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1.  An Observational Study on the Obesity and Metabolic Status of Psoriasis Patients 
Annals of Dermatology  2013;25(4):440-444.
Background
Recent studies have suggested that obesity, hyperlipidemia, ischemic heart diseases, metabolic syndrome and hypertension can combine with psoriasis. However, the metabolic comorbidities have not been clearly demonstrated in Korean psoriasis patients.
Objective
The purpose of this study was to analyze the association between psoriasis and metabolic abnormalities including obesity, glucose intolerance, hypertension and dyslipidemia in our center. Treatment response of cyclosporine between a high body mass index (BMI) group and normal BMI group was also analyzed to investigate how obesity may affect psoriasis treatment.
Methods
A retrospective observational study was made on the obesity and metabolic status of psoriasis patients versus normal control group through electronic medical records from January 2008 to April 2009 at Department of Dermatology, Samsung Medical Center, (Seoul, Korea). Medical records, demographics and the Psoriasis Area and Severity Index score before and after cyclosporine treatment were analyzed.
Results
There were no significant differences in the metabolic status between normal control and psoriasis patients. Also, there was no significant difference in the treatment response between high BMI group and normal BMI group, after 4 weeks and 8 weeks of cyclosporine treatment.
Conclusion
Our study suggests that in Korean patients, an association between psoriasis and metabolic abnormalities is not obvious. This may reflect a different severity of obesity and metabolic abnormalities between Western and Asian populations.
doi:10.5021/ad.2013.25.4.440
PMCID: PMC3870212  PMID: 24371391
Metabolic syndrome; Obesity; Psoriasis
2.  Time to establish multidisciplinary childhood cancer survivorship programs in Korea 
Improved treatment strategies and better supportive care have resulted in increased survival rates for childhood cancers. However, most of the survivors may have complex, long-term health issues. In 2004, Childhood Cancer Survivorship Study of the United States confirmed that both survivors and the medical community need to be educated about the late effects of childhood cancer treatment. Korea, with an estimated number of childhood cancer survivors of 20,000 to 25,000, faces similar challenges that the United States had experienced earlier. Despite of the tight budgetary situation on the part of government and hospitals, nationwide cohort study for Korean childhood cancer survivors was proposed and the versions of instruments to measure the quality of life of childhood cancer survivors were already validated. Nationwide registry of long-term survivors as well as the multi-center study is to be developed not only for the care of the survivors but also to raise the patient's awareness of the importance of regular follow-up. In addition to education of primary care providers regarding the survivorship, the need for special education program in the school system is emphasized.
doi:10.5045/kjh.2010.45.2.84
PMCID: PMC2983029  PMID: 21120183
3.  Oxaliplatin-Induced Chronic Peripheral Neurotoxicity: A Prospective Analysis in Patients with Colorectal Cancer 
Purpose
Oxaliplatin-induced chronic peripheral neurotoxicity (OXCPN) manifests as a loss of sensation and dysesthesia in the distal extremities, which may impair daily activities and increase in incidence with the amount of oxaliplatin delivered. The variation in the reported incidence and severity of OXCPN may be a consequence of differences in the baseline characteristics of patients.
Materials and Methods
This was a prospective study (ClinicalTrials.gov, NCT00977717) in which OXCPN was recorded for all consecutive colon cancer patients treated at Samsung Medical Center (Seoul, Korea) with oxaliplatin-based combination chemotherapy. The primary endpoint was the incidence of severe OXCPN (grade 2 lasting for >7 days, or grade 3). The association of severe OXCPN and pretreatment parameters was evaluated using a multivariate regression model.
Results
Between Jan 2008 and Feb 2010, 100 patients treated with adjuvant folinic acid/fluorouracil plus oxaliplatin (FOLFOX) and 266 patients treated with capecitabine plus oxaliplatin (XELOX) or FOLFOX for advanced disease were registered into our study. The median cumulative dose of oxaliplatin was 796 mg/m2 (range, 85 to 1,583 mg/m2). Severe OXCPN was observed in 126 (34%) patients. Overall, 43 patients discontinued chemotherapy due to toxicity: 23 without severe OXCPN and 20 with severe OXCPN. In univariate analysis, severe OXCPN was frequently observed in patients with age ≥55 years (p<0.01), stage II or III (p<0.01), adjuvant setting (p=0.01), FOLFOX (p<0.01), performance status of 0 (p=0.02), and those with no prior chemotherapy (p<0.01). In a multivariate regression model, the number of chemotherapy cycles and the cumulative oxaliplatin dose were not associated with the development of severe OXCPN.
Conclusion
We failed to find a significant association between patient characteristics at baseline and the development of severe OXCPN after oxaliplatin-based combination chemotherapy. Pharmacogenomic profiling using genome-wide association study in these patients is underway.
doi:10.4143/crt.2010.42.4.185
PMCID: PMC3021736  PMID: 21253319
Colorectal neoplasms; Oxaliplatin; Neurotoxicity
4.  Propofol Infusion Syndrome in Refractory Status Epilepticus 
Journal of Epilepsy Research  2013;3(1):21-27.
Background and Purpose:
Propofol is used for treating refractory status epilepticus, which has high rate of mortality. Propofol infusion syndrome is a rare but often fatal syndrome, characterized by lactic acidosis, lipidemia, and cardiac failure, associated with propofol infusion over prolonged periods of time. We investigated the clinical factors that characterize propofol infusion syndrome to know the risk of them in refractory status epilepticus.
Methods:
This retrospective observation study was conducted in Samsung medical center from Jan. 2005 to Dec. 2009. Thirty two patients (19 males, 13 females, aged between 16 and 64 years), with refractory status epilepsy were included. Their clinical findings and treatment outcomes were evaluated retrospectively. We divided our patients into established status epilepticus (ESE) and refractory status epilepticus (RSE). And then the patients with RSE was further subdivided into propofol treatment group (RSE-P) and the other anesthetics treatment group (RSE-O). We analyzed the clinical characteristics by comparison of the groups.
Results:
There were significant differences of hypotension and lipid change between ESE and RSE (p<0.05). However, there was no significant difference between RSE-P and RSE-O groups. The hospital days were longer in RSE than in ESE (p=0.012) and treatment outcome was also worse in RSE than in ESE (p=0.007) but there were no significant differences of hospital stays and treatment outcome between RSE-P and RSE-O.
Conclusions:
RSE is very critical disease with high mortality, which may show as many clinical changes as propofol infusion syndrome. Therefore propofol infusion syndrome might be considered as one of the clinical manifestations of RSE.
doi:10.14581/jer.13004
PMCID: PMC3957310  PMID: 24649467
Propofol infusion syndrome; Status Epilepticus; Anesthetics
5.  Relation between Obesity and Bone Mineral Density and Vertebral Fractures in Korean Postmenopausal Women 
Yonsei Medical Journal  2010;51(6):857-863.
Purpose
The traditional belief that obesity is protective against osteoporosis has been questioned. Recent epidemiologic studies show that body fat itself may be a risk factor for osteoporosis and bone fractures. Accumulating evidence suggests that metabolic syndrome and the individual components of metabolic syndrome such as hypertension, increased triglycerides, and reduced high-density lipoprotein cholesterol are also risk factors for low bone mineral density. Using a cross sectional study design, we evaluated the associations between obesity or metabolic syndrome and bone mineral density (BMD) or vertebral fracture.
Materials and Methods
A total of 907 postmenopausal healthy female subjects, aged 60-79 years, were recruited from woman hospitals in Seoul, South Korea. BMD, vetebral fracture, bone markers, and body composition including body weight, body mass index (BMI), percentage body fat, and waist circumference were measured.
Results
After adjusting for age, smoking status, alcohol consumption, total calcium intake, and total energy intake, waist circumference was negatively related to BMD of all sites (lumbar BMD p = 0.037, all sites of femur BMD p < 0.001) whereas body weight was still positively related to BMD of all sites (p < 0.001). Percentage body fat and waist circumference were much higher in the fracture group than the non-fracture group (p = 0.0383, 0.082 respectively). Serum glucose levels were postively correlated to lumbar BMD (p = 0.016), femoral neck BMD (p = 0.0335), and femoral trochanter BMD (p = 0.0082). Serum high density lipoprotein cholesterol (HDLC) was positively related to femoral trochanter BMD (p = 0.0366) and was lower in the control group than the fracture group (p = 0.011).
Conclusion
In contrast to the effect favorable body weight on bone mineral density, high percentage body fat and waist circumference are related to low BMD and a vertebral fracture. Some components of metabolic syndrome were related to BMD and a vertebral fracture.
doi:10.3349/ymj.2010.51.6.857
PMCID: PMC2995981  PMID: 20879051
Obesity; metabolic syndrome; bone mineral density; vertebral fracture
6.  Neurocognitive functioning and health-related behaviors in adult survivors of childhood cancer: A report from the Childhood Cancer Survivor Study 
SUMMARY
Background
Positive health-related behaviors are essential for the future wellbeing of childhood cancer survivors, though relatively few maintain healthy behaviors into adulthood.
Methods
Neurocognitive function and emotional distress were examined in 6,440 adult survivors from the Childhood Cancer Survivor Study, and used to predict rates of expected health-related behaviors. Covariates included cancer diagnosis, age, sex, body mass index, insurance status, income, and antidepressant medication use, and multivariable models were constructed adjusting for these factors.
Findings
In multivariable regression models, survivors with neurocognitive problems in task efficiency (RR=0.77, 95% CI=0.72–0.84) were less likely to meet the Centers for Disease Control guidelines for weekly physical activity. Survivors with neurocognitive impairment were more likely to engage in general survivor care (RR=1.20, 95% CI=1.10–1.30), and less likely to engage in dental care (RR=0.92, 95% CI=0.88–0.97). Obese survivors were less likely to report receiving a bone density exam (RR=0.67, 95% CI=0.54–0.82), a mammogram (RR=0.71, 95% CI=0.57–0.89), and a skin exam (RR=0.78, 95% CI = 0.68–0.89). Survivors reporting somatization, i.e. vague physical symptoms associated with anxiety, were more likely to report receiving echocardiograms (RR=1.53, 95% CI = 1.32–1.77).
Interpretation
These results support the link between neurocognitive and emotional problems and health-related behaviors in adult survivors of childhood cancer. Monitoring neurocognitive and emotional outcomes may help to identify survivors at risk for poor adherence to prescribed health behaviors and health screening exams.
doi:10.1016/j.ejca.2011.03.001
PMCID: PMC3103640  PMID: 21458986
7.  Screening and surveillance for second malignant neoplasms in adult survivors of childhood cancer: A report from the Childhood Cancer Survivor Study (CCSS) 
Annals of internal medicine  2010;153(7):442-451.
Background
Childhood cancer survivors may develop a second malignant neoplasm during adulthood and therefore require regular surveillance.
Objective
To examine adherence to population cancer screening guidelines by survivors at average risk of developing a second malignant neoplasm, and to cancer surveillance guidelines by survivors at high risk of developing a second malignant neoplasm.
Design
Retrospective cohort study.
Setting
The Childhood Cancer Survivor Study (CCSS), a 26 center study of long-term survivors of childhood cancer who were diagnosed between 1970 and 1986.
Patients
4,329 male and 4,018 female survivors of childhood cancer who completed a CCSS questionnaire assessing screening and surveillance for new cancers.
Measurements
Patient-reported receipt and timing of mammography, Papanicolaou smear, colonoscopy, or skin examination was categorized as adherent to the United States Preventive Services Task Force guidelines for survivors at average risk for breast or cervical cancer, or the Children’s Oncology Group guidelines for survivors at high risk for developing breast, colorectal or skin cancer as a result of their therapy.
Results
Among average risk female survivors, 2,743/3,392 (80.9%) reported a Papanicolaou smear within the recommended period, and 140/209 (67.0%) reported a mammogram within the recommended period. Among high risk survivors, rates of recommended mammography among females, and colonoscopy and complete skin exams among both genders were only 241/522 (46.2%), 91/794 (11.5%) and 1,290/4,850 (26.6%), respectively.
Limitations
Data were self report. CCSS participants are a select group of survivors and their compliance may not be representative of all childhood cancer survivors.
Conclusions
Female survivors at average risk for developing a second malignant neoplasm demonstrate reasonable rates of screening for cervical and breast cancer. However, surveillance for new cancers is very poor amongst survivors at highest risk for colon, breast or skin cancer, suggesting that survivors and their physicians need education about their risks and the recommended surveillance.
doi:10.1059/0003-4819-153-7-201010050-00007
PMCID: PMC3084018  PMID: 20921543
8.  Cardiovascular Risk Factors in Adult Survivors of Pediatric Cancer – a report from the Childhood Cancer Survivor Study 
Background
Childhood cancer survivors are at higher risk of morbidity and mortality from cardiovascular (CV) disease compared with the general population.
Methods
8,599 survivors (52% male) and 2,936 siblings (46% male).from the Childhood Cancer Survivor Study (CCSS), a retrospectively ascertained – prospectively followed study of persons who survived 5 years after childhood cancer diagnosed from 1970–1986 were evaluated for BMI ≥30 kg/m2 based on self reported heights and weights and self-reported use of medications for hypertension, dyslipidemia, and impaired glucose metabolism. The presence of ≥3 of the above constituted Cardiovascular Risk Factor Cluster (CVRFC) a surrogate for Metabolic Syndrome
Results
Survivors were more likely than siblings to take medications for hypertension (OR 1.9 95% CI 1.6–2.2), dyslipidemia (OR 1.6 95% CI 1.3–2.0) or diabetes (OR 1.7 95% CI 1.2–2.3). Among these young adults (mean age 32 years for survivors and 33 years for siblings) survivors were not more likely than siblings to be obese or have CVRFC. In a multivariable logistic regression analysis, factors associated with having CVRFC included: older age at interview (≥ 40 vs. < 30 years of age [OR 8.2 95% CI 3.5–19.9]), exposure to total body irradiation (OR 5.5 95% CI 1.5–15.8) or radiation to the chest and abdomen (OR 2.3 95% CI 1.2–2.4), and physical inactivity (OR 1.7 95% CI 1.1–2.6).
Conclusions
Among adult survivors of pediatric cancer, older attained age, exposure to TBI or abdominal plus chest radiation, and a sedentary lifestyle are associated with CVRFC.
doi:10.1158/1055-9965.EPI-09-0555
PMCID: PMC2805162  PMID: 20056636
survivor; cardiovascular risk factors; metabolic syndrome
9.  Evaluation of changes in random blood glucose and body mass index during and after completion of chemotherapy in children with acute lymphoblastic leukemia 
Korean Journal of Pediatrics  2012;55(4):121-127.
Purpose
Improved survival of patients with childhood acute lymphoblastic leukemia (ALL) has drawn attention to the potential for late consequences of previous treatments among survivors, including metabolic syndrome. In this study, we evaluated changes in 3 parameters, namely, random blood glucose, body mass index (BMI), and Z score for BMI (Z-BMI), in children with ALL during chemotherapy and after completion of treatment.
Methods
Patients newly diagnosed with ALL from January, 2005 to December, 2008 at Saint Mary's Hospital, The Catholic University of Korea, who completed treatment with chemotherapy only were included (n=107). Random glucose, BMI, and Z-BMI were recorded at 5 intervals: at diagnosis, before maintenance treatment, at completion of maintenance treatment, and 6 and 12 months after completion of maintenance treatment. Similar analyses were conducted on 2 subcohorts based on ALL risk groups.
Results
For random glucose, a paired comparison showed significantly lower levels at 12 months post-treatment compared to those at initial diagnosis (P<0.001) and before maintenance (P<0.001). The Z-BMI score was significantly higher before maintenance than at diagnosis (P<0.001), but decreased significantly at the end of treatment (P<0.001) and remained low at 6 months (P<0.001) and 12 months (P<0.001) post-treatment. Similar results were obtained upon analysis of risk group-based subcohorts.
Conclusion
For a cohort of ALL patients treated without allogeneic transplantation or cranial irradiation, decrease in random glucose and Z-BMI after completion of chemotherapy does not indicate future glucose intolerance or obesity.
doi:10.3345/kjp.2012.55.4.121
PMCID: PMC3346834  PMID: 22574072
Acute lymphoblastic leukemia; Random glucose; Body mass index; Child
10.  Diabetes Mellitus in Long-Term Survivors of Childhood Cancer: Increased Risk Associated with Radiation Therapy A Report for the Childhood Cancer Survivor Study (CCSS) 
Archives of internal medicine  2009;169(15):1381-1388.
Background
Childhood cancer survivors are at increased risk of morbidity and mortality. To further characterize this risk, this study aimed to compare the prevalence of diabetes mellitus (DM) in childhood cancer survivors and their siblings.
Methods
Participants included 8599 survivors in the Childhood Cancer Survivor Study (CCSS), a retrospectively ascertained North American cohort of long-term survivors who were diagnosed 1970–1986, and 2936 randomly selected siblings of CCSS survivors. The main outcome was self-reported DM.
Results
Survivors and siblings had mean ages of 31.5 years (range, 17.0–54.1) and 33.4 years (range, 9.6–58.4), respectively. DM was reported in 2.5% of survivors and 1.7% of siblings. Adjusting for body mass index (BMI), age, sex, race/ethnicity, household income, and insurance, survivors were 1.8 times more likely to report DM (95% confidence interval [CI], 1.3–2.5; P<0.001) than siblings, with survivors who received total body irradiation (odds ratio [OR], 12.6; 95% CI, 6.2–25.3; P<0.001), abdominal irradiation (OR, 3.4; 95% CI, 2.3–5.0; P<0.001) and cranial irradiation (OR, 1.6; 95% CI 1.0–2.3; P=0.03) at increased risk. In adjusted models, increased risk of DM was associated with: total body irradiation (OR 7.2; 95% CI, 3.4–15.0; P<0.001); abdominal irradiation (OR 2.7; 95% CI, 1.9–3.8; P<0.001); alkylating agents (OR 1.7; 95% CI, 1.2–2.3; P<0.01); and younger age at diagnosis (0–4 years; OR 2.4; 95% CI 1.3–4.6; P<0.01).
Conclusions
Childhood cancer survivors treated with total body or abdominal irradiation have an increased risk of diabetes that appears unrelated to BMI or physical inactivity.
doi:10.1001/archinternmed.2009.209
PMCID: PMC3529471  PMID: 19667301
Childhood cancer survivor; diabetes mellitus; abdominal radiation; total body irradiation
11.  Prevalence and Predictors of Prescription Psychoactive Medication Use in Adult Survivors of Childhood Cancer: A Report from the Childhood Cancer Survivor Study 
Purpose
Childhood cancer survivors are at-risk for late effects which may be managed pharmacologically. The purpose of this study was to estimate and compare the prevalence of psychoactive medication use of adult survivors of childhood cancer and sibling controls, identify predictors of medication use in survivors, and investigate associations between psychoactive medications and health-related quality of life (HRQOL).
Methods
Psychoactive medication use from 1994 to 2010 was evaluated in 10,378 adult survivors from the Childhood Cancer Survivor Study. A randomly selected subset of 3,206 siblings served as a comparison group. Multivariable logistic regression models were used to calculate odds ratios (OR) for baseline and new onset of self-reported psychoactive medication use and HRQOL.
Results
Survivors were significantly more likely to report baseline (22% vs. 15%, p<0.001) and new onset (31% vs. 25%, p<0.001) psychoactive medication use compared to siblings, as well as use of multiple medications (p<0.001). In multivariable models, controlling for pain and psychological distress, female survivors were significantly more likely to report baseline and new onset use of antidepressants (OR=2.66; 95% CI=2.01–3.52; OR=2.02; 95% CI=1.72–2.38, respectively) and multiple medications (OR=1.80; 95% CI=1.48–2.19; OR=1.77; 95% CI=1.48–2.13, respectively). Non-cranial radiation and amputation predicted incident use of analgesics >15 years following diagnosis. Antidepressants were associated with impairment across all domains of HRQOL, with the exception of physical function.
Conclusions
Prevalence of psychoactive medication use was higher among survivors for most medication classes, as was the use of multiple medications. Clinicians should be aware of the possible contribution of psychoactive medications to HRQOL.
doi:10.1007/s11764-012-0250-x
PMCID: PMC3568188  PMID: 23224753
psychoactive medication; quality of life; survivorship
12.  Obesity Is Underestimated Using Body Mass Index and Waist-Hip Ratio in Long-Term Adult Survivors of Childhood Cancer 
PLoS ONE  2012;7(8):e43269.
Objective
Obesity, represented by high body mass index (BMI), is a major complication after treatment for childhood cancer. However, it has been shown that high total fat percentage and low lean body mass are more reliable predictors of cardiovascular morbidity. In this study longitudinal changes of BMI and body composition, as well as the value of BMI and waist-hip ratio representing obesity, were evaluated in adult childhood cancer survivors.
Methods
Data from 410 survivors who had visited the late effects clinic twice were analyzed. Median follow-up time was 16 years (interquartile range 11–21) and time between visits was 3.2 years (2.9–3.6). BMI was measured and body composition was assessed by dual X-ray absorptiometry (DXA, Lunar Prodigy; available twice in 182 survivors). Data were compared with healthy Dutch references and calculated as standard deviation scores (SDS). BMI, waist-hip ratio and total fat percentage were evaluated cross-sectionally in 422 survivors, in who at least one DXA scan was assessed.
Results
BMI was significantly higher in women, without significant change over time. In men BMI changed significantly with time (ΔSDS = 0.19, P<0.001). Percentage fat was significantly higher than references in all survivors, with the highest SDS after cranial radiotherapy (CRT) (mean SDS 1.73 in men, 1.48 in women, P<0.001). Only in men, increase in total fat percentage was significantly higher than references (ΔSDS = 0.22, P<0.001). Using total fat percentage as the gold standard, 65% of female and 42% of male survivors were misclassified as non-obese using BMI. Misclassification of obesity using waist-hip ratio was 40% in women and 24% in men.
Conclusions
Sixteen years after treatment for childhood cancer, the increase in BMI and total fat percentage was significantly greater than expected, especially after CRT. This is important as we could show that obesity was grossly underestimated using BMI and waist-hip ratio.
doi:10.1371/journal.pone.0043269
PMCID: PMC3419210  PMID: 22905245
13.  Growth Effects of Methylphenidate Among Childhood Cancer Survivors: A 12-Month Case-Matched Open-Label Study 
Pediatric blood & cancer  2009;52(1):39-43.
Background
To investigate the effect of stimulant medication [methylphenidate (MPH)] on growth patterns among survivors of childhood cancer (acute lymphoblastic leukemia or brain tumor).
Procedure
Using a case-matched comparison design, childhood cancer survivors participating in a 12-month open-label MPH trial (n = 51) were compared with childhood cancer survivors not taking MPH (n = 51). Measures of body mass index (BMI), height, and weight were obtained at hospital visits and corrected for gender and age using Centers for Disease Control normative data.
Results
Significant deceleration of BMI and weight, but not height, was observed during the 12-month MPH trial for those children taking MPH.
Conclusions
Childhood cancer survivors taking MPH experience significant, though modest, deceleration of BMI and weight across the first year of MPH intervention. The absence of height deceleration, and the presence of only modest BMI and weight deceleration, suggests that MPH is reasonably well tolerated by childhood cancer survivors with respect to growth. Such findings are encouraging in light of increasing evidence that MPH mitigates some of the cognitive late-effects of cancer treatments. Nevertheless, on a case-by-case basis, clinicians should balance the intended benefits of MPH with potential growth effects in this vulnerable population.
doi:10.1002/pbc.21770
PMCID: PMC2585147  PMID: 18855893
leukemia; brain tumor; methylphenidate; growth
14.  Prognostic value of pretreatment hemoglobin level in patients with early cervical cancer 
Objective
The purpose of this study is to investigate the prognostic role of pretreatment anemia in patients with early cervical cancer who underwent radical hysterectomy.
Methods
In this study, we retrospectively enrolled patients with early cervical cancer (International Federation of Obstetrics and Gynecology stage IB to IIA) who were treated at Samsung Medical Center, Seoul, Korea, from 1996 to 2007.
Results
We retrospectively enrolled 805 patients. Median pretreatment hemoglobin (Hb) level was 12.8 g/dL (4.0-16.9) in all patients. Ninety-ninth out of 805 patients had pretreatment anemia (12.3%). Pretreatment anemia was significantly associated with large tumor size, advanced clinical stage, and parametrial invasion. In multivariate analysis, higher pretreatment Hb entailed better prognostic significance in disease free survival (hazard ratio [HR], 0.88; 95% confidence interval [CI], 0.078-0.99) but not in overall survival (HR, 0.94; 95% CI, 0.80-1.10).
Conclusion
In conclusion, we found that the negative association between pretreatment Hb level and tumor size and the impact of anemia before treatment on disease free survival adjusted for other factors including clinical stage and pathological findings in early stage cervical cancer.
doi:10.5468/ogs.2014.57.1.28
PMCID: PMC3924748  PMID: 24596815
Anemia; Hemoglobins; Prognosis; Survival; Uterine cervical neoplasms
15.  Predictors of inactive lifestyle among adult survivors of childhood cancer: A report from the Childhood Cancer Survivor Study 
Cancer  2009;115(9):1984-1994.
Background
Participation in physical activity is important for childhood cancer survivors because inactivity may compound cancer/treatment-related late-effects. However, some survivors may have difficulty participating physical activity and these individuals need to be identified so that risk-based guidelines for physical activity, tailored to specific needs, can be developed and implemented.
Purpose
To document physical activity patterns in the Childhood Cancer Survivor Study (CCSS) cohort, compare physical activity patterns to siblings in CCSS and a population based sample from the Behavioral Risk Factor Surveillance System, and evaluate associations between diagnosis, treatment, and personal factors and risk for inactive lifestyle.
Methods
Percentages of participation in recommended physical activity were compared among survivors, siblings and population norms. Generalized linear models were used to evaluate associations between cancer diagnosis and therapy, sociodemographics and risk for inactive lifestyle.
Results
Participants included 9301 adult survivors of childhood cancer and 2886 siblings. Survivors were less likely than siblings (46% vs. 52%) to meet physical activity guidelines and more likely than siblings to report inactive lifestyle (23% vs. 14%). Medulloblastoma (35%) and osteosarcoma (27%) survivors reported highest levels of inactive lifestyle. Treatments with cranial radiation or amputation was associated with an inactive lifestyle as were female gender, black race, older age, lower educational attainment, underweight or obese status, smoking, and depression.
Conclusion
Childhood cancer survivors are less active than a sibling comparison group or an age and gender-matched population sample. Survivors at risk for inactive lifestyle should be considered high priority for developing and testing of intervention approaches.
doi:10.1002/cncr.24209
PMCID: PMC2692052  PMID: 19224548
Childhood Cancer; Physical Activity; Survivorship
16.  Medical Care in Long-Term Survivors of Childhood Cancer: A Report From the Childhood Cancer Survivor Study 
Journal of Clinical Oncology  2008;26(27):4401-4409.
Purpose
To evaluate whether childhood cancer survivors receive regular medical care focused on the specific morbidities that can arise from their therapy.
Patients and Methods
We conducted a cross-sectional survey of health care use in 8,522 participants in the Childhood Cancer Survivor Study, a multi-institutional cohort of childhood cancer survivors. We assessed medical visits in the preceding 2 years, whether these visits were related to the prior cancer, whether survivors received advice about how to reduce their long-term risks, and whether screening tests were discussed or ordered. Completion of echocardiograms and mammograms were assessed in patients at high risk for cardiomyopathy or breast cancer. We examined the relationship between demographics, treatment, health status, chronic medical conditions, and health care use.
Results
Median age at cancer diagnosis was 6.8 years (range, 0 to 20.9 years) and at interview was 31.4 years (range, 17.5 to 54.1 years). Although 88.8% of survivors reported receiving some form of medical care, only 31.5% reported care that focused on their prior cancer (survivor-focused care), and 17.8% reported survivor-focused care that included advice about risk reduction or discussion or ordering of screening tests. Among survivors who received medical care, those who were black, older at interview, or uninsured were less likely to have received risk-based, survivor-focused care. Among patients at increased risk for cardiomyopathy or breast cancer, 511 (28.2%) of 1,810 and 169 (40.8%) of 414 had undergone a recommended echocardiogram or mammogram, respectively.
Conclusion
Despite a significant risk of late effects after cancer therapy, the majority of childhood cancer survivors do not receive recommended risk-based care.
doi:10.1200/JCO.2008.16.9607
PMCID: PMC2653112  PMID: 18802152
17.  Analysis of Prognostic Factors and Treatment Modality Changes in Breast Cancer: A Single Institution Study in Korea 
Yonsei Medical Journal  2007;48(3):465-473.
Purpose
To determine the effects of new breast cancer treatments and to provide a baseline for monitoring the development of breast cancer in Korean women, we conducted an analysis at our institution to determine long-term clinicopathological features, survival rates, and prognostic factors.
Materials and Methods
This study retrospectively analyzed 2,403 patients between Sep 1994 and Dec 2002, who underwent breast cancer surgery at Samsung Medical Center in Korea. Demographic data, pathologic records and surgical records were collected.
Results
After a median follow-up duration of 121.9 (range: 2-158.1) months, the 5-year disease free survival (DFS) was 82.8% and the 10-year DFS was 74.7%. The 5-year and 10-year overall survival (OS) rates were 89.4% and 82.9%, respectively. Using multivariate analyses, we determined that the nodal status (p < 0.001), angioinvasion (p < 0.001), positive PR (p < 0.001), and C-erb-B2 (p < 0.001) were independent prognostic factors for OS. The frequency of breast conserving surgery was 33.9% before Dec 1999, and increased up to 44.1% by year Dec 2002.
Conclusion
Most of the prognostic variables and clinical characteristics of the Korean breast cancer patients were similar to those reported for Western populations. However, the age distribution in Korean patients seemed to be different from that in patients from Western countries.
doi:10.3349/ymj.2007.48.3.465
PMCID: PMC2628104  PMID: 17594155
Breast cancer; survival; disease free survival; breast conserving surgery
18.  Hospitalization Rates Among Survivors of Childhood Cancer in the Childhood Cancer Survivor Study Cohort 
Pediatric blood & cancer  2011;59(1):126-132.
Background
Chronic health conditions are common among long-term childhood cancer survivors, but hospitalization rates have not been reported. The objective of this study was to determine overall and cause-specific hospitalization rates among survivors of childhood cancer and compare rates to the U.S. population.
Procedure
The Childhood Cancer Survivor Study (CCSS) is a retrospective cohort of 5+ year survivors of childhood malignancies treated at 26 participating centers. Self-reported hospitalizations from 10,366 survivors (diagnosed 1970–1986) were compared to U.S. population rates using age-and sex-stratified standardized incidence ratios (SIRs). Reasons for hospitalization were evaluated and associations between demographic, cancer and treatment-related risk factors with hospitalization were investigated.
Results
Survivors were, on average, 20.9 years from cancer diagnosis (SD: 4.6, range: 13–32) and 28.6 years of age (SD: 7.7, range: 13–51). Survivor hospitalization rates were 1.6 times the U.S. population (95% CI: 1.6; 1.7). Increased hospitalization rates were noted irrespective of gender, age at follow-up and cancer diagnosis, with highest SIRs noted among male (SIR=2.6, 95% CI: 2.2; 3.0) and female (SIR=2.7, 95% CI: 2.4; 3.1) survivors aged 45–54. Female gender, an existing chronic health condition and/or a second neoplasm, and prior treatment with radiation were associated with an increased risk of non-obstetrical hospitalization.
Conclusions
Survivors of childhood cancer demonstrate substantially higher hospitalization rates. Additional research is needed to further quantify the healthcare utilization and economic impact of treatment-related complications as this population ages.
doi:10.1002/pbc.24017
PMCID: PMC3359936  PMID: 22180128
childhood cancer; cancer survivor; hospitalization
19.  Longitudinal Changes in Obesity and Body Mass Index Among Adult Survivors of Childhood Acute Lymphoblastic Leukemia: A Report From the Childhood Cancer Survivor Study 
Journal of Clinical Oncology  2008;26(28):4639-4645.
Purpose
We examined the rate of increase in the body mass index (BMI; kg/m2) after final height attainment in survivors of acute lymphoblastic leukemia (ALL) and a noncancer comparison group.
Methods
Childhood Cancer Survivor Study (CCSS) is a retrospectively ascertained cohort study that prospectively tracks the health status of adults who were diagnosed with childhood cancer between 1970 and 1986 and a comparison group of siblings. Changes in BMI from baseline enrollment to time of completion of follow-up (mean interval, 7.8 years) were calculated for 1,451 ALL survivors (mean age, 32.3 years at follow-up) and 2,167 siblings of childhood cancer survivors (mean age, 35.9 years).
Results
The mean BMI of the CCSS sibling comparison group increased with age (women, 0.25 units/yr, 95% CI, 0.22 to 0.28 units; men, 0.23 units/yr, 95% CI, 0.20 to 0.25 units). Compared with CCSS siblings, ALL survivors who were treated with cranial radiation therapy (CRT) had a significantly greater increase in BMI (women, 0.41 units/yr, 95% CI, 0.37 to 0.45 units; men, 0.29 units/yr; 95% CI, 0.26 to 0.32 units). The rate of BMI increase was not significantly increased for ALL survivors who were treated with chemotherapy alone. Younger age at CRT exposure significantly modified risk.
Conclusion
CRT used in the treatment of childhood ALL is associated with a greater rate of increasing BMI, particularly among women treated with CRT during the first decade of life. Health care professionals should be aware of this risk and interventions to reduce or manage weight gain are essential in this high-risk population.
doi:10.1200/JCO.2008.16.3527
PMCID: PMC2653124  PMID: 18824710
20.  Assessment of Selection Bias in Clinic-Based Populations of Childhood Cancer Survivors 
Pediatric blood & cancer  2009;52(3):379-386.
Background
It is not known to what extent prevalence estimates of late effects among childhood cancer survivors derived from clinic based samples represent the actual estimates that would be derived if the entire population of childhood cancer survivors was recruited and evaluated for a particular outcome.
Procedure
In a large retrospective cohort study of childhood cancer survivors, the Childhood Cancer Survivor Study (CCSS), the prevalence of chronic health conditions among participants who reported being seen in a cancer center or long-term follow-up clinic was compared to the prevalence of chronic conditions in the entire cohort.
Results
When compared to survivors who had no medical care in the previous two years, survivors accessing medical follow-up were significantly more likely to have chronic health conditions. Relative risks of reporting a chronic health condition were 1.4 (95% CI 1.3 – 1.5) if seen in a cancer center or long-term follow-up clinic and 1.2 (95% CI 1.1-1.3) if seen in a general medical care setting. Estimates derived from only those childhood cancer survivors who were seen in a cancer center or long term follow-up clinic overestimate the prevalence of any chronic disease by 9.3% (95% CI: 7.0-11.6%).
Conclusions
Applying chronic condition prevalence estimates from a clinical population to the general population of childhood cancer survivors must be undertaken with caution. Survivorship research must maintain a high level of scientific rigor to ensure that results reported in the literature are interpreted within the appropriate context.
doi:10.1002/pbc.21829
PMCID: PMC2628420  PMID: 18989878
21.  Continuous renal replacement therapy in neonates weighing less than 3 kg 
Korean Journal of Pediatrics  2012;55(8):286-292.
Purpose
Continuous renal replacement therapy (CRRT) is becoming the treatment of choice for supporting critically ill pediatric patients. However, a few studies present have reported CRRT use and outcome in neonates weighing less than 3 kg. The aim of this study is to describe the clinical application, outcome, and complications of CRRT in small neonates.
Methods
A retrospective review was performed in 8 neonatal patients who underwent at least 24 hours of pumped venovenous CRRT at the Samsung Medical Center in Seoul, Korea, between March 2007 and July 2010. Data, including demographic characteristics, diagnosis, vital signs, medications, laboratory, and CRRT parameters were recorded.
Results
The data of 8 patients were analyzed. At the initiation of CRRT, the median age was 5 days (corrected age, 38+2 weeks to 23 days), and the median body weight was 2.73 kg (range, 2.60 to 2.98 kg). Sixty-two patient-days of therapy were reviewed; the median time for CRRT in each patient was 7.8 days (range, 1 to 37 days). Adverse events included electrolyte disturbances, catheter-related complications, and CRRT-related hypotension. The mean circuit functional survival was 13.9±8.6 hours. Overall, 4 patients (50%) survived; the other 4 patients, who developed multiorgan dysfunction syndrome, died.
Conclusion
The complications of CRRT in newborns are relatively high. However, the results of this study suggest that venovenous CRRT is feasible and effective in neonates weighing less than 3 kg under elaborate supportive care. Furthermore, for using potential benefit of CRRT in neonates, efforts are required for prolonging filter survival.
doi:10.3345/kjp.2012.55.8.286
PMCID: PMC3433565  PMID: 22977441
Critical illness; Infant; Renal replacement therapy; Treatment outcome
22.  Trajectories of social isolation in adult survivors of childhood cancer 
Purpose
Long-term childhood cancer survivors may be at increased risk for poor social outcomes as a result of their cancer treatment, as well as physical and psychological health problems. Yet, important challenges, namely social isolation, are not well understood. Moreover, survivors' perspectives of social isolation as well as the ways in which this might evolve through young adulthood have yet to be investigated. The purpose of this research was to describe the trajectories of social isolation experienced by adult survivors of a childhood cancer.
Methods
Data from 30 in-depth interviews with survivors (9 to 38 years after diagnosis, currently 22 to 43 years of age, 60 % women) were analyzed using qualitative, constant comparative methods.
Results
Experiences of social isolation evolved over time as survivors grew through childhood, adolescence and young adulthood. Eleven survivors never experienced social isolation after their cancer treatment, nor to the present day. Social isolation among 19 survivors followed one of three trajectories; (1) diminishing social isolation: it got somewhat better, (2) persistent social isolation: it never got better or (3) delayed social isolation: it hit me later on.
Conclusions
Knowledge of when social isolation begins and how it evolves over time for different survivors is an important consideration for the development of interventions that prevent or mitigate this challenge.
Implications for Cancer Survivors
Assessing and addressing social outcomes, including isolation, might promote comprehensive long-term follow-up care for childhood cancer survivors.
doi:10.1007/s11764-013-0321-7
PMCID: PMC3923114  PMID: 24202698
Survivorship; Adolescent and young adult; Childhood cancer survivor; Qualitative; Psychosocial; Social isolation; Social outcomes
23.  SECONDARY GASTROINTESTINAL MALIGNANCIES IN CHILDHOOD CANCER SURVIVORS: A COHORT STUDY 
Annals of internal medicine  2012;156(11):757-260.
Background
Childhood cancer survivors develop gastrointestinal malignancies more frequently and at a younger age than the general population, but risk factors for their development have not been well characterized.
Objective
To determine the risk and associated risk factors for gastrointestinal subsequent malignant neoplasms (SMN) in childhood cancer survivors.
Design
Retrospective cohort study.
Setting
The Childhood Cancer Survivor Study, a multi-center study of childhood cancer survivors diagnosed between 1970 and 1986.
Patients
14,358 survivors of a malignancy diagnosed at < 21 years who had survived for 5 or more years from initial diagnosis.
Measurements
Standardized incidence ratios (SIR) for gastrointestinal SMN were calculated using age-specific population data. Multivariate Cox regression models identified associations between risk factors and gastrointestinal SMN development.
Results
At median follow-up of 22.8 years (range: 5.5-30.2), 45 gastrointestinal malignancies were identified. Gastrointestinal SMN risk was 4.6-fold higher in childhood cancer survivors than the general population (95% confidence interval [CI]: 3.5-6.1). Colorectal cancer SIR was 4.2 (95% CI: 2.8-6.3). The highest gastrointestinal SMN risk was associated with abdominal radiation (SIR=11.2, 95% CI: 7.6-16.4). However, survivors not exposed to radiation had a significantly increased risk (SIR=2.4, 95% CI-1.4-3.9). In addition to abdominal radiation, high dose procarbazine (RR=3.2, 95% CI 1.1-9.4) and platinum drugs (RR 7.6, 95% CI: 2.3-25.5) independently increased the gastrointestinal SMN risk.
Limitations
This cohort has not yet attained an age at which gastrointestinal malignancy risk is greatest.
Conclusions
Childhood cancer survivors, particularly those exposed to abdominal radiation, are at increased risk for gastrointestinal SMN. These findings suggest that surveillance of at-risk childhood cancer survivors should commence at a younger age than recommended for the general population.
doi:10.1059/0003-4819-156-11-201206050-00002
PMCID: PMC3554254  PMID: 22665813
24.  Medical Screening Participation Among Childhood Cancer Survivors 
Archives of internal medicine  2009;169(5):454-462.
Purpose
Despite their risk for serious late sequelae, childhood cancer survivors do not adhere to recommended medical screenings. We identified treatment, survivor, physician, and contextual factors that may influence survivors' adherence to recommended echocardiography and bone densitometry screening.
Methods
Structural equation modeling of data from the Childhood Cancer Survivor Study (CCSS); participants (N=838) were diagnosed and treated for pediatric malignancies between 1970 and 1986 .
Results
Survivors ( Mean age = 31 years; Mean age @ diagnosis = 10 years; Mean time since diagnosis = 21 years) at risk of cardiac sequelae (N=316) who reported more cancer-related visits (P = 0.01), having discussed heart disease with a physician (P ≤ 0.001), a sedentary lifestyle (P = 0.05), and less frequent health fears (P=0.05) were most likely to follow the recommended echocardiogram schedule (R2 = 23%). Survivors (Mean age=30 years; Mean age @ diagnosis = 9 years; Mean time since diagnosis = 21 years) at risk for osteoporosis (N=324) who reported more cancer-related visits (P = 0.05), were followed up at an oncology clinic (P = 0.01), had discussed osteoporosis with a physician (P ≤ 0.001), and had a lower BMI (P = 0.05) were most likely to adhere to the recommended bone density screening guidelines (R2 = 26%). Symptoms and motivation influenced screening frequency in both models.
Conclusions
Multiple factors influence survivors' adherence to screening recommendations. It is likely that tailored interventions would be more successful in encouraging recommended screening among childhood cancer survivors than will traditional health education approaches.
doi:10.1001/archinternmed.2008.588
PMCID: PMC2654585  PMID: 19273775
25.  The correlates of unemployment and its association with quality of life in cervical cancer survivors 
Journal of Gynecologic Oncology  2013;24(4):367-375.
Objective
Little is known regarding cervical cancer survivors' employment status, which represents social integration of cancer survivors as a pivotal domain of long-term quality of life. The goal of this study was to assess the correlates of unemployment and evaluate the impact on the comprehensive quality of life in cervical cancer survivors.
Methods
We enrolled 858 cervical cancer survivors from the gynecologic oncology departments of multi-centers in Korea. Factors associated with unemployment were identified using multivariate logistic regression analyses. We assessed different health-related quality of life domains with multivariate-adjusted least-square means between cervical cancer survivors who currently work and do not.
Results
After diagnosis and treatment, the percentage of unemployed survivors increased from 50.6% to 72.8%. Lower income (adjusted odds ratio [aOR], 1.97; 95% confidence interval [CI], 1.38 to 2.81), medical aid (aOR, 1.58; 95% CI, 1.05 to 2.38), two or more comorbidities (aOR, 1.80; 95% CI, 1.12 to 2.90), current alcohol drinkers (aOR, 2.33; 95% CI, 1.54 to 3.52), and employed at the time of diagnosis (aOR, 10.72; 95% CI, 7.10 to 16.16) were significantly associated with unemployment. Non-working groups showed significant differences with respect to physical functioning, role functioning, depression, and existential well-being.
Conclusion
The proportion of unemployed cervical cancer survivors seems to increase, with low-income status and the presence of medical aid negatively being associated with employment, in addition to other comorbidities and previous working status. Effort should be made to secure the financial status of cervical cancer survivors.
doi:10.3802/jgo.2013.24.4.367
PMCID: PMC3805918  PMID: 24167673
Cancer survivor; Cervical cancer; Health-related quality of life; Unemployment

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