A caregivers' perspective on social reintegration and stigma of childhood cancer survivors in Kenya.

OBJECTIVES: Childhood cancer survivors' social reintegration may be hampered in low and middle-income countries. The nature and extent of social challenges and prejudices that survivors encounter in such settings are largely unknown. This study explores caregivers' perspectives on social reintegration and stigmatization of Kenyan childhood cancer survivors. METHODS: Caretakers of childhood cancer survivors (<18 years) were interviewed using mixed-methods questionnaires during home or clinic visits between 2021 and 2022. Stigma was assessed with an adjusted Social Impact Scale and risk factors were investigated. RESULTS: Caretakers of 54 survivors (median age 11 years) were interviewed. Families' income (93%) decreased since start of treatment. Caretakers (44%) often lost their jobs. Financial struggles (88%) were a burden that provoked conflicts within communities (31%). School fees for siblings became unaffordable (52%). Families received negative responses (26%) and were left or avoided (13%) by community members after cancer disclosure. Survivors and families were discriminated against because the child was perceived fragile, and cancer was considered fatal, contagious, or witchcraft. Survivors repeated school levels (58%) and were excluded from school activities (19%) or bullied (13%). Performance limitations of daily activities (p = 0.019), male sex (p = 0.032), solid tumors (p = 0.056) and a short time since treatment completion (p = 0.047) were associated with increased stigma. Caretakers recommended educational programs in schools and communities to raise awareness about cancer treatment and curability. CONCLUSIONS: Childhood cancer survivors and their families experienced difficulties with re-entry and stigmatization in society. Increasing cancer and survivorship awareness in schools and communities should facilitate social reintegration and prevent stigmatization.

Expanding Myeloma Training and Care in Western Kenya Through the ECHO Model: The Pilot Phase.

PURPOSE: Multiple myeloma (MM) in rural western Kenya is characterized by under and late diagnosis with poor long-term outcomes. Inadequate skilled rural health care teams are partly to blame. The Extension for Community Healthcare Outcomes (ECHO) model attempts to bridge this skills gap by linking rural primary/secondary health care teams (spokes) to myeloma experts in a tertiary care center (hub) in a longitudinal training program. METHODS: A hub team comprising myeloma experts and administrators from Moi Teaching and Referral Hospital/Academic Model Providing Access to Healthcare was assembled and spoke sites were recruited from rural health care facilities across western Kenya. A curriculum was developed by incorporating input from spokes on their perceived skills gaps in myeloma. Participants joined sessions remotely through virtual meeting technology. ECHO sessions consisted of a spoke-led case presentation with guided discussion followed by an expert-led lecture. An end-of-program survey was used to evaluate participant satisfaction, knowledge, and practice patterns. RESULTS: A total of eight sessions were conducted between April and November 2021 with a median of 40 attendees per session drawn from diverse health care disciplines. Twenty-four spoke sites were identified from 15 counties across western Kenya. The majority of attendees reported satisfaction with the ECHO program (25 of 29) and improvement in their myeloma knowledge (24 of 29). There were 74 new myeloma diagnoses made at the hub site in 2021, representing a 35% increase from the previous 3-year average despite the COVID-19 pandemic that suppressed health care access globally. RECOMMENDATIONS: The pilot ECHO model was successfully implemented in myeloma training for rural-based health care teams. Key attributes included collaborative curriculum development, interactive case-based bidirectional learning, and multidisciplinary engagement.

Barriers to and facilitators of effective management of fever episodes in hospitalised Kenyan children with cancer: protocol for convergent mixed methods study.

INTRODUCTION: Febrile neutropenia is an oncological emergency in children with cancer, associated with serious infections and complications. In low-resourced settings, death from infections in children with cancer is 20 times higher than in high-resourced treatment settings, thought to be related to delays in antibiotic administration and management. The barriers to effective management of fever episodes in children with cancer have not previously been described. This convergent mixed-methods study will provide the evidence to develop fever treatment guidelines and to inform their effective implementation in children with cancer at Moi Teaching and Referral Hospital (MTRH), a level 6 referral hospital in western Kenya. METHODS AND ANALYSIS: Prospective data collection of paediatric patients with cancer with new fever episodes admitted to MTRH will be performed during routine treatment. Clinical variables will be collected from 50 fever episodes, including cancer diagnosis and infectious characteristics of the fever episode, and elapsed time from fever onset to various milestones in the management workflow. Semistructured qualitative interviews with healthcare providers (estimated 20 to reach saturation) will explore the barriers to and facilitators of appropriate management of fever episodes in children with cancer. The interview guide was informed by a theoretical framework and Consolidated Framework for Implementation Research. A mixed-methods analysis use of joint display tables and process mapping will link and integrate the two types of data with meta-inferences. ETHICS AND DISSEMINATION: Institutional review board approval was obtained from the MTRH (0004273) and the University of Michigan (HUM0225674), and the study was registered with National Commission for Science Technology and Innovation (P/23/22885). Written consent will be obtained from all participants. Results will be formally shared with local and national policy leadership and local end users, presented at relevant national academic conferences and submitted for publication in a peer-reviewed journal.

Influence of health-insurance on treatment outcome of childhood cancer in Western Kenya.

BACKGROUND: Few governments in low and middle-income countries (LMIC) have responded favourably to the international plea for Universal Health Coverage. Childhood cancer survival in LMIC is often below 20%. Limited health-insurance coverage may contribute to this poor survival. Our study explores the influence of health-insurance status on childhood cancer treatment outcomes in a Kenyan academic hospital. METHODS: This was a retrospective medical records review of all children diagnosed with cancer at Moi Teaching and Referral Hospital between 2010 and 2016. Socio-demographic and clinical data was collected using a structured data collection form. Fisher's exact test, chi-squared test, Kaplan-Meier method, log-rank test and Cox proportional hazard model were used to evaluate relationships between treatment outcomes and patient characteristics. Study was approved by Institutional Research Ethics Committee. FINDINGS: From 2010-2016, 879 children were newly diagnosed with cancer. Among 763 patients whose records were available, 28% abandoned treatment, 23% died and 17% had progressive/relapsed disease resulting in 32% event-free survival. In total 280 patients (37%) had health-insurance at diagnosis. After active enrolment during treatment, total health-insurance registration level reached 579 patients (76%). Treatment outcomes differed by health-insurance status (P < 0.001). The most likely treatment outcome in uninsured patients was death (49%), whereas in those with health-insurance at diagnosis and those who enrolled during treatment it was event-free survival (36% and 41% respectively). Overall survival (P < 0.001) and event-free survival (P < 0.001) were higher for insured versus uninsured patients. The hazard-ratio for treatment failure was 0.30 (95% CI:0.22-0.39; P < 0.001) for patients insured at diagnosis and 0.32 (95% CI:0.24-0.41; P < 0.001) for patients insured during treatment in relation to those without insurance. INTERPRETATION: Our study highlights the need for Universal Health Coverage in LMIC. Children without health-insurance had significantly lower survival. Childhood cancer treatment outcomes can be ameliorated by strategies that improve health-insurance access.

Treatment outcomes of pediatric acute myeloid leukemia in Western Kenya before and after the implementation of the SIOP PODC treatment guideline.

PURPOSE: The Pediatric Oncology in Developing Countries (PODC) committee of the International Society of Pediatric Oncology (SIOP) published a pediatric acute myeloid leukemia (AML)-specific adapted treatment guideline for low- and middle-income countries. We evaluated the outcomes of children with AML at a large Kenyan academic hospital before (period 1) and after (period 2) implementing this guideline. PATIENTS AND METHODS: Records of children (≤17 years) newly diagnosed with AML between 2010 and 2021 were retrospectively studied. In period 1, induction therapy comprised two courses with doxorubicin and cytarabine, and consolidation comprised two courses with etoposide and cytarabine. In period 2, a prephase with intravenous low-dose etoposide was administered prior to induction therapy, induction course I was intensified, and consolidation was adapted to two high-dose cytarabine courses. Probabilities of event-free survival (pEFS) and overall survival (pOS) were estimated using the Kaplan-Meier method. RESULTS: One-hundred twenty-two children with AML were included - 83 in period 1 and 39 in period 2. Overall, 95 patients received chemotherapy. The abandonment rate was 19% (16/83) in period 1 and 3% (1/39) in period 2. The early death, treatment-related mortality, complete remission, and relapse rates in periods 1 and 2 were 46% (29/63) versus 44% (14/32), 36% (12/33) versus 47% (8/17), 33% (21/63) versus 38% (12/32), and 57% (12/21) versus 17% (2/12), respectively. The 2-year pEFS and pOS in periods 1 and 2 were 5% versus 15% (p = .53), and 8% versus 16% (p = .93), respectively. CONCLUSION: The implementation of the SIOP PODC guideline did not result in improved outcomes of Kenyan children with AML. Survival of these children remains dismal, mainly attributable to early mortality.

Improvement of diagnosis in children with Burkitt lymphoma in Kenya: feasibility study for the implementation of fluorescence in situ hybridisation testing for MYC and the MYC/IGH translocation.

Background: Indiana University (IU) initiated fluorescence in situ hybridisation (FISH) methodology for Burkitt Lymphoma (BL) to advance the accuracy and speed of diagnosis in the AMPATH Reference Laboratory at Moi Teaching and Referral Hospital (MTRH) in Eldoret, Kenya. Standard diagnostic testing for BL at MTRH includes morphology of the biopsy specimen or aspirate and limited immunohistochemistry panels. Methods: Tumour specimens from 19 children enrolled from 2016 to 2018 in a prospective study to improve the diagnosis and staging of children with suspected BL were evaluated. Touch preps from biopsy specimens or smears from fine needle aspiration were collected, stained with Giemsa and/or H&E and reviewed by pathologists to render a provisional diagnosis. Unstained slides were stored and later processed for FISH. Duplicate slides were split between two laboratories for analysis. Flow cytometry results were available for all specimens. Results from the newly established FISH laboratory in Eldoret, Kenya were cross-validated in Indianapolis, Indiana. Results: Concordance studies found 18 of 19 (95%) of specimens studied yielded analysable FISH results for one or both probe sets (MYC and MYC/IGH) in both locations. There was 94% (17/18) concordance of results between the two FISH laboratories. FISH results were 100% concordant for the 16 specimens with a histopathological diagnosis of BL and two of three non-BL cases (one case no result in IU FISH lab). FISH was similarly concordant with flow cytometry for specimens with positive flow results with the exception of a nasopharyngeal tumour with positive flow results for CD10 and CD20 but was negative by FISH. The modal turn-around time for FISH testing on retrospective study specimens performed in Kenya ranged between 24 and 72 hours. Conclusion: FISH testing was established, and a pilot study performed, to assess the feasibility of FISH as a diagnostic tool for the determination of BL in a Kenyan paediatric population. This study supports FISH in limited resource settings to improve the accuracy and speed of diagnosis of BL in Africa.

Late effects of childhood cancer survivors in Africa: A scoping review.

INTRODUCTION: The number of children surviving cancer in Africa is increasing. Knowledge about late effects of survivors is lacking. Our study maps literature regarding late effects of childhood cancer survivors in Africa. METHODS: Scoping review was performed following JBI-guidelines. Systematic literature search was conducted in: Medline, Embase, African Index Medicus, Web of Science, Scopus, Psycinfo. Titles and abstracts were screened by two reviewers, followed by full-text analysis by the lead reviewer. RESULTS: Sixty-eight studies were included for content analysis. Studies originated from 10 of 54 African countries. Most studies had retrospective study design, 2-5 years follow-up, solely chemotherapy as treatment modality, Egypt as country of origin. Fifty-three studies described physical, and seventeen studies described psychosocial late effects. CONCLUSION: Literature concerning late effects is available from a limited number of African countries. Psychosocial domain lacks attention compared to the physical domain. More countries should report on this topic to prevent, identify and monitor late effects.

The continuing evolution of a cancer prevention, screening, and survivorship ECHO: A second year of implementation.

INTRODUCTION: An estimated 39,010 Indiana residents were diagnosed with cancer in 2021. To address the cancer burden, Project ECHO (Extension Community Healthcare Outcomes) was launched in 2019 in Indiana to build specialty healthcare capacity among non-specialists. Due to positive outcomes from the pilot year, the Cancer Prevention, Screening, and Survivorship ECHO was implemented for a second year. The purpose of this study was to measure the participation and regional impact of this ECHO. METHODS: ECHO sessions occurred twice monthly from October 2020 to October 2021. Changes were implemented in response to feedback from the pilot year, including making the curriculum more practical for learners and adding accreditation opportunities. Participant information and feedback was extracted from electronic surveys for review. RESULTS: There were 24 ECHO sessions with 213 unique participants, increased from 140 unique participants in the pilot year. An average of 23.5 individuals attended each session, increased from 15.5 individuals per session. Enrolled participants served in a diverse set of roles and represented 247 zip codes, 30 Indiana counties, and 32 states across the United States, each of which increased from the pilot year. DISCUSSION: In this second year, this ECHO expanded to reach more participants with increased attendance and a more diverse distribution of roles within healthcare, which may be attributed to feedback-driven curriculum design. Cancer care is multi-disciplinary, with health educators, nurses, and administrators, each acting within the cancer care continuum. As a result, this ECHO has been adapted to serve an increasingly broad distribution of professionals. CONCLUSION: The second year of the Cancer Prevention, Screening, and Survivorship ECHO displayed increased overall enrollment and participation, greater diversity among participant roles, and a wider reach across Indiana and the United States.

Early Discharge of Adolescent and Young Adult Patients During Induction Chemotherapy for Newly Diagnosed Acute Lymphoblastic Leukemia: Is It Safe?

There is a lack of consensus for safely discharging adolescent and young adults (AYA) with newly diagnosed acute lymphoblastic leukemia. From 2017 to 2019 we evaluated predefined early discharge criteria for 41 AYA patients during induction chemotherapy. Only 17% (7/41) of patients met criteria for early discharge. Two (29%) patients who were discharged early were readmitted, but not to the pediatric intensive care unit (PICU). This outcome was compared to a historic cohort at our institution of 73 patients who were discharged without predefined discharge criteria. Twenty-seven (37%, p = 0.7) patients were readmitted, but 13 (48%) were readmitted to the PICU (p = 0.004).

Building Cancer Control Capacity in Health Professionals Through Telementoring: A Survey Study of a Cancer Prevention and Survivorship Care ECHO Program.

Project Extension for Community Healthcare Outcomes (Project ECHO©) was developed to democratize knowledge among health professionals in underserved communities. Evidence supporting the use of this model for cancer control is limited. Using surveys adapted from Moore's evaluation framework, we evaluated the training outcomes of an ECHO program on cancer prevention and survivorship care. The study provides preliminary evidence that the ECHO model is a feasible way to build cancer control capacity among the healthcare workforce.

An evaluation of the disparities affecting the underdiagnosis of pediatric cancer in Western Kenya.

INTRODUCTION: Western Kenya is home to approximately 24 million people, with 10 million children under the age of 15 years.1 Based on estimates of cancer incidence in similar populations from around the world, approximately 1500 patients should be diagnosed with pediatric cancer each year. This article describes the international collaboration that investigates potential barriers preventing the effective diagnosis of pediatric patients with cancer. METHODS: Here, we describe a multidisciplinary and sequential approach to better evaluate the complex factors affecting the lack of appropriate diagnosis of pediatric cancer in Western Kenya. RESULTS: Internal review at a large tertiary hospital noted 200-250 patients were diagnosed annually, suggesting the remaining 75%-80% of patients go undiagnosed and do not receive treatment. Following our screening process at a local referring hospital, 41 malaria slides demonstrated both morphologic and genetic evidence of leukemia. Knowledge assessments of local providers at referring institutions suggested a lack of education and training as the factors that contribute to lower rates of diagnosis. DISCUSSION: Through a multi-step approach, our teams were better able to isolate potential issues impeding the appropriate and timely diagnosis of pediatric cancer in Kenya.

An evaluation of an Extension for Community Healthcare Outcomes (ECHO) intervention in cancer prevention and survivorship care.

To improve cancer care in Indiana, a telementoring program using the Extension for Community Healthcare Outcomes (ECHO) model was introduced in September 2019 to promote best-practice cancer prevention, screening, and survivorship care by primary care providers (PCPs). The aim of this study was to evaluate the program's educational outcomes in its pilot year, using Moore's Evaluation Framework for Continuing Medical Education and focusing on the program's impact on participants' knowledge, confidence, and professional practice. We collected data in 22 semi-structured interviews (13 PCPs and 9 non-PCPs) and 30 anonymous one-time surveys (14 PCPs and 16 non-PCPs) from the program participants (hub and spoke site members), as well as from members of the target audience who did not participate. In the first year, average attendance at each session was 2.5 PCPs and 12 non-PCP professionals. In spite of a relatively low PCP participation, the program received very positive satisfaction scores, and participants reported improvements in knowledge, confidence, and practice. Both program participants and target audience respondents particularly valued three features of the program: its conversational format, the real-life experiences gained, and the support received from a professional interdisciplinary community. PCPs reported preferring case discussions over didactics. Our results suggest that the Cancer ECHO program has benefits over other PCP-targetted cancer control interventions and could be an effective educational means of improving cancer control capacity among PCPs and others. Further study is warranted to explain the discrepancies among study participants' perceptions of the program's strengths and the relatively low PCP participation before undertaking a full-scale effectiveness study.

Enhancing cancer prevention and survivorship care with a videoconferencing model for continuing education: a mixed-methods study to identify barriers and incentives to participation.

OBJECTIVE: To enhance cancer prevention and survivorship care by local health care providers, a school of public health introduced an innovative telelearning continuing education program using the Extension for Community Healthcare Outcomes (ECHO) model. In ECHO's hub and spoke structure, synchronous videoconferencing connects frontline health professionals at various locations ("spokes") with experts at the facilitation center ("hub"). Sessions include experts' didactic presentations and case discussions led by spoke site participants. The objective of this study was to gain a better understanding of the reasons individuals choose or decline to participate in the Cancer ECHO program and to identify incentives and barriers to doing so. MATERIALS AND METHODS: Study participants were recruited from the hub team, spoke site participants, and providers who attended another ECHO program but not this one. Participants chose to take a survey or be interviewed. The Consolidated Framework for Implementation Research guided qualitative data coding and analysis. RESULTS: We conducted 22 semistructured interviews and collected 30 surveys. Incentives identified included the program's high-quality design, supportive learning climate, and access to information. Barriers included a lack of external incentives to participate and limited time available. Participants wanted more adaptability in program timing to fit providers' busy schedules. CONCLUSION: Although the merits of the Cancer ECHO program were widely acknowledged, adaptations to facilitate participation and emphasize the program's benefits may help overcome barriers to attending. As the number of telelearning programs grows, the results of this study point to ways to expand participation and spread health benefits more widely.

Outcomes of Wilms tumor treatment in western Kenya.

BACKGROUND/OBJECTIVES: Wilms tumor (WT) is a curable type of cancer with 5-year survival rates of over 90% in high-income countries, whereas this is less than 50% in low- and middle-income countries. We assessed treatment outcomes of children with WT treated at a large Kenyan teaching and referral hospital. DESIGN/METHODS: We conducted a retrospective record review of children diagnosed with WT between 2013 and 2016. Treatment protocol consisted of 6 weeks of preoperative chemotherapy and surgery, and 4-18 weeks of postoperative chemotherapy depending on disease stage. Probability of event-free survival (pEFS) and overall survival (pOS) was assessed using Kaplan-Meier method with Cox regression analysis. Competing events were analyzed with cumulative incidences and Fine-Gray regression analysis. RESULTS: Of the 92 diagnosed patients, 69% presented with high-stage disease. Two-year observed EFS and OS were, respectively, 43.5% and 67%. Twenty-seven percent of children died, 19% abandoned treatment, and 11% suffered from progressive or relapsed disease. Patients who were diagnosed in 2015-2016 compared to 2013-2014 showed higher pEFS. They less often had progressive or relapsed disease (p = .015) and borderline significant less often abandonment of treatment (p = .09). Twenty-nine children received radiotherapy, and 2-year pEFS in this group was 86%. CONCLUSION: Outcome of children with WT improved over the years despite advanced stage at presentation. Survival probabilities of patients receiving comprehensive therapy including radiation are approaching those of patients in high-income countries. Additional improvement could be achieved by ensuring that patients receive all required treatment and working on earlier diagnosis strategies.

Cancer prevention, screening, and survivorship ECHO: A pilot experience with an educational telehealth program.

INTRODUCTION: The American Cancer Society, Inc. (ACS) estimates that 37,940 Indiana residents were diagnosed with cancer in 2020, which remains the leading cause of death in the state. Across the cancer continuum, national goals have been established targeting recommended benchmarks for states in prevention, screening, treatment, and survivorship. Indiana consistently falls below most goals for each of these targeted categories. METHODS: To address these disparities, we implemented Project ECHO (Extension for Community Healthcare Outcomes) as a virtual telehealth educational platform targeted at local healthcare providers. ECHO programs utilize a novel tele-mentoring approach to the education of clinicians in a hub/spoke design. Sessions occurred twice monthly from September 2019 to September 2020 and consisted of a traditional didactic lecture and a case-based discussion led by participating providers. RESULTS: During the pilot year there were a total of 22 ECHO sessions with 140 different participants. On average, 15.5 spokes attended each session with increasing participation at the end of the year. Post-session surveys suggested generally favorable perception with 72% of respondents finding the quality "excellent." DISCUSSION: Given the increasing rate of recurrent participation toward the end of the pilot year in conjunction with the favorable survey responses following each session, it was felt that the program was overall successful and warranted continued implementation. CONCLUSION: The Project ECHO platform is a validated telehealth education platform that has the potential to impact cancer care at multiple points along the cancer continuum at the regional level.

Outcomes of pediatric acute myeloid leukemia treatment in Western Kenya.

BACKGROUND: Pediatric acute myeloid leukemia (AML) is a challenging disease to treat in low- and middle-income countries (LMICs). Literature suggests that survival in LMICs is poorer compared with survival in high-income countries (HICs). AIMS: This study evaluates the outcomes of Kenyan children with AML and the impact of sociodemographic and clinical characteristics on outcome. METHODS AND RESULTS: A retrospective medical records study was performed at Moi Teaching and Referral Hospital (MTRH) in Eldoret, Kenya, between January 2010 and December 2018. Sociodemographic and clinical characteristics, and treatment outcomes were evaluated. Chemotherapy included two "3 + 7" induction courses with doxorubicin and cytarabine and two "3 + 5" consolidation courses with etoposide and cytarabine. Supportive care included antimicrobial prophylaxis with cotrimoxazole and fluconazole, and blood products, if available. Seventy-three children with AML were included. The median duration of symptoms before admission at MTRH was 1 month. The median time from admission at MTRH to diagnosis was 6 days and to the start of AML treatment 16 days. Out of the 55 children who were started on chemotherapy, 18 (33%) achieved complete remission, of whom 10 (56%) relapsed. The abandonment rate was 22% and the early death rate was 46%. The 2-year probabilities of event-free survival and overall survival were 4% and 7%, respectively. None of the sociodemographic and clinical characteristics were significantly associated with outcome. CONCLUSION: Survival of Kenyan children with AML is dismal and considerably lower compared with survival in HICs. Strategies to improve survival should be put in place including better supportive care, optimization of the treatment protocol, and reduction of the abandonment rate and time lag to diagnosis with sooner start of treatment.

Building a Sustainable Comprehensive Multiple Myeloma Program in Western Kenya.

Despite improved treatment strategies for multiple myeloma (MM), patient outcomes in low- and middle-income countries remain poor, unlike high-income countries. Scarcity of specialized human resources and diagnostic, treatment, and survivorship infrastructure are some of the barriers that patients with MM, clinicians, and policymakers have to overcome in the former setting. To improve outcomes of patients with MM in Western Kenya, the Academic Model Providing Access to Healthcare (AMPATH) MM Program was set up in 2012. In this article, the program's activities, challenges, and future plans are described distilling important lessons that can be replicated in similar settings. Through the program, training on diagnosis and treatment of MM was offered to healthcare professionals from 35 peripheral health facilities across Western Kenya in 2018 and 2019. Access to antimyeloma drugs including novel agents was secured, and pharmacovigilance systems were developed. Finally, patients were supported to obtain health insurance in addition to receiving peer support through participation in support group meetings. This article provides an implementation blueprint for similar initiatives aimed at increasing access to care for patients with MM in underserved areas.

Retrospective Analysis of Presentation, Treatment, and Outcomes of Multiple Myeloma at a Large Public Referral Hospital in Eldoret, Kenya.

PURPOSE: Treatment patterns and survival outcomes of patients with multiple myeloma (MM) in Kenya have not been adequately characterized. The objectives of this study were to describe the clinical, laboratory, and imaging findings at diagnosis, to describe the treatment offered, and to determine the survival outcomes of patients with MM over an 11-year period. PATIENTS AND METHODS: A retrospective chart review was carried out for all patients who were diagnosed and treated for MM at Moi Teaching and Referral Hospital from 2009 to 2019. The Kaplan-Meier method was used to estimate survival. Factors affecting survival were identified using univariate and multivariate analyses. RESULTS: A total of 221 patient charts were analyzed of which 124 belonged to male patients (56.1%). The median age at diagnosis was 61 years. Bone pain was the most common presenting complaint observed in 69.6% of 194 patients assessed. Out of 102 patients who received imaging studies, 60 (58.8%) had lytic lesions, 30 (29.4%) had fractures, whereas 30 (29.4%) had spinal cord compression. Anemia, renal failure, and hypercalcemia were observed in 87/187 (46.5%), 22/161 (13.7%), and 23/42 (54.8%) patients, respectively. Thalidomide and dexamethasone (65.2%); bortezomib, thalidomide, and dexamethasone (14.6%); and melphalan and prednisolone (11.9%) were the most prescribed initial chemotherapy regimens among 219 patients analyzed. Overall survival at 1 and 5 years was 70% and 21%, respectively; median overall survival was 29.0 months. In multivariate analysis, male sex (hazard ratio [HR] 1.9), baseline anemia (HR 1.8), and baseline renal failure (HR 3.2) were associated with significantly shorter survival. CONCLUSION: Survival outcomes were poor despite increased use of multiagent-based chemotherapy regimens. Greater access to available diagnostics and treatments is required to achieve rational treatment and increased survival.

Retroperitoneal and Pelvic Lymph Nodes in Children: What Is Normal?

OBJECTIVE. The purpose of this study was to evaluate size criteria for retroperitoneal and pelvic lymph nodes in healthy children. MATERIALS AND METHODS. We identified all trauma patients younger than 18 years old without underlying disease and with CT scans without abnormalities in the abdomen and pelvis during 2014-2015. Two pediatric radiologists reviewed the studies independently and recorded the number of retroperitoneal and pelvic lymph nodes with a long diameter 5 mm or greater and the size (two perpendicular diameters) of the largest lymph node in five anatomic locations. Discrepant results were reviewed in consensus. The relationship of short diameter to age and interobserver variability was evaluated. RESULTS. A total of 166 patients (86 boys) with a mean age of 7.2 years old (range, 0.1-18.0 years old) were identified. More than 95% of lymph nodes in the retroperitoneum and pelvis had a short diameter measuring at most 7 and 8 mm, respectively, by consensus. The size of the largest short diameter of lymph nodes did not vary with age. More than four lymph nodes were identified in any anatomic location in only three patients, by only one of the radiologists. Agreement for lymph nodes with largest diameter of 5 mm or greater between radiologists ranged from 70.5% to 97.6% for the five anatomic locations with poor interobserver agreement (κ, 0.2-0.3). CONCLUSION. The size and number of retroperitoneal and pelvic lymph nodes in children are less than in adults. A short diameter threshold of 7 mm (retroperitoneal) and 8 mm (pelvic) and more than four lymph nodes with long diameter of 5 mm or greater in one location may define disease.