Closing the global cancer divide--performance of breast cancer care services in a middle income developing country.

BACKGROUND: Cancer is the leading cause of deaths in the world. A widening disparity in cancer burden has emerged between high income and low-middle income countries. Closing this cancer divide is an ethical imperative but there is a dearth of data on cancer services from developing countries. METHODS: This was a multi-center, retrospective observational cohort study which enrolled women with breast cancer (BC) attending 8 participating cancer centers in Malaysia in 2011. All patients were followed up for 12 months from diagnosis to determine their access to therapies. We assess care performance using measures developed by Quality Oncology Practice Initiative, American Society of Clinical Oncology/National Comprehensive Cancer Network, American College of Surgeons' National Accreditation Program for Breast Centers as well as our local guideline. RESULTS: Seven hundred and fifty seven patients were included in the study; they represent about 20% of incident BC in Malaysia. Performance results were mixed. Late presentation was 40%. Access to diagnostic and breast surgery services were timely; the interval from presentation to tissue diagnosis was short (median = 9 days), and all who needed surgery could receive it with only a short wait (median = 11 days). Performance of radiation, chemo and hormonal therapy services showed that about 75 to 80% of patients could access these treatments timely, and those who could not were because they sought alternative treatment or they refused treatment. Access to Trastuzumab was limited to only 19% of eligible patients. CONCLUSIONS: These performance results are probably acceptable for a middle income country though far below the 95% or higher adherence rates routinely reported by centres in developed countries. High cost trastuzumab was inaccessible to this population without public funding support.

A reappraisal of thyroid surgery under local anaesthesia: back to the future?

BACKGROUND: Thyroid surgery is usually performed under general anaesthesia. However, for a selected group of patients, local anaesthesia may be preferable. The aim of this study was to review the authors' experiences with local anaesthesia with regard to the safety and outcome of this approach. METHODS: A total of 65 consecutive patients who underwent primary thyroid surgery were accrued prospectively into this study from May to December 1999. A field block with 0.5% bupivacaine and adrenaline in 1:200 000 dilutions was given in all cases. In addition, light sedative and narcotics were given as necessary to achieve patient comfort and cooperation. The pain experienced during surgery was recorded using a visual analogue scoring system on a scale of 1-10. RESULTS: Unilateral thyroid resection was performed in 58 patients, isthmectomy in four patients and bilateral thyroid resection in three patients, two of which were in their second trimester of pregnancy diagnosed with papillary thyroid cancer. There were 55 women and 10 men with an average age of 38.2 years (range: 18-67 years). No conversion to general anaesthetic was needed, and the mean operating time was 80 min. The postoperative recovery was quick with this technique and, of interest, 22 (33.9%) patients were discharged within 6 h following the surgery. Overall 62 (95.4%) patients were discharged in the first 24 h and three (4.6%) patients after 24 h. There were no significant postoperative complications encountered except for wound infection in two (3.1%) patients. CONCLUSIONS: Thyroid surgery under local anaesthesia can be performed safely in a selected group of patients. It offers an effective alternative approach to general anaesthesia and is associated with low morbidity and high levels of patient satisfaction.

Tear production in vitamin A-responsive xerophthalmia.

Schirmer tests showed decreased tearing (less than 15 mm of wetting) in 32 of 54 eyes (59%) of a representative group of patients with corneal xerophthalmia but in only four of 60 eyes (7%) of age-, sex-, and neighborhood-matched controls (P less than .001). The occurrence of decreased tearing was directly related to protein status: eight of 18 eyes (44%) of children with serum transferrin levels below 50 mg/100 ml but only 13 of 62 eyes (21%) of children with higher levels produced less than 15 mm of wetting (P less than .01). Among otherwise well-nourished children, the occurrence of decreased tearing was directly related to the severity of xerophthalmia and thus to vitamin A status. We found decreased tearing in eight of 86 eyes (9%) of a group of unpaired controls, in nine of 38 eyes (24%) of children with conjunctival xerosis, and in 17 of 62 eyes (27%) of children with corneal involvement (P less than .01).

Clinical characteristics of vitamin A responsive and nonresponsive Bitot's spots.

We examined and followed up 59 patients with conjunctival xerosis with a without classic Bitot's spots. Of these, 50 were responsive and nine were unresponsive to vitamin A. Despite a recent World Health Organization classification suggesting otherwise, all cases appeared to represent the same process. In preschool children, the presence of the Bitot's spots on both sides of the corneoscleral limbus or in association with night blindness or punctate keratopathy suggests active vitamin A deficiency. Pigmentation and wrinkling were not useful diagnostic criteria and lesions isolated to the nasal corneoscleral limbus suggested a different diagnosis. At least some cases of nonresponsive conjunctival xerosis and Bitot's spots were probably sequelae of past vitamin A deficiency.

Lissamine green staining in the clinical diagnosis of xerophthalmia.

Lissamine green staining of the conjunctiva, a new and widely heralded aid for diagnosing early xerophthalmia, was found to be a reasonably specific but inadequately sensitive test for practical use. While 82% of clinically normal children failed to show staining, so did 57% with night blindness, 29% with vitamin A responsive Bitot's spots, and, most significantly, 26% with severe, vitamin A related corneal involvement. The test also failed to distinguish vitamin A responsive "Bitot's spots" from nonresponsive ones.

Vitamin A-responsive punctate keratopathy in xerophthalmia.

Slit-lamp examination of 78 cases of xerophthalmia and 29 controls matched for age, sex, and locale indicated a direct correlation between the presence, density, and extent of punctate epithelial keratopathy and the severity of corneal and noncorneal involvement. Only 7% (four or 58) of control eyes but 60% (six of ten) of cases with confirmed night blindness, 75% (47 of 63) of eyes with conjunctival xerosis, and all eyes with corneal xerosis (47) were affected. Within one week of high-dose systemic vitamin A therapy all affected corneas had improved. None of ten patients receiving low-dose systemic therapy showed any improvement over a two-month period, whereas 61% of involved corneas actually deteriorated in the interim. Punctate epithelial keraptopathy appears to be the earliest corneal manifestation of xerophthalmia, and is already present in the vast majority of cases classically considered free of corneal involvement.

Topical retinoic acid in the treatment of corneal xerophthalmia.

Eight children with corneal xerophthalmia (x2 or x3A) received standard high-protein diets and massive systemic vitamin A therapy. Retinoic acid, 0.1% in oil, was applied daily to one eye, and oil alone to the other. Topical retinoic acid proved safe and effective in speeding corneal healing, especially during the first critical days.