ABSTRACT
Background. The event-free survival for pediatric leukemia in low-income Countries is much lower than in high-income countries. Late diagnosis, which is regarded as a contributing factor, may be due to "parental" or "medical" delay. Procedures. The present study analyses determinants of lag time from first symptoms to diagnosis of leukemia, comparing pediatric (0-16 years old) patients in two referral centers, one in Nicaragua and one in Italy. An observational retrospective study was conducted to assess factors influencing the time to diagnosis. Results. 81 charts of children diagnosed with acute myeloid leukemia or lymphoblastic leukemia were analyzed from each centre. Median lag time to diagnosis was higher in Nicaragua than in Italy (29 versus 14 days, P < 0.001) and it was mainly due to "physician delay" (16.5 versus 7 days, P < 0.001), whereas "patient delay" from symptoms to first medical assessment was similar in the two centers (7 versus 5 days, P = 0.27). Moreover, median lag time from symptoms to diagnosis was decreased in Nicaraguan districts were a specific training program upon childhood oncological diseases was carried out (20.5 versus 40 days, P = 0.0019). Conclusions. Our study shows that delay in diagnosis of childhood leukemia is mainly associated with "physician delay" and it may be overcome by programs of continuous medical education.
ABSTRACT
CASE REPORT: We report the case of a 70-year-old patient with serpiginous choroiditis and uterine cervix carcinoma. DISCUSSION: The etiology of serpiginous choroiditis is unknown, but similar lesions have been described in association with systemic lupus erythematosus, non-Hodgkin lymphoma, Crohn's disease, sarcoidosis, tuberculosis, herpes virus infection, autoimmune hepatitis and lung carcinoma.
Subject(s)
Carcinoma, Squamous Cell/complications , Choroiditis/etiology , Paraneoplastic Syndromes, Ocular/etiology , Uterine Cervical Neoplasms/complications , Aged , Anti-Inflammatory Agents/therapeutic use , Atrophy , Autoimmune Diseases/complications , Carcinoma, Squamous Cell/diagnosis , Choroiditis/diagnosis , Choroiditis/drug therapy , Choroiditis/pathology , Fatal Outcome , Female , Fluorescein Angiography , Fundus Oculi , Humans , Metrorrhagia/etiology , Multiple Organ Failure/etiology , Paraneoplastic Syndromes, Ocular/diagnosis , Paraneoplastic Syndromes, Ocular/drug therapy , Paraneoplastic Syndromes, Ocular/pathology , Prednisone/therapeutic use , Retinal Pigment Epithelium/pathology , Uterine Cervical Neoplasms/diagnosisABSTRACT
For the aerobic biodegradation of the fungicide and defoliant 2,4,6-trichlorophenol (2,4,6-TCP), a bench-scale packed-bed bioreactor equipped with a net draft tube riser for liquid circulation and oxygenation (PB-ALR) was constructed. To obtain a high packed-bed volume relative to the whole bioreactor volume, a high A(D)/A(R) ratio was used. Reactor's downcomer was packed with a porous support of volcanic stone fragments. PB-ALR hydrodynamics and oxygen mass transfer behavior was evaluated and compared to the observed behavior of the unpacked reactor operating as an internal airlift reactor (ALR). Overall gas holdup values epsilon(G), and zonal oxygen mass transfer coefficients determined at various airflow rates in the PB-ALR, were higher than those obtained with the ALR. When comparing mixing time values obtained in both cases, a slight increment in mixing time was observed when reactor was operated as a PB-ALR. By using a mixed microbial community, the biofilm reactor was used to evaluate the aerobic biodegradation of 2,4,6-TCP. Three bacterial strains identified as Burkholderia sp., Burkholderia kururiensis and Stenotrophomonas sp. constituted the microbial consortium able to cometabolically degrade the 2,4,6-TCP, using phenol as primary substrate. This consortium removed 100% of phenol and near 99% of 2,4,6-TCP. Mineralization and dehalogenation of 2,4,6-TCP was evidenced by high COD removal efficiencies ( approximately 95%), and by the stoichiometric release of chloride ions from the halogenated compound ( approximately 80%). Finally, it was observed that the microbial consortium was also capable to metabolize 2,4,6-TCP without phenol as primary substrate, with high removal efficiencies (near 100% for 2,4,6-TCP, 92% for COD and 88% for chloride ions).
Subject(s)
Biodegradation, Environmental , Bioreactors , Adsorption , Biofilms , Burkholderia/metabolism , Chlorides/chemistry , Chlorophenols/chemistry , Equipment Design , Hydrogen-Ion Concentration , Ions , Oxygen/chemistry , Phenol/chemistry , Porosity , Stenotrophomonas/metabolismABSTRACT
We report the results of a protocol for the diagnosis and treatment of pediatric non-Hodgkin lymphomas (NHL) conducted in Nicaragua in the context of an international collaborative program. Fifty-three children with NHL treated between 1996 and 2003 were retrospectively evaluated. Therapy was designed based on local drug availability and affordability with dose and schedule adaptations for Burkitt and lymphoblastic lymphomas. With a median follow-up of 3 years, the projected 9-year overall survival was 63% and event-free survival 53%. The treatment was efficacious, feasible, and well tolerated in spite of the local socio-economical conditions.
Subject(s)
Antineoplastic Combined Chemotherapy Protocols/therapeutic use , Developing Countries , Lymphoma, Non-Hodgkin/drug therapy , Adolescent , Child , Child, Preschool , Female , Humans , Infant , Male , NicaraguaABSTRACT
BACKGROUND: Countries with scarce resources have the right to appropriate essential health care but very few reports discuss how this can be achieved. We assessed the survival of a large cohort of pediatric oncological patients to provide hard data on which to base realistic evaluation and planning schemes. PATIENTS AND METHODS: This multicenter retrospective survey covered consecutively diagnosed and treated patients admitted to eight national level hospitals in seven countries in Central America and the Caribbean. The research protocol was discussed extensively, so the data to be collected and the criteria for their evaluation were clearly pre-defined. We analysed 2214 patients diagnosed between 1996 and 1999 with various cancers, classified as hemato-oncological disorders (70%) and solid tumors (30%). RESULTS: Three-year overall survival was 48.4% [standard error (SE) 1.3]. Detailed analysis of acute lymphoblastic leukemia highlighted the wide intercountry variability: 3-year survival was 62.2% (SE 5.3) in Cuba, 74.2% (SE 3.3) in Costa Rica, 61.7% (SE 4.9) in Nicaragua, and lower in the other four countries. CONCLUSIONS: The yield of diagnostic-therapeutic protocols depends largely on the context of care in which they are applied. This paper documents the importance of including epidemiological research in interventions for cooperation in complex health areas such as pediatric oncology.
Subject(s)
Neoplasms/epidemiology , Caribbean Region/epidemiology , Central America/epidemiology , Child , Humans , Leukemia, Myeloid, Acute/epidemiology , Precursor Cell Lymphoblastic Leukemia-Lymphoma/epidemiology , Retrospective Studies , Survival AnalysisABSTRACT
BACKGROUND: Recent trends in therapeutic strategies for Wilms' tumor are based on an attempt to reduce or omit radiotherapy (RT) in a sizable fraction of patients. We report here the clinical and histological features as well as the results obtained in 37 children (23 males, 14 females; median age at diagnosis 3 years, range 0.8-8 years) diagnosed between 1991 and 1996, and treated with chemotherapy (CT) and surgery at La Mascota Hospital, Managua, Nicaragua. PATIENTS AND METHODS: Patients were grouped as follows: those who underwent surgery at diagnosis (group A, n = 4), patients who received preoperative CT because of large tumor size (group B, n = 27), lung metastases (n = 5) or bilateral disease (n = 1) (group C, n = 6). Treatment consisted of vincristine (VCR) and actinomycin-D (ACTD) for 24 weeks in group A, and of VCR, ACTD and adriamycin for 68 weeks in groups B and C. Histology was classified as favorable in 30 patients (81%), unfavorable in six patients (all of group B) and unknown in one. RESULTS: With a median follow-up time of 6.4 years the event-free survival for the whole group was 80.1%+/-6.8 (SE). No event occurred beyond 5 years of diagnosis. CONCLUSIONS: These results suggest that RT does not appear necessary for the majority of patients, and that an excellent surgical approach associated with an intensive CT schedule can control the disease, even in the absence of adequate information on the intra-abdominal tumor extent.
Subject(s)
Antineoplastic Combined Chemotherapy Protocols/administration & dosage , Kidney Neoplasms/drug therapy , Kidney Neoplasms/surgery , Wilms Tumor/drug therapy , Wilms Tumor/surgery , Antineoplastic Combined Chemotherapy Protocols/adverse effects , Biopsy, Needle , Child , Child, Preschool , Combined Modality Therapy , Dactinomycin/administration & dosage , Dactinomycin/adverse effects , Doxorubicin/administration & dosage , Doxorubicin/adverse effects , Female , Humans , Infant , Kidney Neoplasms/mortality , Kidney Neoplasms/pathology , Male , Neoplasm Staging , Nephrectomy/methods , Nicaragua , Survival Analysis , Treatment Outcome , Vincristine/administration & dosage , Vincristine/adverse effects , Wilms Tumor/mortality , Wilms Tumor/pathologyABSTRACT
We describe the La Mascota twinning programme between La Mascota paediatric hospital in Managua, Nicaragua, and hospitals in Monza and Milan, Italy, and Bellinzona, Switzerland. The programme was based on the belief that an attempt to reduce the gap in mortality from cancer in childhood between developed and less developed countries should become an integral part of the care and research activity of a haemato-oncological department of a developed country and not simply an exercise in solidarity. This programme for acute lymphoblastic leukaemia shows that intellectual, organisational, and financial resources can be generated by a twinning programme. What is vital for such programmes is a long-term commitment to a comprehensive and holistic strategy that incorporates supply of drugs, training and supervision of health professionals, and the care of the children and of their parents.
Subject(s)
International Cooperation , Precursor Cell Lymphoblastic Leukemia-Lymphoma/therapy , Child , Developing Countries , Financing, Organized , Hematology/economics , Hematology/methods , Humans , Italy , Medical Oncology/economics , Medical Oncology/methods , Nicaragua , Pediatric Nursing/education , Pediatrics/education , Quality of Health Care , SwitzerlandABSTRACT
BACKGROUND: Childhood Hodgkin's disease (HD) in low-income countries has been reported to have distinct presenting features, including a high prevalence of the mixed cellularity subtype, which also seems to be associated with poorer prognosis. Further investigations are needed to evaluate these issues. Another controversial aspect of childhood HD is the use of radiotherapy (RT) in its treatment and the growing concern about its serious adverse side effects. In this paper, data on the diagnosis and outcome of children treated without RT in a low-income country (Nicaragua) are reported. PATIENTS AND METHODS: Forty-eight consecutive children aged 0-15 years, diagnosed at 'La Mascota' Hospital of Managua (Nicaragua) from January 1990 to October 1995. entered this study. Follow-up was updated in May 1996. Clinical and histopathological staging was performed according to Ann Arbor and Rye criteria, respectively. Treatment consisted of COPP (six cycles) for stages I or IIA, or COPP-ABV hybrid): eight cycles for stages IIB or III, and ID cycles for stage IV. Total cumulative doses of adriamycin and bleomycin in this protocol are, respectively, 200 and 80 mg:sqm for stages II B or III and 250 and 100 mg/sqm for stage IV. RESULTS: The median age of the 48 patients at diagnosis was seven years, and the mean age was 7.9 years (range 3-15 years). Clinical stages were IA in 5, IIA in 9, IIB in 6, IIIA in 5, IIIB in 14, and IVB in 9. Histopathologically, 25 cases presented with mixed cellularity, 15 with nodular sclerosis, 5 with lymphocytic predominance and 3 with lymphocytic depletion. Four patients did not proceed with treatment and were lost to follow-up. Two patients (stages IIIB and IVB), who never achieved complete remission (CR) during treatment, presented progressive disease at the end of the scheduled chemotherapy. The remaining 42 patients were in complete remission at the end of chemotherapy. Following discontinuation of therapy, one patient (stage IA) was lost to follow-up and two patients with stage IIIB, who were in CR after the second chemotherapy cycle, relapsed 20 and 9 months following the diagnosis. EFS at three years is 100% for the 25 patients with stages I, II, IIIA and 74.9% for the 23 patients with stages IIIB or IV. CONCLUSION: The presenting features found in these patients are similar to those reported from other low-income countries. In our experience, however, the high prevalence of the mixed cellularity subtype was not associated with poorer prognosis. Satisfactory results have been achieved in patients with stages I, II or IIIA HD using COPP or COPP-ABV (hybrid) regimens without RT. The treatment was also well tolerated and can thus be recommended for these patients in low-income countries, where RT facilities may be scarce or unavailable. The use of more aggressive treatment schedules and/or RT on involved fields in front-line treatment may, however, be needed for the more advanced stages IIIB or IV. Large studies with adequate follow-up are needed to evaluate whether, if RT is omitted, higher cumulative doses of more toxic drugs are required and thus compare the long-term toxic effects of different treatment modalities.
Subject(s)
Antineoplastic Combined Chemotherapy Protocols/therapeutic use , Hodgkin Disease/drug therapy , Adolescent , Bleomycin/administration & dosage , Child , Child, Preschool , Cyclophosphamide/administration & dosage , Doxorubicin/administration & dosage , Female , Hodgkin Disease/diagnosis , Hodgkin Disease/radiotherapy , Humans , Male , Nicaragua , Prednisone/administration & dosage , Procarbazine/administration & dosage , Treatment Outcome , Vinblastine/administration & dosage , Vincristine/administration & dosageABSTRACT
We observed a child with acute promyelocytic leukemia (APL) who, at the onset, had extremely severe hemorrhagic and septic complications. According to our experience in Nicaragua, there was a very high risk of early death. The patient was successfully treated with a program that included all-trans retinoic acid (ATRA) followed by cytotoxic chemotherapy. ATRA has two important features: it is effective in initial treatment of APL and it is inexpensive. Because of the high cost and the need for extensive supportive care, optimal myeloablative therapy used in patients with various types of acute myeloid leukemia generally cannot be given in developing countries. ATRA treatment for APL is affordable everywhere.
Subject(s)
Antineoplastic Agents/therapeutic use , Leukemia, Promyelocytic, Acute/drug therapy , Tretinoin/therapeutic use , Antineoplastic Agents/administration & dosage , Antineoplastic Agents/economics , Bacteremia/microbiology , Child , Developing Countries , Drug Costs , Female , Hemorrhage/etiology , Humans , Nicaragua , Pseudomonas Infections , Pseudomonas aeruginosa , Remission Induction , Skin Diseases, Bacterial/etiology , Staphylococcal Skin Infections , Tretinoin/administration & dosage , Tretinoin/economicsABSTRACT
Twenty nine patients with the histological diagnosis of cancer and with positive blood cultures are presented. The majority of this group presented tumor activity at the time of developing septicemia. Some of these patients presented a history of recurrent infections. Only 20% of this population had no history of infection preceeding septicemia. The majority of the patients presented leucopenia and thrombocytopenia. All of the patients admitted to the Oncology Unit showed fever but no clinical evidence of the site of the infection. Several cultures were made but the patients were started at once on systemic antibiotics. The antibiotic combination used in every case was freely selected according with the physician's criteria; however, six patients were not treated with antibiotics and died. There was a definitive predominance of gram-negative blood cultures. The mortality in this group was 68% and was secondary to three main factors: those patients which were not treated with any antibiotic; granulocitopenia and inadequate selection of the antibiotic used in some of the patients. Pertinent literature regarding infection and cancer was reviewed, including the cause/effect of chemotherapy, radiotherapy and surgery, as well as other factors, such as the immunosuppression produced by the malignant disease. Emphasis is placed on the usage of prophylactic antibiotics in patients with cancer, neutropenia and fever of unknown origin.