A multimodal strategy to improve health care for pediatric patients with cancer and fever in Peru.

Objective: The DoTT (Decreasing Time to Therapy) project aimed to minimize the interval between fever onset and medical interventions for children with febrile neutropenia. The objective of this study was to determine the effect of implementing the DoTT project on the hospital time to antibiotic (TTA) and patient time to arrival (PTA) at the hospital in children with febrile neutropenia admitted to the emergency department. Methods: The DoTT project was implemented at a Peruvian hospital and followed the World Health Organization (WHO) multimodal improvement strategy model. Components included creating a healthcare delivery bundle and antibiotic selection pathways, training users of the bundle and pathways, monitoring patient outcomes and obtaining user feedback, encouraging use of the new system, and promoting the integration of DoTT into the institutional culture. Emergency room providers were trained in the care delivery for children with cancer and fever and taught to use the bundle and pathways. DoTT was promoted via pamphlets and posters, with a view to institutionalizing the concept and disseminating it to other hospital services. Results: Admission data for 129 eligible patients in our registry were analyzed. The TTA and PTA were compared before and after the DoTT intervention. The median TTA was 146 minutes (interquartile range [IQR] 97-265 minutes) before the intervention in 99 patients, and 69 minutes (IQR 50-120 minutes) afterwards in 30 patients (p < 0.01). The median PTA was reduced from 1 483 minutes at baseline to 660 minutes after the intervention (p < 0.01). Conclusions: Applying the WHO multimodal improvement strategy model to the care of children with febrile neutropenia arriving at the hospital had a positive impact on the PTA and TTA, thus potentially increasing the survival of these patients.

Strengthening public health policies for childhood cancer: Peru's achievements through the WHO Global Initiative for Childhood Cancer.

Objective: To report the progress in Peru, since June 2019, in the implementation of the World Health Organization Global Initiative for Childhood Cancer using the CureAll framework, which can be replicated in low- and middle-income countries. Methods: A mixed method was used of participatory and documentary evaluation. The participatory evaluation included stakeholders from various government institutions, nonprofit organizations, and international partners. The documentary aspect consisted of a review of data on the regulatory environment, national projects, and interventions implemented. The Ministry of Health engaged more than 150 participants to form working committees, which have developed policy and regulatory documents to strengthen care services. Results: Achievements include a decrease in the national treatment abandonment rate from 18.6% to 8.5%, the approval of the Childhood Cancer Law, improvements in the management of patients with febrile neutropenia, and a reduction in rates of events of clinical deterioration and mortality of hospitalized patients. The Cure All implementation framework allows local teams to implement specific strategies and monitor early outcomes in pediatric oncology. Conclusions: The results obtained reflect the teamwork, the leadership of the authorities, the technical support of professionals, and the support of involved organizations. Further actions will be needed to guarantee sustainability, and monitoring tools are needed to assure success in the planned activities.

Impact of COVID-19 in pediatric oncology care in Latin America during the first year of the pandemic.

BACKGROUND: The ongoing coronavirus 2019 disease (COVID-19) pandemic strained medical systems worldwide. We report on the impact on pediatric oncology care in Latin American (LATAM) during its first year. METHOD: Four cross-sectional surveys were electronically distributed among pediatric onco-hematologists in April/June/October 2020, and April/2021 through the Latin American Society of Pediatric Oncology (SLAOP) email list and St Jude Global regional partners. RESULTS: Four hundred fifty-three pediatric onco-hematologists from 20 countries responded to the first survey, with subsequent surveys response rates above 85%. More than 95% of participants reported that treatment continued without interruption for new and active ongoing patients, though with disruptions in treatment availability. During the first three surveys, respondents reported suspensions of outpatient procedures (54.2%), a decrease in oncologic surgeries (43.6%), radiotherapy (28.4%), stem cell transplants (SCT) (69.3%), and surveillance consultations (81.2%). Logistic regression analysis showed that at the beginning of the first wave, participants from countries with healthcare expenditure below 7% were more likely to report a decrease in outpatient procedures (odds ratio [OR]: 1.84, 95% CI: 1.19-2.8), surgeries (OR: 3, 95% CI: 1.9-4.6) and radiotherapy (OR: 6, 95% CI: 3.5-10.4). Suspension of surveillance consultations was higher in countries with COVID-19 case fatality rates above 2% (OR: 3, 95% CI: 1.4-6.2) and SCT suspensions in countries with COVID-19 incidence rate above 100 cases per 100,000 (OR: 3.48, 95% CI: 1.6-7.45). Paradoxically, at the beginning of the second wave with COVID-19 cases rising exponentially, most participants reported improvements in cancer services availability. CONCLUSION: Our data show the medium-term collateral effects of the pandemic on pediatric oncology care in LATAM, which might help delineate oncology care delivery amid current and future challenges posed by the pandemic.

ONCOPEDS: A mobile application to improve early diagnosis and timely referral in childhood cancer in a low- and middle-income country-A pilot study.

BACKGROUND: Diagnosis delay in children and adolescents with cancer is a public health problem in Peru that leads to high rates of advanced disease and mortality. We aimed to assess the implementation feasibility and potential utility of ONCOpeds®, a mobile application that provides consultations with pediatric oncologists, in reducing the latency to diagnosis (LD) and referral time (RT) among children and adolescents in Peru diagnosed with cancer. MATERIAL AND METHODS: A prospective pilot study was conducted in the region of Callao between November 2017 and April 2018. Primary and secondary care providers were trained on the use of ONCOpeds in five educational sessions. Patients younger than 18 years who resided in Callao and were diagnosed with cancer at four pediatric cancer units in Lima were analyzed by referral type: ONCOpeds facilitated or conventional. RESULTS: ONCOpeds was successfully installed in the smartphones of 78 primary and secondary care providers of Callao. During the study period, 23 new cases of cancer in children and adolescents from the region were diagnosed. Ten patients received ONCOpeds-facilitated referrals and 13 received conventional referrals. The RT decreased among those who received ONCOpeds-facilitated referrals by 66% (P = 0.02); however, the LD did not significantly decrease with the use of ONCOpeds. CONCLUSIONS: The implementation of ONCOpeds was found to be feasible in this pilot study, having a potential utility in improving early diagnosis and referral in children and adolescents newly diagnosed with cancer. Directions for future research include multicenter studies with a larger population to further test the application's effectiveness.

Prognostic impact of diagnostic and treatment delays in children with osteosarcoma.

BACKGROUND: The aim of this study is to evaluate the relationship between the latency to diagnosis (LD) and the time to completion of chemotherapy (TCC) with clinical outcomes in children with osteosarcoma. METHODS: We performed a retrospective analysis of all patients who received treatment for osteosarcoma in two tertiary centers in Peru from 2008 to 2015. All causes of delayed LD or TCC were evaluated. Overall survival (OS) and event-free-survival (EFS) were estimated and compared according to LD, TCC, and established clinical prognostic factors. RESULTS: One hundred and thirteen patients were included in the study. The median LD was 13.5 weeks (interquartile range, 10-18.5 weeks). No association was observed among clinical stage, tumor size, and LD. Delayed LD was not associated with a worse clinical outcome. Multivariate analysis confirmed that OS and EFS were significantly worse in cases of a delayed TCC (≥4 weeks), with hazard ratios of 2.70 (1.11-6.76, P = 0.003) and 1.13 (1.00-1.26, P = 0.016), respectively. Most delays in TCC (85%) were due to extramedical reasons (e.g., lack of available hospital beds). CONCLUSION: The LD did not seem to influence the EFS and OS in pediatric patients with osteosarcoma. However, a delay in TCC from any cause is independently associated with poor outcome in pediatric patients with osteosarcoma. Based on these results, further efforts may be needed to avoid treatment delays in patients with osteosarcoma in middle-income countries.

An Efficient Distributed Area Division Method for Cooperative Monitoring Applications with Multiple UAVs.

This article addresses the area division problem in a distributed manner providing a solution for cooperative monitoring missions with multiple UAVs. Starting from a sub-optimal area division, a distributed online algorithm is presented to accelerate the convergence of the system to the optimal solution, following a frequency-based approach. Based on the "coordination variables" concept and on a strict neighborhood relation to share information (left, right, above and below neighbors), this technique defines a distributed division protocol to determine coherently the size and shape of the sub-area assigned to each UAV. Theoretically, the convergence time of the proposed solution depends linearly on the number of UAVs. Validation results, comparing the proposed approach with other distributed techniques, are provided to evaluate and analyze its performance following a convergence time criterion.

A Precise and GNSS-Free Landing System on Moving Platforms for Rotary-Wing UAVs.

This article presents a precise landing system that allows rotary-wing UAVs to approach and land safely on moving platforms, without using GNSS at any stage of the landing maneuver, and with a centimeter level accuracy and high level of robustness. This system implements a novel concept where the relative position and velocity between the aerial vehicle and the landing platform are calculated from the angles of a cable that physically connects the UAV and the landing platform. The use of a cable also incorporates a number of extra benefits, such as increasing the precision in the control of the UAV altitude. It also facilitates centering the UAV right on top of the expected landing position, and increases the stability of the UAV just after contacting the landing platform. The system was implemented in an unmanned helicopter and many tests were carried out under different conditions for measuring the accuracy and the robustness of the proposed solution. Results show that the developed system allowed landing with centimeter accuracy by using only local sensors and that the helicopter could follow the landing platform in multiple trajectories at different velocities.

Efficient Lazy Theta* Path Planning over a Sparse Grid to Explore Large 3D Volumes with a Multirotor UAV.

Exploring large, unknown, and unstructured environments is challenging for Unmanned Aerial Vehicles (UAVs), but they are valuable tools to inspect large structures safely and efficiently. The Lazy Theta* path-planning algorithm is revisited and adapted to generate paths fast enough to be used in real time and outdoors in large 3D scenarios. In real unknown scenarios, a given minimum safety distance to the nearest obstacle or unknown space should be observed, increasing the associated obstacle detection queries, and creating a bottleneck in the path-planning algorithm. We have reduced the dimension of the problem by considering geometrical properties to speed up these computations. On the other hand, we have also applied a non-regular grid representation of the world to increase the performance of the path-planning algorithm. In particular, a sparse resolution grid in the form of an octree is used, organizing the measurements spatially, merging voxels when they are of the same state. Additionally, the number of neighbors is trimmed to match the sparse tree to reduce the number of obstacle detection queries. The development methodology adopted was Test-Driven Development (TDD) and the outcome was evaluated in real outdoors flights with a multirotor UAV. In the results, the performance shows over 90 percent decrease in overall path generation computation time. Furthermore, our approach scales well with the safety distance increases.

Autonomous 3D Exploration of Large Structures Using an UAV Equipped with a 2D LIDAR.

This paper addressed the challenge of exploring large, unknown, and unstructured industrial environments with an unmanned aerial vehicle (UAV). The resulting system combined well-known components and techniques with a new manoeuvre to use a low-cost 2D laser to measure a 3D structure. Our approach combined frontier-based exploration, the Lazy Theta* path planner, and a flyby sampling manoeuvre to create a 3D map of large scenarios. One of the novelties of our system is that all the algorithms relied on the multi-resolution of the octomap for the world representation. We used a Hardware-in-the-Loop (HitL) simulation environment to collect accurate measurements of the capability of the open-source system to run online and on-board the UAV in real-time. Our approach is compared to different reference heuristics under this simulation environment showing better performance in regards to the amount of explored space. With the proposed approach, the UAV is able to explore 93% of the search space under 30 min, generating a path without repetition that adjusts to the occupied space covering indoor locations, irregular structures, and suspended obstacles.

Factors associated with abandonment of therapy by children diagnosed with solid tumors in Peru.

BACKGROUND: Abandonment of treatment is a major cause of treatment failure and poor survival in children with cancer in low- and middle-income countries. The incidence of treatment abandonment in Peru has not been reported. The aim of this study was to examine the prevalence of and factors associated with treatment abandonment by pediatric patients with solid tumors in Peru. METHODS: We retrospectively reviewed the sociodemographic and clinical data of children referred between January 2012 and December 2014 to the two main tertiary centers for childhood cancer in Peru. The definition of treatment abandonment followed the International Society of Paediatric Oncology, Paediatric Oncology in Developing Countries, Abandonment of Treatment recommendation. RESULTS: Data from 1135 children diagnosed with malignant solid tumors were analyzed, of which 209 (18.4%) abandoned treatment. Bivariate logistic regression analysis showed significantly higher abandonment rates in children living outside the capital city, Lima (forest; odds ratio [OR] 3.25; P < 0.001), those living in a rural setting (OR 3.44; P < 0.001), and those whose parent(s) lacked formal employment (OR 4.39; P = 0.001). According to cancer diagnosis, children with retinoblastoma were more likely to abandon treatment compared to children with other solid tumors (OR 1.79; P = 0.02). In multivariate regression analyses, rural origin (OR 2.02; P = 0.001) and lack of formal parental employment (OR 2.88; P = 0.001) were independently predictive of abandonment. CONCLUSION: Treatment abandonment prevalence of solid tumors in Peru is high and closely related to sociodemographical factors. Treatment outcomes could be substantially improved by strategies that help prevent abandonment of therapy based on these results.

Pretreatment Neutrophil-to-Lymphocyte Ratio and Lymphocyte Recovery: Independent Prognostic Factors for Survival in Pediatric Sarcomas.

BACKGROUND: Pretreatment neutrophil-to-lymphocyte ratio (NLR) and absolute lymphocyte count (ALC) recovery have been shown to be associated with prognosis in several types of cancer in adults. However, evidence in pediatric cancer is scarce. The aim of our study was to evaluate whether pretreatment NLR and lymphocyte recovery are prognostic factors in pediatric sarcomas. MATERIALS AND METHODS: Study participants were identified from a retrospective cohort of 100 children with osteosarcoma (n=55), rhabdomyosarcoma (n=22), and Ewing sarcoma (n=23). Data for the hematological variables were obtained from medical records and analyzed with other known prognostic factors in univariate and multivariate analyses. RESULTS: In multivariate analysis, NLR>2 was an independent prognostic factor for OS in patients with osteosarcoma (hazard ratio [HR], 2.27, 95% confidence interval [CI], 1.07-5.30; P=0.046) along with metastatic disease and poor histologic response; as well as in patients with rhabdomyosarcoma (HR, 4.76, 95% CI, 1.01-22.24; P=0.0237) along with metastatic disease and risk group. ALC recovery correlated for inferior OS in osteosarcoma (HR, 3.34, 95% CI, 1.37-8.12; P=0.008) and rhabdomyosarcoma (HR, 3.89; 95% CI, 1.01-14.89; P=0.0338). CONCLUSIONS: Our study confirms that NLR and ALC recovery are independent prognostic factors for pediatric sarcomas, implying an important role of immune system in survival. Clinical utility of these prognostic biomarkers should be validated in larger pediatric studies.

Coastal Areas Division and Coverage with Multiple UAVs for Remote Sensing.

This paper tackles the problems of exact cell decomposition and partitioning of a coastal region for a team of heterogeneous Unmanned Aerial Vehicles (UAVs) with an approach that takes into account the field of view or sensing radius of the sensors on-board. An initial sensor-based exact cell decomposition of the area aids in the partitioning process, which is performed in two steps. In the first step, a growing regions algorithm performs an isotropic partitioning of the area based on the initial locations of the UAVs and their relative capabilities. Then, two novel algorithms are applied to compute an adjustment of this partitioning process, in order to solve deadlock situations that generate non-allocated regions and sub-areas above or below the relative capabilities of the UAVs. Finally, realistic simulations have been conducted for the evaluation of the proposed solution, and the obtained results show that these algorithms can compute valid and sound solutions in complex coastal region scenarios under different setups for the UAVs.

Factors associated with the latency to diagnosis of childhood cancer in Peru.

BACKGROUND: The latency to diagnosis is the time between the detection of a patient's first symptoms and the cancer diagnosis. The aim of this study was to identify the latency to the diagnosis of cancer in children in Peru and the clinical and sociodemographic factors associated with this latency. METHODS: All patients diagnosed with lymphoma and solid tumors between 2012 and 2014 at a social security referral hospital in Peru were retrospectively evaluated. Clinical and demographic variables were analyzed to assess their association with the latency to diagnosis. RESULTS: A total of 284 patients younger than 18 years of age were included in the study. The median time to diagnosis was 8.8 weeks, with a median patient interval of 2 weeks and diagnostic interval of 4.4 weeks. We found significant differences in the latency to diagnosis for different types of cancer (longer for Hodgkin lymphoma and shorter for Wilms tumor). Older children had significantly longer latencies to diagnosis (P = 0.048; OR: 1.05, 95% CI [1.0-1.1]), as did children who were first diagnosed by a general physician rather than by a pediatrician or surgeon (P = 0.028; OR: 2.1, 95% CI [1.1-4.2]). Parental age, level of education, marital status, metastatic disease, clinical stage, and gender did not significantly affect latency to diagnosis as analyzed by a multivariate analysis. CONCLUSION: In Peru, median latency to diagnosis was comparable to that described in developing countries, where the index of suspicion for childhood cancer remains low. It is crucial to establish strategies to optimize early diagnoses using associated factors.

[Colorectal cancer in children: report of three cases]. / Cáncer colorrectal en niños: reporte de tres casos.

Colorectal cancer (CRC) is extremely infrequent in children and adolescents. There is little information about this entity, mainly case reports and review articles. We describe three cases of children with poor-differentiated colorectal carcinoma and advanced disease at onset. The presenting symptoms were abdominal pain and constipation, with a median of latency of symptoms of 4-48 months. None of these patients had operable disease at onset; having a disease progression despite therapy in two cases. This study reaffirms poor prognosis of pediatric CRC, probably due to an aggressive tumoral biology and advanced stage at diagnosis. Therapeutic guidelines are based in adult treatment; therefore, efforts should be made to improve tools in early diagnosis and future therapies for a better survival in childhood.

A robust head tracking system based on monocular vision and planar templates.

This paper details the implementation of a head tracking system suitable for its use in teleoperation stations or control centers, taking into account the limitations and constraints usually associated to those environments. The paper discusses and justifies the selection of the different methods and sensors to build the head tracking system, detailing also the processing steps of the system in operation. A prototype to validate the proposed approach is also presented along with several tests in a real environment with promising results.

Multi-Unmanned Aerial Vehicle (UAV) Cooperative Fault Detection Employing Differential Global Positioning (DGPS), Inertial and Vision Sensors.

This paper presents a method to increase the reliability of Unmanned Aerial Vehicle (UAV) sensor Fault Detection and Identification (FDI) in a multi-UAV context. Differential Global Positioning System (DGPS) and inertial sensors are used for sensor FDI in each UAV. The method uses additional position estimations that augment individual UAV FDI system. These additional estimations are obtained using images from the same planar scene taken from two different UAVs. Since accuracy and noise level of the estimation depends on several factors, dynamic replanning of the multi-UAV team can be used to obtain a better estimation in case of faults caused by slow growing errors of absolute position estimation that cannot be detected by using local FDI in the UAVs. Experimental results with data from two real UAVs are also presented.

Primary osteosarcoma of the skull in teenager.

Osteosarcoma of the skull is a rare primary malignant bone tumour in children, representing 1-2% of all cranial tumours. We describe a case of a 17-year-old adolescent with chondroblastic osteosarcoma of the parietal-occipital bone and no distant metastases at presentation treated with neoadjuvant chemotherapy, surgery and, later, concurrent chemoradiotherapy. The patient suffered progressive disease and died 15 months after diagnosis. There are at least 15 paediatric cases of osteosarcoma of the skull described in the literature. Due to its rarity, there are no broad prospective studies on this entity, which has distinctive features when compared to other craniofacial tumours, carrying a worse prognosis. Complete surgical resection is needed for long-term survival, whereas chemotherapy and radiotherapy have still questionable indications.

Advancing Parental Age and Risk of Solid Tumors in Children: A Case-Control Study in Peru.

BACKGROUND: The causes of childhood cancer are not well known, but the advanced age of the parents has been suggested as a risk factor for childhood cancer in several observational studies. In this study, we examine a possible link between parental age and childhood solid tumors. METHODS: We conducted a hospital-based case-control study (310 cases and 620 controls, matched by age and gender) at Rebagliati Hospital, Lima, Peru. Odd ratio was used to compare categories of advancing maternal and paternal age with and without adjusting for possible confounding factors were calculated. RESULTS: The risk of childhood retinoblastoma was significantly higher among children of mothers aged> 35 years (adjusted OR 1.21; 95% CI, 1.09-6.08) and fathers aged> 35 years (OR 1.17; 1.01-16.33). A significant trend with increasing mother's age (p = 0.037) and father's age (p = 0.005) was found. There were more risks to development of non-Hodgkin's lymphoma (p = 0.047) and gonadal germ cell tumors (p = 0.04) for advanced paternal age. There was a strong protective effect of increasing parity on risk of solid tumors in children (p=0.0015). CONCLUSION: Our results suggest that advanced parental age is associated with the risk for the development of retinoblastoma. Advanced paternal age increases the risk of non-Hodgkin lymphoma and gonadal germ cell tumor. The higher the order of birth of the children, the less the chance of developing any neoplasm.