Clarice Franco Meneses

Poverty levels and children's health status: study of risk factors in an urban population of low socioeconomic level

To test the hypothesis that the low socioeconomic population living in shanty towns in Porto Alegre presents different levels of poverty which are reflected on its health status, a cross-sectional study was designed involving 477 families living in Vila Grande Cruzeiro, Porto Alegre, Brazil. The poverty level of the families was measured by using an instrument specifically designed for poor urban populations. Children from families living in extreme poverty (poorest quartile) were found to have higher infant mortality rate, lower birth weights, more hospitalizations, and higher malnutrition rates, in addition to belonging to more numerous families. Thus, the shanty town population of Porto Alegre is not homogeneous, and priority should be given to the more vulnerable subgroups.

Breastfeeding pattern in a population with different levels of poverty in southern Brazil.

A cross‐sectional study was conducted on 477 poor children aged 12–59 months in order to investigate their breastfeeding pattern, taking into account the poverty level of their families. Although the population living in extreme poverty had the same pattern of breastfeeding as the rest of the poor population, the former group should still have priority in breastfeeding promotion programs, since they are the population who benefit most with breastfeeding.

The influence of traumatic lumbar puncture and timing of intrathecal therapy on outcome of pediatric acute lymphoblastic leukemia

The CNS is a frequent site of relapse of childhood acute lymphoblastic leukemia (ALL). Traumatic lumbar puncture (TLP) is thought to increase the risk of CNS relapse. The authors examined whether TLP at the time of diagnosis affected outcome and whether this effect was influenced by the timing of intrathecal therapy (IT) in 77 patients with newly diagnosed ALL. IT was instilled at the time of either the diagnostic LP (early) or a second LP 24–48 h later (delayed). Of the 19 patients who had a TLP at diagnosis and received late IT therapy, 6 had isolated CNS relapse and 2 had combined CNS and bone marrow (BM) relapse. Of the 9 patients who had TLP and received early IT therapy, 1 had a CNS relapse (p = .20). In an analysis stratified according to risk of relapse, the odds ratio (OR) for relapse was 0.8 among patients at low and standard risk who had delayed IT therapy after TLP (p = .99) vs. 0.17 for those who had early IT (p = .47). Importantly, among patients with high-risk ALL, the OR for relapse was 21.0 for delayed IT therapy (p = .09) and only 1.5 for early IT therapy after TLP (p = .99). The results indicate that TLP at diagnosis appears to increase the risk of CNS relapse markedly in patients with high-risk ALL, and the use of early IT therapy appears to reduce this risk. These findings need to be confirmed by prospective, randomized studies.

Safety of general anesthesia for lumbar puncture and bone marrow aspirate/biopsy in pediatric oncology patients.

Introduction Painful short duration procedures such as bone marrow aspiration/biopsy and the lumbar puncture with or without intrathecal chemotherapy are frequently performed during the treatment of children with cancer. This study evaluated the frequency and severity of complications of bone marrow aspiration biopsy and lumbar puncture/intrathecal chemotherapy under general anesthesia. Patients and Methods A prospective observational study was performed from November 2003 to August 2005. Patients with cancer younger than 21 years old, receiving treatment at the Pediatric Oncology Unity of Hospital de Clínicas de Porto Alegre, undergoing diagnostic and/or therapeutic short duration procedures carried out under general anesthesia in the outpatient surgery unit. Results One hundred and thirty-seven patients were submitted to 423 procedures under general anesthesia. There were 61% boys, mean age of 7.5 years (0.2 to 21) and ASA II 98%. Eighty seven percent of the procedures were carried out in patients with leukemia or lymphoma. The majority of the procedures had no adverse events during intraoperative and postoperative periods. No procedure had to be suspended after it had begun. One patient had lumbar pain after the procedure and was admitted to the ward with suspected subdural bleeding, but this was not confirmed. No patient needed cardiopulmonary reanimation or treatment in the intensive care unit. Conclusions General anesthesia for short duration painful procedures in children undergoing treatment for malignancies is safe when carried out by trained professionals in outpatient clinical surgery unit.

Dasatinib after allogeneic stem cell transplantation in a child with Philadelphia chromosome positive acute lymphoblastic leukemia.

To the Editor: We read with interest the article ‘‘Successful second allogeneic stem cell transplantation in second remission induced by dasatinib in a child with Philadelphia chromosome positive acute lymphoblastic leukemia’’ [1]. We would like to share a similar experience with a 4-year-old male diagnosed with Philadelphia (Ph) positive acute lymphoblastic leukemia (ALL) at our institution. He initially received conventional chemotherapy using an induction protocol similar to BFM 95 achieving a hematological remission, although he remained Ph PCR positive. Seven months after diagnosis he received bone marrow transplantation (BMT) from his identical matched HLA sister. Conditioning regimen consisted of etoposide 60 mg/kg and total body irradiation of 1,200 cGy. Conventional immunosuppressive doses of cyclosporine and methotrexate were used. He had no severe complications and no evidence of graft versus host disease. A bone marrow aspiration 2 months after BMT showed a complete remission and a female karyotype with no evidence of Ph chromosome. Three months post-BMT he had a bone marrow relapse; cyclosporin was resumed and he received induction chemotherapy with vincristine, asparaginase, and prednisone which lead to a bone marrow remission. Four months post-BMT he had a second relapse; following 1 month of re-induction therapy with oral etoposide, vincristine, prednisone, and asparaginase he again achieved a remission. IRB approved compassionate treatment with dasatinib was instituted 2 months later at the dose of 60 mg/m bid (40 mg bid) combined with vincristine (1.5 mg/m weekly for 4 weeks). Unfortunately after 2 months of therapy he had another relapse; prednisone and asparaginase were added to the schema and dasatinib was kept at the same dose. Bone marrow remission was again achieved; however, PCR for Ph was still positive. Due to his excellent clinical condition, he received a new transplantation from the same donor, using a non-myeloablative regimen with fludarabine, melphalan, and carmustine. Dasatinib was tapered off during conditioning and resumed 20 days after transplantation. Two months after the second BMT he had a CSF and the fourth bone marrow relapse. Dasatinib was tapered off and he received palliative care, dying 4 months after the second transplantation. In this heavily pretreated patient, dasatinib in combination with other agents was well tolerated with no moderate or severe toxicities; which is in concordance to the experience described by Milott et al. [1]. Unfortunately, we were not able to obtain a longterm remission of this disease. We believe that dasatinib deserves more investigational studies in children. CML and Ph positive ALL are rare in this population and prospective studies take a long time to be completed; we believe that sharing single cases or series of cases experiences may help children in this same condition.

Autologous stem cell transplantation as first line treatment after incomplete excision of pancreatoblastoma.

Pancreatoblastoma is a rare tumor and surgery with complete resection is the main treatment approach. Prognosis for patients with residual disease after surgery is usually dismal. A 14-year-old girl with pancreatoblastoma in the pancreatic body and tail was submitted to preoperative chemotherapy. She underwent surgery and the tumor was resected with microscopic margins. Postoperative chemotherapy was followed by high dose chemotherapy and autologous hematopoietic stem cell transplantation. After four years she remains very well with no evidence of disease. This is the first case reported of pancreatoblastoma that was treated with autologous hematopoietic stem cell transplantation as first line treatment without radiotherapy at the site of the microscopic disease.