Expert review provides road map for clinicians in managing patients post-transplant
UH Innovations in Pediatrics - Fall 2018
JIGNESH DALAL, MD
Director of Pediatric Bone Marrow Transplant at UH Rainbow Babies & Children’s Hospital; Professor of Pediatrics, Case Western Reserve University School of Medicine
Neurocognitive dysfunction is increasingly recognized as a consequence of hematopoietic stem cell transplantation (HSCT), significantly affecting the early and late post-HSCT course. Still, information on the extent of the problem and how best to manage it is relatively scarce.
“There is still a lot to learn,” says pediatric hematologist and oncologist Jignesh Dalal, MD, Director of Pediatric Bone Marrow Transplant at UH Rainbow Babies & Children’s Hospital. “Neuropsychological effects have not typically been considered at the time of transplant. The ‘storm’ of the transplant can seem all-consuming. But they are crucial to plan for, consider and manage.”
To address this knowledge gap, Dr. Dalal and HSCT colleagues from the United States and Europe recently conducted an expert review, detailing neurocognitive issues in adults in children, risk factors, assessment and interventions. The group was composed of members from relevant committees of the Center for International Blood and Marrow Transplant Research and the European Group for Blood and Marrow Transplantation.
“This has never been done before,” Dr. Dalal says. “With this kind of consensus, this kind of document, the hope is this will become the standard of care.”
The review, published in the journal Biology of Blood and Marrow Transplantation, is a road map for clinicians.
“This review aims to help clinicians understand the scope of this health-related problem, highlight its impact on well-being of survivors and help determine factors that may improve identification of patients at risk for declines in cognitive functioning after HSCT,” it says.
Integrating management of neurocognitive effects into their practice may not be the most natural fit for HSCT specialists, Dr. Dalal says.
“Unlike a lab test, neuropsychological tests are not black and white,” he says. “There is a measure of abstract level thinking based on performance of certain tasks. Ultimately, we need the help of professionals who can administer these different kinds of tests.”
At UH Rainbow, Dr. Dalal and his colleagues have begun a bone marrow transplant survivorship clinic, with plans to monitor and manage patients into their 30s. Neurocognitive effects of HSCT are an important component of care.
“Patients see a neuropsychologist at the time of transplant and subsequently to undergo annual neuropsychological testing,” Dr. Dalal says. “We follow them and share that report with the school.”
This kind of alliance between healthcare providers and local school districts is crucial to HSCT patients getting the support they need to succeed, Dr. Dalal says.
“School districts need to rise to this challenge,” he says. “We need more resources to help these kind of children. Also what complicates neurocognitive effects is that they’re not immediate. As the child grows older, that is where they manifest more and more. With more time, there are more sequelae. When school districts know this, they can plan their services in a proper direction. This kind of knowledge can be extremely helpful, for example, to teachers.”
For more information about Dr. Dalal’s role on the expert panel on neurocognitive effects of HSCT or the survivorship clinic at UH Rainbow, please email Peds.Innovations@UHhospitals.org.