Design and Technical Validation of a Telemedicine Service for Rural Healthcare in Ecuador.

BACKGROUND: Telemedicine is becoming increasingly important in Ecuador, especially in areas such as rural primary healthcare and medical education. Rural telemedicine programs in the country need to be strengthened by means of a technological platform adapted to local surroundings and offering advantages such as access to specialized care, continuing education, and so on, combined with modest investment requirements. INTRODUCTION: This present article presents the design of a Telemedicine Platform (TMP) for rural healthcare services in Ecuador and a preliminary technical validation with medical students and teachers. MATERIALS AND METHODS: An initial field study was designed to capture the requirements of the TMP. In a second phase, the TMP was validated in an academic environment along three consecutive academic courses. Assessment was by means of user polls and analyzing user interactions as registered automatically by the platform. The TMP was developed using Web-based technology and open code software. RESULTS: One hundred twenty-four students and 6 specialized faculty members participated in the study, conducting a total of 262 teleconsultations of clinical cases and 226 responses, respectively. CONCLUSION: The validation results show that the TMP is a useful communication tool for the documentation and discussion of clinical cases. Moreover, its usage may be recommended as a teaching methodology, to strengthen the skills of medical undergraduates. The results indicate that implementing the system in rural healthcare services in Ecuador would be feasible.

Prevalence of High-Risk Genotypes of Human Papillomavirus: Women Diagnosed with Premalignant and Malignant Pap Smear Tests in Southern Ecuador.

Human papillomavirus (HPV) is the primary infectious agent for the development of cervical cancer, although the presence of the virus alone is insufficient for viral development and proliferation; this can be attributed to the increase in potential oncogenic risk, along with other risk factors. In the present investigation, the prevalence of high-risk HPV was determined from samples of premalignant or malignant cervical cytology in women from the southern region of Ecuador. The kit we used was able to detect genotypes 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, and 59. In addition, 64.5% of the analyzed samples were positive for HPV, with genotypes 16 and 18 being the most prevalent (16 was detected in 148 samples and 18 in 108). Genotypes 58 and 51 were the third most frequent simple and multiple infections, respectively. The data are very similar to those obtained worldwide, suggesting that the strategy of sex education, and the use of vaccines as primary prevention agents, could significantly decrease the incidence and mortality rate of cervical cancer in the southern region of Ecuador.

Adjuvant chemotherapy for early-stage non-small-cell lung cancer. Single-centre experience and literature review.

BACKGROUND: In recent years platinum-based chemotherapy has become the standard of care for patients with good performance status after complete resection in stages IB-IIIA non-small-cell lung cancer (NSCLC), although the benefit is mainly in stages II and IIIA. PATIENTS AND METHODS: In a retrospective trial we evaluate the clinical efficacy and toxicity profile of a platinum- and taxanes-based adjuvant chemotherapy in completely resected IB-IIIA NSCLC. The primary end point was relapse- free survival (RFS); principal secondary end points were overall survival (OS) and safety of the regimen. Potential predictive factors of efficacy and clinical patterns of relapse were also analysed. RESULTS: From January 2003 to December 2006, 41 patients met the inclusion criteria and were evaluable. Median age at diagnosis was 68.1 years (CI 95% 54-72; range 45-78). Most patients were males (87.7%) and had an Eastern Cooperative Oncology Group performance status score (PS) of 0-1 (87.8%), and 53.6% had adenocarcinomas. Pathological stages were as follow: 48.7% stage IB, 24.3% stage II and 26.8% stage IIIA. 75.6% of patients underwent a lobectomy and mediastinal lymphadenectomy and were treated with a combination of carboplatin AUC6 and paclitaxel 200 mg/m2 (85.36%) for 3 or 4 cycles. With a median follow-up of 18.2 months (range 5.1-46.5), 26 patients (63%) were free of disease and 32 of them were alive (78%). Median RFS was 12.1 months (CI 95% 9.8-14.9) and median OS had not been reached at the time of analysis. Patients with PS< or =1 at diagnosis had a higher RFS [p=0.051 (CI 95% 0.90-0.96)]. Toxicity was generally mild and haematologic events were the most frequent. Non-haematologic toxic effects of chemotherapy were asthenia/ anorexia (12.2%), nausea/vomiting (12.2%) and peripheral neuropathy (17%), but severe toxic effects (grade 3 or greater) were uncommon (<10%). We did not observe treatment-related deaths. CONCLUSIONS: Platinum-taxane-based adjuvant chemotherapy in IB-IIIA NSCLC following complete resection is feasible, well tolerated and can be delivered in most patients in the adjuvant setting. Ongoing molecular studies may have value in determining which patients will benefit from adjuvant chemotherapy.

Prognostic and predictive markers of benefit from adjuvant chemotherapy in early-stage non-small cell lung cancer.

Lung cancer-predominantly non-small cell lung cancer (NSCLC)-is the leading cause of death from cancer in most industrialized countries. Patients with early-stage NSCLC are at substantial risk for recurrence and death even after potentially curative surgery. Multiple large randomized trials have demonstrated that adjuvant chemotherapy using modern cisplatin-based regimens can significantly improve 5-year survival in carefully selected patients with NSCLC.The current staging system is inadequate for predicting the outcome of treatment and the prognosis in an individual patient. Molecular markers may provide additional information about the likelihood of relapse beyond that obtained from pathologic staging. They may also have value in determining which patients will benefit from adjuvant platinum-based chemotherapy.This is a review focused on approaches and specific markers under study, including gene expression profiles, DNA repair pathways, class III beta-tubulin expression, abnormalities in the k-ras oncogene and p53 tumor suppressor gene, and DNA methylation markers. Additional studies will be required to determine whether these markers are useful in selecting patients for adjuvant platinum-based chemotherapy.

Circulating tumour cells in locally advanced breast cancer.

MATERIAL AND METHODS: A prospective study was conducted to determine the value of changes in circulating tumour cell (CTC) levels prior to and after the first cycle of neoadjuvant treatment in early prediction of pathologic response in locally advanced breast cancer (LABC). Two blood samples were obtained from 72 eligible LABC patients to isolate and enumerate CTCs before neoadjuvant chemotherapy started on day 1, and on day 21, immediately before second cycle administration. RESULTS: Sixty patients (83.3%) had <1 CTC in the first sample and response rates in this cohort were pathologic complete response (PCR) in 2 patients (5%), partial response (PR) in 35 (87.5%), stable disease (SD) in 2 (5%) and progressive disease (PD) in 1 (2.5%). Twelve patients (16.7%) had >2 CTCs in the first sample; these patients were more likely to have triple negative tumours. All 12 had fewer CTCs in the second sample. Response rates in this second cohort of 12 patients were PCR in 4 (34%), PR in 6 (50%), SD in 1 (8%) and PD in 1 (8%). PCR rate was markedly better in this second cohort (p<0.0042; OR 14.5, 95% CI 2.3-92). DISCUSSION: This study suggests that the presence of CTCs prior to neoadjuvant therapy might be a predictor of response to this therapy.