Roberto Vasquez

Low Socioeconomic Status Is Associated with Prolonged Times to Assessment and Treatment, Sepsis and Infectious Death in Pediatric Fever in El Salvador

Background Infection remains the most common cause of death from toxicity in children with cancer in low- and middle-income countries. Rapid administration of antibiotics when fever develops can prevent progression to sepsis and shock, and serves as an important indicator of the quality of care in children with acute lymphoblastic leukemia and acute myeloid leukemia. We analyzed factors associated with (1) Longer times from fever onset to hospital presentation/antibiotic treatment and (2) Sepsis and infection-related mortality. Method This prospective cohort study included children aged 0–16 years with newly diagnosed acute leukemia treated at Benjamin Bloom Hospital, San Salvador. We interviewed parents/caregivers within one month of diagnosis and at the onset of each new febrile episode. Times from initial fever to first antibiotic administration and occurrence of sepsis and infection-related mortality were documented. Findings Of 251 children enrolled, 215 had acute lymphoblastic leukemia (85.7%). Among 269 outpatient febrile episodes, median times from fever to deciding to seek medical care was 10.0 hours (interquartile range [IQR] 5.0–20.0), and from decision to seek care to first hospital visit was 1.8 hours (IQR 1.0–3.0). Forty-seven (17.5%) patients developed sepsis and 7 (2.6%) died of infection. Maternal illiteracy was associated with longer time from fever to decision to seek care (P = 0.029) and sepsis (odds ratio [OR] 3.06, 95% confidence interval [CI] 1.09–8.63; P = 0.034). More infectious deaths occurred in those with longer travel time to hospital (OR 1.36, 95% CI 1.03–1.81; P = 0.031) and in families with an annual household income <US

PREDICTORS OF OUTCOME AND METHODOLOGICAL ISSUES IN CHILDREN WITH ACUTE LYMPHOBLASTIC LEUKAEMIA IN EL SALVADOR

2,000 (OR 13.90, 95% CI 1.62–119.10; P = 0.016). Interpretation Illiteracy, poverty, and longer travel times are associated with delays in assessment and treatment of fever and with sepsis and infectious mortality in pediatric leukemia. Providing additional education to high-risk families and staying at a nearby guest house during periods of neutropenia may decrease sepsis and infectious mortality.

Pediatric oncology research in low income countries: ethical concepts and challenges.

BACKGROUND Most children with cancer live in low-income countries (LICs) where risk factors in paediatric acute lymphoblastic leukaemia (ALL) developed in high-income countries may not apply. METHODS We describe predictors of survival for children in El Salvador with ALL. We included patients <16 years diagnosed with ALL between January 2001 and July 2007 treated with the El Salvador-Guatemala-Honduras II protocol. Demographic, disease-related, socioeconomic and nutritional variables were examined as potential predictors of event-free survival (EFS) and overall survival (OS). RESULTS 260/443 patients (58.7%) were classified as standard risk. Standard- and high-risk 5-year EFS were 56.3 ± 4.5% and 48.6 ± 5.5%; 5-year OS were 77.7 ± 3.8% and 61.9 ± 5.8%, respectively. Among standard-risk children, socioeconomic variables such as higher monthly income (hazard ratio [HR] per

Interventions targeting absences increase adherence and reduce abandonment of childhood cancer treatment in El Salvador

100 = 0.84 [95% confidence interval (CI) 0.70-0.99; P=0.04]) and parental secondary education (HR = 0.49, 95% CI 0.29-0.84; P = 0.01) were associated with better EFS. Among high-risk children, higher initial white blood cell (HR per 10×10(9)/L = 1.03, 95% CI 1.02-1.05; P<0.001) predicted worse EFS; socioeconomic variables were not predictive. The difference in EFS and OS appeared related to overestimating OS secondary to poor follow-up after abandonment/relapse. CONCLUSION Socioeconomic variables predicted worse EFS in standard-risk children while disease-related variables were predictive in high-risk patients. Further studies should delineate pathways through which socioeconomic status affects EFS in order to design effective interventions. EFS should be the primary outcome in LIC studies.

Outcome of children treated for relapsed acute myeloid leukemia in Central America.

Uneven strides in research and care have led to discrepancies in childhood cancer outcomes between high and low income countries (LICs). Collaborative research may help improve outcomes in LICs by generating knowledge for local scientific communities, augmenting knowledge translation, and fostering context‐specific evaluation of treatment protocols. However, the risks of such research have received little attention. This paper investigates the relationship between pediatric oncology research in LICs and four core issues in the ethics literature: standard of care, trial benefits, ethics review, and informed consent. Our aims are to highlight the importance of this field and the need for further inquiry. Pediatr Blood Cancer 2012; 58: 492–497.

Late relapse of embryonal rhabdomyosarcoma, botryoid variant, of the vagina

In El Salvador, about 200 new cases of pediatric cancer are diagnosed each year, and survival rates approach 70%. Although treatment is available at no cost, abandonment of therapy has remained at a steady yearly rate of 13% during the past decade. A time sensitive adherence tracking procedure (TS‐ATP) was recently implemented to detect missed appointments, identify their causes, and intervene promptly.

Outcome of Children Treated for Relapsed Acute Lymphoblastic Leukemia in Central America

Relapsed childhood acute myeloid leukemia (AML) outcomes have not been documented in resource‐limited settings. We examined survival after relapse for children with AML (non‐APML) and acute promyelocytic leukemia (APML) in Central America.

Anaplastic Large Cell Lymphoma in Central America: A Report From the Central American Association of Pediatric Hematology Oncology (AHOPCA).

We report on two very similar cases of vaginal embryonal RMS, botryoid variant, that relapsed 9 and 10 years after initial diagnosis, a few months after the menarche in both cases. A possible causal association with estrogen hormones is hypothesized, particularly for the second case described, in which estrogen receptors were negative in the primary tumor specimen and positive in the relapsing tumor specimen. Pediatr Blood Cancer 2008;51:140–141.

Improving childhood cancer care in Latin America and the Caribbean: a PAHO childhood cancer working group position statement

Outcomes for relapsed childhood acute lymphoblastic leukemia (ALL) have not been documented in resource‐limited settings. This study examined survival after relapse for children with ALL in Central America.

Cost and Cost-Effectiveness of Childhood Cancer Treatment in El Salvador: A Collaborative Budget Model

Although anaplastic large cell lymphoma (ALCL) is curable in high‐income countries (HIC), data from low‐ and middle‐income countries (LMIC) are lacking. We therefore conducted a retrospective study of the Central American Association of Pediatric Hematology Oncology (AHOPCA) experience in treating ALCL.