateral Wilms tumor, we sought to review the early postoperative complications associated with NSS.

Methods: A retrospective review of patients who underwent NSS at our institution from 2000 to 2017 was performed. For comparison, a cohort of patients who underwent radical nephrectomy (RN) was also reviewed. Early (30-day) postoperative complications and oncologic outcomes were assessed.

Results: Fifty-five patients underwent either bilateral (46) NSS or unilateral (9) NSS owing to prior resection or congenital solitary kidney. Fifty-four patients who underwent unilateral RN were also evaluated. Twenty NSS patients (36.4%) experienced 21 postoperative complications, including prolonged urine leak (9), infection (8), transient renal insufficiency (1), and intussusception (3). Seven RN patients (13.0%) experienced surgical complications, including infection (4) and intussusception (3). Average intraoperative blood loss was significantly greater in NSS as compared to RN (483.51 ± 337.92 mL and 278.15 mL ± 390.25, respectively, p < 0.001), as was the incidence of positive tumor resection margins (20 [36.4%] and 12 [22.2%], respectively, (p = 0.037).

Conclusions: In our experience, prolonged urine leak, intraoperative blood loss, and positive margins were more frequent in patients undergoing NSS as compared to RN. However, the complications were successfully managed, suggesting that an aggressive approach to NSS in patients with bilateral Wilms tumor is safe and appropriate.

Level Of Evidence: Level III TYPE OF STUDY: Treatment study.
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http://dx.doi.org/10.1016/j.jpedsurg.2019.09.066DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6989361PMC
January 2020

Impact of MYCN status on response of high-risk neuroblastoma to neoadjuvant chemotherapy.

J Pediatr Surg 2020 Jan 25;55(1):130-134. Epub 2019 Oct 25.

Department of Surgery, St. Jude Children's Research Hospital, Memphis, TN; Division of Pediatric Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, TN. Electronic address:

Background/purpose: MYCN-amplification in neuroblastoma is associated with an aggressive clinical phenotype. We evaluated the association of MYCN amplification with tumor response to neoadjuvant chemotherapy.

Methods: Primary tumor response, assessed by percentage volume change on CT scan and degree of tumor resection, assessed by the operating surgeon, were retrospectively compared in 84 high-risk neuroblastoma patients. There were thirty-four (40%) with MYCN-amplified tumors and fifty (60%) with non-amplified tumors treated at our institution from 1999 to 2016. Metastatic disease response was assessed on MIBG scan by change in Curie score.

Results: MYCN-amplification was associated with a greater mean percentage reduction in primary tumor volume after neoadjuvant chemotherapy (72.27% versus 46.83% [non-amplified tumors], p = 0.001). The percentage of patients with a Curie score > 2 at diagnosis who then had a score ≤ 2 after neoadjuvant chemotherapy was not significantly different (8 [61.5%] and 8 [34.8%], respectively, p = 0.37). Twenty-eight (85.7%) patients with MYCN-amplification had ≥90% surgical resection compared to 45 (91.84%) patients with non-amplified tumors (p = 0.303).

Conclusions: MYCN-amplification in high-risk neuroblastoma was associated with a better response of the primary tumor to neoadjuvant chemotherapy, but not metastatic sites, than in patients with non-amplified tumors. This did not significantly impact the ability to resect ≥90% of the primary tumor/locoregional disease.

Type Of Study: Treatment Study LEVEL OF EVIDENCE: Level III.
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http://dx.doi.org/10.1016/j.jpedsurg.2019.09.067DOI Listing
January 2020

A Novel Audiovisual P300-Speller Paradigm Based on Cross-Modal Spatial and Semantic Congruence.

Front Neurosci 2019 27;13:1040. Epub 2019 Sep 27.

Department of Electrical and Computer Engineering, Florida International University, Miami, FL, United States.

Objective: Although many studies have attempted to improve the performance of the visual-based P300-speller system, its performance is still not satisfactory. The current system has limitations for patients with neurodegenerative diseases, in which muscular control of the eyes may be impaired or deteriorate over time. Some studies have shown that the audiovisual stimuli with spatial and semantic congruence elicited larger event-related potential (ERP) amplitudes than do unimodal visual stimuli. Therefore, this study proposed a novel multisensory P300-speller based on audiovisual spatial and semantic congruence.

Methods: We designed a novel audiovisual P300-speller paradigm (AV spelling paradigm) in which the pronunciation and visual presentation of characters were matched in spatial position and semantics. We analyzed the ERP waveforms elicited in the AV spelling paradigm and visual-based spelling paradigm (V spelling paradigm) and compared the classification accuracies between these two paradigms.

Results: ERP analysis revealed significant differences in ERP amplitudes between the two paradigms in the following areas (AV > V): the frontal area at 60-140 ms, frontal-central-parietal area at 360-460 ms, frontal area at 700-800 ms, right temporal area at 380-480 and 700-780 ms, and left temporal area at 500-780 ms. Offline classification results showed that the accuracies were significantly higher in the AV spelling paradigm than in the V spelling paradigm after superposing 1, 2, 5, 6, 9, and 10 times ( < 0.05), and there were trends toward improvement in the accuracies at superposing 3, 4, 7, and 8 times ( = 0.06). Similar results were found for information transfer rate between V and AV spelling paradigms at 1, 2, 5, 6, and 10 superposition times ( < 0.05).

Significance: The proposed audiovisual P300-speller paradigm significantly improved the classification accuracies compared with the visual-based P300-speller paradigm. Our novel paradigm combines spatial and semantic features of two sensory modalities, and the present findings provide valuable insights into the development of multimodal ERP-based BCI paradigms.
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http://dx.doi.org/10.3389/fnins.2019.01040DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6777004PMC
September 2019

Sensitivity and Specificity of the Modified Epworth Sleepiness Scale in Children With Craniopharyngioma.

J Clin Sleep Med 2019 10;15(10):1487-1493

Department of Pediatric Medicine, Division of Nursing Research, St. Jude Children's Research Hospital, Memphis, Tennessee.

Study Objectives: Children with craniopharyngioma are at risk for excessive daytime sleepiness (EDS). Multiple Sleep Latency Testing (MSLT) is the gold standard for objective evaluation of EDS; however, it is time and resource intensive. We compared the reliability, sensitivity, and specificity of the modified Epworth Sleepiness Scale (M-ESS) and MSLT in monitoring EDS in children with craniopharyngioma.

Methods: Seventy patients (ages 6 to 20 years) with craniopharyngioma completed the M-ESS and were evaluated by polysomnography and MSLT. Evaluations were made after surgery, if performed, and before proton therapy.

Results: MSLT revealed that 66 participants (81.8%) had EDS, as defined by a mean sleep latency (MSL) < 10 minutes, with only 28.8% reporting EDS on the M-ESS by using a cutoff score of 10. The M-ESS demonstrated adequate internal consistency and specificity (91.7%) but poor sensitivity (33.3%) with the established cutoff score of 10. A cutoff score of 6 improved the sensitivity to 64.8% but decreased the specificity to 66.7%.

Conclusions: Patients with craniopharyngioma are at high risk for EDS, as documented objectively on the MSLT, but they frequently do not recognize or accurately report their sleepiness. Future sleep studies should investigate whether specific items or alternative self- and parent-reported measures of sleepiness may have greater clinical utility in monitoring sleepiness in this population.
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http://dx.doi.org/10.5664/jcsm.7982DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6778340PMC
October 2019

Optimizing the Performance of the Visual P300-Speller Through Active Mental Tasks Based on Color Distinction and Modulation of Task Difficulty.

Front Hum Neurosci 2019 17;13:130. Epub 2019 Apr 17.

School of Computer Science and Technology, Changchun University of Science and Technology, Changchun, China.

: P300-speller is the most commonly used brain-computer interface (BCI) for providing a means of communication to patients with amyotrophic lateral sclerosis. However, the performance of the P300-speller BCI is still inadequate. We investigated whether the performance of P300-speller can be further improved by increasing the mental effort required of the user. : We designed two active mental tasks for a P300-speller based on a differently colored smiling cartoon-face paradigm. The tasks were based on color distinction, and their difficulty was modulated. One of the active mental tasks (DC task) required participants to focus on and distinguish the color of a target, while the other task (CN + DC task) required participants to simultaneously count the number of times a target flashed and distinguish its color. : The amplitudes of the event-related potentials (ERPs) in both DC and CN + DC tasks were higher than that in the CN task. The significant difference in the amplitudes between the DC and CN tasks was observed around the parietal-central area from 440 to 800 ms (late positive component, LPC), and that between the CN + DC and CN tasks was observed around the left-frontal and right-frontal areas from 320 to 480 ms (P3a) and the parietal-central area from 480 to 800 ms (P3b and LPC). The latency of the P300 potential in the CN + DC task was significantly longer than that in the CN task at F3, Fz, F4, C4, Pz, and P4 ( < 0.05). Offline ( < 0.05 at superposing once, twice, and thrice) and online ( < 0.001) classification results showed that the average accuracies in the CN + DC task were significantly greater than that in the CN task. Similar results were found for online information transfer rates (ITRs; < 0.001). In addition, we found that the average online accuracies in the DC task were greater than those in the CN task, although the difference was not statistically significant ( = 0.051). : The active mental task based on task difficulty modulation can significantly improve the performance of the P300-speller, and that based on color distinction shows a trend of improved performance.
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http://dx.doi.org/10.3389/fnhum.2019.00130DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6478661PMC
April 2019

Structured Genome-Wide Association Studies with Bayesian Hierarchical Variable Selection.

Genetics 2019 06 22;212(2):397-415. Epub 2019 Apr 22.

Department of Biostatistics, University of Florida, Gainesville, Florida 32611.

It becomes increasingly important in using genome-wide association studies (GWAS) to select important genetic information associated with qualitative or quantitative traits. Currently, the discovery of biological association among SNPs motivates various strategies to construct SNP-sets along the genome and to incorporate such set information into selection procedure for a higher selection power, while facilitating more biologically meaningful results. The aim of this paper is to propose a novel Bayesian framework for hierarchical variable selection at both SNP-set (group) level and SNP (within group) level. We overcome a key limitation of existing posterior updating scheme in most Bayesian variable selection methods by proposing a novel sampling scheme to explicitly accommodate the ultrahigh-dimensionality of genetic data. Specifically, by constructing an auxiliary variable selection model under SNP-set level, the new procedure utilizes the posterior samples of the auxiliary model to subsequently guide the posterior inference for the targeted hierarchical selection model. We apply the proposed method to a variety of simulation studies and show that our method is computationally efficient and achieves substantially better performance than competing approaches in both SNP-set and SNP selection. Applying the method to the Alzheimers Disease Neuroimaging Initiative (ADNI) data, we identify biologically meaningful genetic factors under several neuroimaging volumetric phenotypes. Our method is general and readily to be applied to a wide range of biomedical studies.
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http://dx.doi.org/10.1534/genetics.119.301906DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6553832PMC
June 2019

Speaking genomics to parents offered germline testing for cancer predisposition: Use of a 2-visit consent model.

Cancer 2019 07 22;125(14):2455-2464. Epub 2019 Mar 22.

Division of Cancer Predisposition, St. Jude Children's Research Hospital, Memphis, Tennessee.

Background: Patients with cancer are increasingly offered genomic sequencing, including germline testing for cancer predisposition or other disorders. Such testing is unfamiliar to patients and families, and clear communication is needed to introduce genomic concepts and convey risk and benefit information.

Methods: Parents of children with cancer were offered the opportunity to have their children's tumor and germline examined with clinical genomic sequencing. Families were introduced to the study with a 2-visit informed consent model. Baseline genetic knowledge and self-reported literacy/numeracy were collected before a study introduction visit, during which basic concepts related to genomic sequencing were discussed. Information was reinforced during a second visit, during which informed consent was obtained and a posttest was administered.

Results: As reflected by the percentage of correct answers on the pretest and posttest assessments, this model increased genetic knowledge by 11.1% (from 77.8% to 88.9%; P < .0001) in 121 parents participating in both the study introduction and consent visits. The percentage of parents correctly identifying the meaning of somatic and germline mutations increased significantly (from 18% to 59% [somatic] and from 31% to 64% [germline]; P < .0001). Nevertheless, these concepts remained unfamiliar to one-third of the parents. No relation was identified between the change in the overall percentage of correct answers and self-reported literacy, numeracy, or demographics.

Conclusions: The use of a 2-visit communication model improved knowledge of concepts relevant to genomic sequencing, particularly differences between somatic and germline testing; however, these areas remained confusing to many participants, and reinforcement may be necessary to achieve complete understanding.
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http://dx.doi.org/10.1002/cncr.32071DOI Listing
July 2019

Impact of Race and Ethnicity on End-of-Life Experiences for Children With Cancer.

Am J Hosp Palliat Care 2019 Sep 13;36(9):767-774. Epub 2019 Mar 13.

1 Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA.

Background: Racial and ethnic disparities in the provision of end-of-life care are well described in the adult oncology literature. However, the impact of racial and ethnic disparities at end of life in the context of pediatric oncology remains poorly understood.

Objective: To investigate associations between end-of-life experiences and race/ethnicity for pediatric patients with cancer.

Methods: A retrospective cohort study was conducted on 321 children with cancer enrolled on a palliative care service at an urban pediatric cancer who died between 2011 and 2015.

Results: Compared to white patients, black patients were more likely to receive cardiopulmonary resuscitation (CPR; odds ratio [OR]: 4.109, confidence interval [CI]: 1.432-11.790, = .009) and underwent 3.136 (CI: 1.433-6.869, = .004) CPR events for every 1 white patient CPR event. The remainder of variables related to treatment and end-of-life care were not significantly correlated with race. Hispanic patients were less likely to receive cancer-directed therapy within 28 days prior to death (OR: 0.493, CI: 0.247-0.982, = .044) as compared to non-Hispanic patients, yet they were more likely to report a goal of cure over comfort as compared to non-Hispanic patients (OR: 3.094, CI: 1.043-9.174, = .042). The remainder of variables were not found to be significantly correlated with ethnicity.

Conclusions: Race and ethnicity influenced select end-of-life variables for pediatric palliative oncology patients treated at a large urban pediatric cancer center. Further multicenter investigation is needed to ascertain the impact of racial/ethnic disparities on end-of-life experiences of children with cancer.
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http://dx.doi.org/10.1177/1049909119836939DOI Listing
September 2019

Are we meeting the informational needs of cancer patients and families? Perception of physician communication in pediatric oncology.

Cancer 2019 05 2;125(9):1518-1526. Epub 2019 Jan 2.

Division of Quality-of-life and Palliative Care, Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee.

Background: High-quality oncology care is marked by skillful communication, yet little is known about patient and family communication perceptions or content preferences. Our study sought to elicit pediatric oncology patient and parent perceptions of early cancer communication to establish whether informational needs were met and identify opportunities for enhanced communication throughout cancer care.

Method: An original survey instrument was developed, pretested, and administered to 129 patients, age 10-18 years, and their parents at 3 cancer centers between 2011 and 2015. Statistical analysis of survey items about perceived communication, related associations, and patient/parent concordance was performed.

Results: A greater percentage of participants reported "a lot" of discussion about the physical impact of cancer (patients, 58.1% [n = 75]; parents, 69.8% [n = 90]) compared with impact on quality of life (QOL) (patients, 44.2% [n = 57]; parents, 55.8% [n = 72]) or emotional impact (patients, 31.8% [n = 41]; parents, 43.4% [n = 56]). One fifth of patients (20.9% [n = 27]) reported they had no up-front discussion about the emotional impact of cancer treatment. Parents indicated a desire for increased discussion regarding impact on family life (27.9% [n = 36]), long-term QOL (27.9% [n = 36]), and daily activities (20.2% [n = 26]). Patients more frequently than parents indicated a desire for increased physician/patient discussion around the impact on daily activities (patients, 40.3% [n = 52]; parents, 21.7% [n = 28]; P < .001), long-term QOL (patients, 34.9% [n = 45]; parents, 16.3% [n = 21]; P < .001), pain management (patients, 23.3% [n = 30]; parents, 7% [n = 9]; P < .001), physical symptom management (patients, 24% [n = 31]; parents, 7.8% [n = 10]; P < .001), short-term QOL (patients, 23.3% [n = 30]; parents, 9.3% [n = 12]; P = .001), and curative potential (patients, 21.7% [n = 28]; parents, 8.5% [n = 11]; P = .002, P values calculated using McNemar's test).

Conclusion: Oncologists may not be meeting the informational needs of many patients and some parents/caregivers. Communication could be enhanced through increased direct physician-patient communication, as well as proactive discussion of emotional symptoms and impact of cancer on QOL.
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http://dx.doi.org/10.1002/cncr.31937DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6945977PMC
May 2019

Provision of Palliative and Hospice Care to Children in the Community: A Population Study of Hospice Nurses.

J Pain Symptom Manage 2019 02 1;57(2):241-250. Epub 2018 Nov 1.

St. Jude Children's Research Hospital, Memphis, Tennessee, USA.

Context: Approximately 500,000 children in the United States suffer from life-limiting illnesses each year, many of whom are hospice eligible each year. Few hospice agencies, however, offer formal pediatric programs.

Objective: To determine the levels of experience and comfort of hospice nurses who provide care to children and families in the community.

Methods: A cross-sectional survey was developed to assess hospice nurse experience/comfort across the domains of symptom management, end-of-life care, goals of care, family-centered care, and bereavement. The survey was pilot tested and distributed to hospice nurses across a tristate region.

Results: A total of 551 respondents across 71 hospices completed surveys. The majority of nurses reported no training in pediatric palliative or hospice care (89.8%), with approximately half reporting <5 years of hospice experience (53.7%) and no pediatric hospice experience (49.4%). Those with pediatric hospice experience reported limited opportunities to maintain or build their skills, with the majority providing care to children several times a year or less (85.7%). Nurses reported feeling somewhat or very uncomfortable providing services to children during the illness trajectory and at the end of life across all domains.

Conclusion: Children with serious illness who receive care from local hospices often interface with nurses who lack training, experience, and comfort in the provision of palliative and hospice care to pediatric patients. These findings should inform future development and investigation of educational resources, training programs, and child- and family-centered policies to improve the delivery of palliative and hospice care to children in the community.
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http://dx.doi.org/10.1016/j.jpainsymman.2018.10.509DOI Listing
February 2019

Incorporating Bereaved Parents as Faculty Facilitators and Educators in Teaching Principles of Palliative and End-of-Life Care.

Am J Hosp Palliat Care 2018 Dec 16;35(12):1518-1525. Epub 2018 Jul 16.

2 Division of Quality of Life and Palliative Care, Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA.

Background:: Education and training for interdisciplinary pediatric providers requires training in principles of palliative and end-of-life (EOL) care. The experiences of bereaved parents can inform and enhance palliative care educational curricula in uniquely powerful and valuable ways. The objective of this study is to present an innovative palliative care educational program facilitated by trained bereaved parents who serve as volunteer educators in local and national palliative care educational forums and to describe how incorporation of bereaved parents in these educational forums affects participant comfort with communication and management of children at the EOL.

Methods:: Parent educators underwent both general and session-specific training and participated in debriefings following each session. Survey tools were developed or adapted to determine how bereaved parent educators affected participant experiences in 3 different educational forums. Pre- and postsession surveys with incorporation of retrospective preprogram assessment items to control for response shift were used in the evaluation of institutional seminars on pediatric palliative and EOL care and role-play-based communication training sessions. Results from feedback surveys sent to attendees were used to appraise the participants' experience at the international oncology symposium.

Results:: Involvement of trained parent educators across diverse, interdisciplinary educational forums improved attendee comfort in communicating with, and caring for, patients and families with serious illness. Importantly, parent educators also derive benefit from involvement in educational sessions with interdisciplinary clinicians.

Conclusions:: Integration of bereaved parents into palliative and EOL care education is an innovative and effective model that benefits both interdisciplinary clinicians and bereaved parents.
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http://dx.doi.org/10.1177/1049909118786875DOI Listing
December 2018

Clinical Characteristics of Children and Adolescents Undergoing Hematopoietic Cell Transplantation Who Develop Oral Mucositis.

Oncol Nurs Forum 2018 07;45(4):457-462

St. Jude Children's Research Hospital.

Objectives: To describe the clinical characteristics of children and adolescents undergoing hematopoietic cell transplantation (HCT) who develop oral mucositis.

Sample & Setting: 45 patients who underwent HCT from July 2015 to May 2016 at St. Jude Children's Research Hospital in Memphis, Tennessee.

Methods & Variables: Clinical factors were described as transplantation type, mucositis severity or grade, mucositis duration, days to engraftment, total parenteral nutrition (TPN) support, IV opioid pain management use during mucositis, positive blood or oral cultures, and length of hospitalization, then compared across mucositis grade.

Results: 24 patients had grade 3 or greater mucositis onset from day -3 to day 9 of transplantation; of these, 23 required IV opioid medication to treat mucosal pain. Patients with mucositis grade 3 or greater were more likely to have undergone an allogeneic transplantation, receive TPN, have documented positive blood or oral cultures, and have longer hospitalizations than those with low-grade mucositis.

Implications For Nursing: Nurses are in a unique position to propose and administer interventions to prevent and alleviate symptoms of mucositis.
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http://dx.doi.org/10.1188/18.ONF.457-462DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6152915PMC
July 2018

Predictors of Location of Death for Children with Cancer Enrolled on a Palliative Care Service.

Oncologist 2018 12 4;23(12):1525-1532. Epub 2018 May 4.

St. Jude Children's Research Hospital, Memphis, Tennessee, USA.

Background: In the U.S., more children die from cancer than from any other disease, and more than one third die in the hospital setting. These data have been replicated even in subpopulations of children with cancer enrolled on a palliative care service. Children with cancer who die in high-acuity inpatient settings often experience suffering at the end of life, with increased psychosocial morbidities seen in their bereaved parents. Strategies to preemptively identify children with cancer who are more likely to die in high-acuity inpatient settings have not been explored.

Materials And Methods: A standardized tool was used to gather demographic, disease, treatment, and end-of-life variables for 321 pediatric palliative oncology (PPO) patients treated at an academic pediatric cancer center who died between 2011 and 2015. Multinomial logistic regression was used to predict patient subgroups at increased risk for pediatric intensive care unit (PICU) death.

Results: Higher odds of dying in the PICU were found in patients with Hispanic ethnicity (odds ratio [OR], 4.02;  = .002), hematologic malignancy (OR, 7.42;  < .0001), history of hematopoietic stem cell transplant (OR, 4.52;  < .0001), total number of PICU hospitalizations (OR, 1.98;  < .0001), receipt of cancer-directed therapy during the last month of life (OR, 2.96;  = .002), and palliative care involvement occurring less than 30 days before death (OR, 4.7;  < .0001). Conversely, lower odds of dying in the PICU were found in patients with hospice involvement (OR, 0.02;  < .0001) and documentation of advance directives at the time of death (OR, 0.37;  = .033).

Conclusion: Certain variables may predict PICU death for PPO patients, including delayed palliative care involvement. Preemptive identification of patients at risk for PICU death affords opportunities to study the effects of earlier palliative care integration and increased discussions around preferred location of death on end-of-life outcomes for children with cancer and their families.

Implications For Practice: Children with cancer who die in high-acuity inpatient settings often experience a high burden of intensive therapy at the end of life. Strategies to identify patients at higher risk of dying in the pediatric intensive care unit (PICU) have not been explored previously. This study finds that certain variables may predict PICU death for pediatric palliative oncology patients, including delayed palliative care involvement. Preemptive identification of patients at risk for PICU death affords opportunities to study the effects of earlier palliative care integration and increased discussions around preferred location of death on end-of-life outcomes for children with cancer and their families.
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http://dx.doi.org/10.1634/theoncologist.2017-0650DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6292533PMC
December 2018

Predictors of Late Palliative Care Referral in Children With Cancer.

J Pain Symptom Manage 2018 06 8;55(6):1550-1556. Epub 2018 Feb 8.

St. Jude Children's Research Hospital, Memphis, Tennessee, USA.

Context: Early integration of palliative care (PC) in the management of children with high-risk cancer is widely endorsed by patients, families, clinicians, and national organizations. However, optimal timing for PC consultation is not standardized, and variables that influence timing of PC integration for children with cancer remain unknown.

Objectives: To investigate associations between demographic, disease, treatment, and end-of-life attributes and timing of PC consultation for children with high-risk cancer enrolled on a PC service.

Methods: A comprehensive standardized tool was used to abstract data from the medical records of 321 patients treated at a large academic pediatric cancer center, who died between 2011 and 2015.

Results: Gender, race, ethnicity, enrollment on a Phase I protocol, number of high-acuity hospitalizations, and receipt of cardiopulmonary resuscitation were not associated with timing of PC involvement. Patients with hematologic malignancy, those who received cancer-directed therapy during the last month of life, and those with advance directives documented one week or less before death had higher odds of late PC referral (malignancy: odds ratio [OR] 3.24, P = 0.001; therapy: OR 4.65, P < 0.001; directive: OR 4.81, P < 0.0001). Patients who received hospice services had lower odds of late PC referral <30 days before death (OR 0.31, P < 0.001).

Conclusion: Hematologic malignancy, cancer-directed therapy at the end of life, and delayed documentation of advance directives are associated with late PC involvement in children who died of cancer. Identification of these variables affords opportunities to study targeted interventions to enhance access to earlier PC resources and services for children with high-risk cancer and their families.
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http://dx.doi.org/10.1016/j.jpainsymman.2018.01.021DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6223026PMC
June 2018