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Assessment of Barriers and Enablers to Implementation of a Pediatric Early Warning System in Resource-Limited Settings
(2022) Agulnik, Asya; Ferrara, Gia; Puerto-Torres, Maria; Gillipelli, Srinithya R; Elish, Paul; Muniz-Talavera, Hilmarie; Gonzalez-Ruiz, Alejandra; Armenta, Miriam; Barra, Camila; Diaz, Rosdali; Hernandez, Cinthia; Juárez Tobias, Susana; de Jesus Loeza, Jose; Mendez, Alejandra; Montalvo, Erika; Penafiel, Eulalia; Pineda, Estuardo; Graetz, Dylan E
Importance: Pediatric early warning systems (PEWS) aid with early identification of clinical deterioration and improve outcomes in children with cancer hospitalized in resource-limited settings; however, there may be barriers to implementation. Objective: To evaluate stakeholder-reported barriers and enablers to PEWS implementation in resource-limited hospitals. Design, setting, and participants: In this qualitative study, semistructured stakeholder interviews were conducted at 5 resource-limited pediatric oncology centers in 4 countries in Latin America. Hospitals participating in a multicenter collaborative to implement PEWS were purposefully sampled based on time required for implementation (fast vs slow), and stakeholders interviewed included physicians, nurses, and administrators, involved in PEWS implementation. An interview guide was developed using the Consolidated Framework for Implementation Research (CFIR). Interviews were conducted virtually in Spanish, audiorecorded, and professionally transcribed and translated into English. A codebook was developed a priori using the CFIR and supplemented with codes inductively derived from transcript review. Two coders independently analyzed all transcripts, achieving a κ of 0.8 to 0.9. The study was conducted from June 1 to August 31, 2020. Main outcomes and measures: Thematic analysis was conducted based on CFIR domains (inner setting, characteristics of individuals, outer setting, intervention characteristics, and implementation process) to identify barriers and enablers to PEWS implementation. Results: Seventy-one staff involved in PEWS implementation were interviewed, including 32 physicians (45%), 32 nurses (45%), and 7 administrators (10%). Of these, 50 were women (70%). Components of the 5 CFIR domains were mentioned by participants as barriers and enablers to PEWS implementation at both fast- and slow-implementing centers. Participants emphasized barriers at the level of the clinical staff, hospital, external factors, and PEWS intervention. These barriers included staff resistance to change, inadequate resources, components of health systems, and the perceived origin and complexity of PEWS. At all centers, most barriers were successfully converted to enablers during the implementation process through targeted strategies, such as early stakeholder engagement and adaptation, including adapting PEWS to better fit the local context and changing the hospital setting to support ongoing use of PEWS. Conclusions and relevance: To date, this is the first multicenter, multinational study describing barriers and enablers to PEWS implementation in resource-limited settings. Findings suggest that many barriers are not immutable and can be converted to enablers during the implementation process. This work can serve as a guide for clinicians looking to implement evidence-based interventions to reduce global disparities in patient outcomes.
Characteristics and outcomes of thymomas in Latin America: Results from over 10 years of experience (CLICaP-LATimus)
(Thorac Cancer, 2021) Martín, Claudio; Enrico, Diego; Mas, Luis; Patane, Ana Karina; Arrieta, Oscar; Soria, Tannia; Cardona, Andres F.; Ruiz-Patiño, A.; Ruiz, Rossana; Rioja, Patricia; Lozano, Sophia; Zatarain-Barrón Zyanya Lucia; Barrón, Feliciano; Puparelli, Carmen; Tsou Florencia; Corassa, Marcelo P.; Freitas, Helano C.; Cordeiro de Lima, Vladmir Cláudio; Rojas, Leonardo; Ordóñez-Reyes, Camila; Corrales, Luis; Sotelo, Carolina; Rodríguez, July; Ricaurte, Luisa; Ávila, Jenny; Archila, Pilar; Rosell, Rafael; Cuello, Mauricio; Remon, Jordi
Background: Thymomas are a group of rare neoplasms of the anterior mediastinum. The objective of this study was to describe the demographics, clinical characteristics and treatment approaches in Latin America. Methods: This was a retrospective multicenter cohort study including patients with histologically proven thymomas diagnosed between 1997 and 2018. Demographics, clinicopathological characteristics and therapeutic outcomes were collected locally and analyzed in a centralized manner. Results: A total of 135 patients were included. Median age at diagnosis was 53 years old (19-84), 53.3% (n = 72) of patients were female and 87.4% had an ECOG performance score ranging from 0-1. A total of 47 patients (34.8%) had metastatic disease at diagnosis. Concurrent myasthenia gravis occurred in 21.5% of patients. Surgery was performed in 74 patients (54.8%), comprising 27 (20%) tumorectomies and 47 (34.8%) thymectomies. According to the Masaoka-Koga system, overall survival (OS) at five-years was 73.4%, 63.8% and 51%, at stages I-II, III-IVA and IVB, respectively (p = 0.005). Furthermore, patients with low lactate dehydrogenase (LDH) (≤373 IU/L) at baseline and myasthenia gravis concurrence showed significantly better OS (p = 0.001 and p = 0.008, respectively). In multivariate analysis, high LDH levels (HR 2.8 [95% confidence interval [CI]: 1.1-7.8]; p = 0.036) at baseline and not performing a surgical resection (HR 4.1 [95% CI: 1.3-12.7]; p = 0.016) were significantly associated with increased risk of death. Conclusions: Our data provides the largest insight into the clinical characteristics and outcomes of patients with thymomas in Latin America. Survival in patients with thymomas continues to be very favorable, especially when subjected to adequate local control. Keywords: Latin America; cohort studies; medical oncology; thymoma.
Clinical and organizational risk factors for mortality during deterioration events among pediatric oncology patients in Latin America: A multicenter prospective cohort
(2021) Agulnik, Asya; Cárdenas, Adolfo; Carrillo, Angela K; Bulsara, Purva; Garza, Marcela; Alfonso Carreras, Yvania; Alvarado, Manuel; Calderón, Patricia; Díaz, Rosdali; de León, Claudia; Del Real, Claudia; Huitz, Tania; Martínez, Angélica; Miralda, Scheybi; Montalvo, Erika; Negrín, Octavia; Osuna, Alejandra; Perez Fermin, Clara Krystal; Pineda, Estuardo; Soberanis, Dora; Juárez Tobias, Maria Susana; Lu, Zhaohua; Rodriguez-Galindo, Carlos; EVAT Study Group
Background Hospitalized pediatric hematology‐oncology (PHO) patients have frequent clinical deterioration events (CDE) requiring intensive care unit (ICU) admission, particularly in resource‐limited settings. The objective of this study was to describe CDEs in hospitalized PHO patients in Latin America and to identify event‐level and center‐level risk factors for mortality. Methods In 2017, the authors implemented a prospective registry of CDEs, defined as unplanned transfers to a higher level of care, use of ICU‐level interventions on the floor, or nonpalliative floor deaths, in 16 PHO centers in 10 countries. PHO hospital admissions and hospital inpatient days were also reported. This study analyzes the first year of registry data (June 2017 to May 2018). Results Among 16 centers, 553 CDEs were reported in PHO patients during 11,536 admissions and 119,414 inpatient days (4.63 per 1000 inpatient days). Event mortality was 29% (1.33 per 1000 inpatient days) but ranged widely across centers (11%‐79% or 0.36‐5.80 per 1000 inpatient days). Significant risk factors for event mortality included requiring any ICU‐level intervention on the floor and not being transferred to a higher level of care. Events with organ dysfunction, a higher severity of illness, and a requirement for ICU intervention had higher mortality. In center‐level analysis, hospitals with a higher volume of PHO patients, less floor use of ICU intervention, lower severity of illness on transfer, and lower rates of floor cardiopulmonary arrest had lower event mortality. Conclusions Hospitalized PHO patients who experience CDEs in resource‐limited settings frequently require floor‐based ICU interventions and have high mortality. Modifiable hospital practices around the escalation of care for these high‐risk patients may contribute to poor outcomes. Earlier recognition of critical illness and timely ICU transfer may improve survival in hospitalized children with cancer. Keywords: clinical deterioration, intensive care, Latin America, pediatric oncology, Pediatric Early Warning Systems (PEWS), resource‐limited settings
Clinical characteristics, systemic complications, and in-hospital outcomes for patients with COVID-19 in Latin America. LIVEN-Covid-19 study: A prospective, multicenter, multinational, cohort study
(2022) Reyes, Luis F; Bastidas, Alirio; Narváez, Paula O; Parra-Tanoux, Daniela; Fuentes, Yuli V; Serrano-Mayorga, Cristian C; Ortíz, Valentina; Caceres, Eder L; Ospina-Tascon, Gustavo; Díaz, Ana M; Jibaja, Manuel; Vera, Magdalena; Silva, Edwin; Gorordo-Delsol, Luis Antonio; Maraschin, Francesca; Varón-Vega, Fabio; Buitrago, Ricardo; Poveda, Marcela; Saucedo, Lina M; Estenssoro, Elisa; Ortíz, Guillermo; Nin, Nicolás; Calderón, Luis E; Montaño, Gina S; Chaar, Aldair J; García, Fernanda; Ramírez, Vanessa; Picoita, Fabricio; Peláez, Cristian; Unigarro, Luis; Friedman, Gilberto; Cucunubo, Laura; Bruhn, Alejandro; Hernández, Glenn; Martin-Loeches, Ignacio
Purpose: The COVID-19 pandemic has spread worldwide, and almost 396 million people have been infected around the globe. Latin American countries have been deeply affected, and there is a lack of data in this regard. This study aims to identify the clinical characteristics, in-hospital outcomes, and factors associated with ICU admission due to COVID-19. Furthermore, to describe the functional status of patients at hospital discharge after the acute episode of COVID-19. Material and methods: This was a prospective, multicenter, multinational observational cohort study of subjects admitted to 22 hospitals within Latin America. Data were collected prospectively. Descriptive statistics were used to characterize patients, and multivariate regression was carried out to identify factors associated with severe COVID-19. Results: A total of 3008 patients were included in the study. A total of 64.3% of patients had severe COVID-19 and were admitted to the ICU. Patients admitted to the ICU had a higher mean (SD) 4C score (10 [3] vs. 7 [3)], p<0.001). The risk factors independently associated with progression to ICU admission were age, shortness of breath, and obesity. In-hospital mortality was 24.1%, whereas the ICU mortality rate was 35.1%. Most patients had equal self-care ability at discharge 43.8%; however, ICU patients had worse self-care ability at hospital discharge (25.7% [497/1934] vs. 3.7% [40/1074], p<0.001). Conclusions: This study confirms that patients with SARS CoV-2 in the Latin American population had a lower mortality rate than previously reported. Systemic complications are frequent in patients admitted to the ICU due to COVID-19, as previously described in high-income countries.
Cytogenetic and Molecular Characterization of Hematological Neoplasm in an Ecuadorian population
(Open Journal of Blood Diseases, 2013-12-01) Paz-y-Miño, César; Sánchez, María Eugenia; Araujo, Santiago; Ocampo, Ligia; Espín, Víctor Hugo; Leone, Paola E.
Cancer is one of the major causes of mortality in Ecuador and annually, hematological malignancies are within the top ten most common cancers. In this multicentric study, we analyzed a series of patients diagnosed with different hematological disorders between the years 1984 and 2012. Chromosome abnormalities were detected in 1886 (45.9%) patients. FISH and RT-PCR techniques were used in order to determine the presence of genetic rearrangements and complement conventional cytogenetics results. Using FISH and RT-PCR, positive cases were increased by 1.8% and 6.9% respec- tively. We analyzed fusion genes resulting from t(8;21), t(15;17), inv(16), t(9;22), 11q23 rearrangements, t(4;11) and t(1;19). The frequency of transcripts of some of these fusion genes was of particular interest as our results differ from studies on other populations. Specifically, the fusion gene BCR-ABL was present in the form of the b2/a2 transcript in 95% of CML patients and in the form of b3/a2 transcript in the remaining 5%. The PML-RARA fusion gene also showed a distinct pattern of transcript expression. This fusion gene exhibited the bcr2 (36%) and bcr3 (64%) transcripts, how- ever the bcr1 transcript was absent from our sample population. All cases carrying the CBFB-MYH11 fusion gene ex- hibited the F transcript. This was also of interest due to the rarity of this particular transcript worldwide. Finally all cases carrying the MLL-AF4 fusion gene displayed the e7-e8 transcript. The frequency of the subtypes of some fusion genes differ from those reported in other populations, possibly due to the particular genetic make-up of the Ecuadorian population, mostly mestizo, as well as environmental factors.
Early rise in central venous pressure during a spontaneous breathing trial: A promising test to identify patients at high risk of weaning failure?
(2019) Dubo, Sebastián; Valenzuela, Emilio Daniel; Aquevedo, Andrés; Jibaja, Manuel; Berrutti, Dolores; Labra, Christian; Lagos, Rossana; García, María Fernanda; Ramírez, Vanessa; Tobar, Milton; Picoita, Fabricio; Peláez, Cristian; Carpio, David; Alegría, Leyla; Hidalgo, Carolina; Godoy, Karen; Bruhn, Alejandro; Hernández, Glenn; Bakker, Jan; Castro, Ricardo
Background The spontaneous breathing trial (SBT) assesses the risk of weaning failure by evaluating some physiological responses to the massive venous return increase imposed by discontinuing positive pressure ventilation. This trial can be very demanding for some critically ill patients, inducing excessive physical and cardiovascular stress, including muscle fatigue, heart ischemia and eventually cardiac dysfunction. Extubation failure with emergency reintubation is a serious adverse consequence of a failed weaning process. Some data suggest that as many as 50% of patients that fail weaning do so because of cardiac dysfunction. Unfortunately, monitoring cardiovascular function at the time of the SBT is complex. The aim of our study was to explore if central venous pressure (CVP) changes were related to weaning failure after starting an SBT. We hypothesized that an early rise on CVP could signal a cardiac failure when handling a massive increase on venous return following a discontinuation of positive pressure ventilation. This CVP rise could identify a subset of patients at high risk for extubation failure. Methods Two-hundred and four mechanically ventilated patients in whom an SBT was decided were subjected to a monitoring protocol that included blinded assessment of CVP at baseline, and at 2 minutes after starting the trial (CVP-test). Weaning failure was defined as reintubation within 48-hours following extubation. Comparisons between two parametric or non-parametric variables were performed with student T test or Mann Whitney U test, respectively. A logistic multivariate regression was performed to determine the predictive value on extubation failure of usual clinical variables and CVP at 2-min after starting the SBT. Results One-hundred and sixty-five patients were extubated after the SBT, 11 of whom were reintubated within 48h. Absolute CVP values at 2-minutes, and the change from baseline (dCVP) were significantly higher in patients with extubation failure as compared to those successfully weaned. dCVP was an early predictor for reintubation (OR: 1.70 [1.31,2.19], p<0.001). Conclusions An early rise in CVP after starting an SBT was associated with an increased risk of extubation failure. This might represent a warning signal not captured by usual SBT monitoring and could have relevant clinical implications.
Effect of High Altitude on the Survival of COVID-19 Patients in Intensive Care Unit: A Cohort Study
(2022) Jibaja, Manuel; Roldan-Vasquez, Estefania; Rello, Jordi; Shen, Hua; Maldonado, Nelson; Grunauer, Michelle; Díaz, Ana María; García, Fernanda; Ramírez, Vanessa; Sánchez, Hernán; Barberán, José Luis; Paredes, Juan Pablo; Cevallos, Mónica; Montenegro, Francisco; Puertas, Soraya; Briones, Killen; Martínez, Marlon; Vélez-Páez, Jorge; Montalvo-Villagómez, Mario; Herrera, Luis; Garrido, Santiago; Sisa, Ivan
Purpose: The effect of high altitude ( ≥ 1500 m) and its potential association with mortality by COVID-19 remains controversial. We assessed the effect of high altitude on the survival/discharge of COVID-19 patients requiring intensive care unit (ICU) admission for mechanical ventilation compared to individuals treated at sea level. Methods: A retrospective cohort multi-center study of consecutive adults patients with a positive RT-PCR test for COVID-19 who were mechanically ventilated between March and November 2020. Data were collected from two sea-level hospitals and four high-altitude hospitals in Ecuador. The primary outcome was ICU and hospital survival/discharge. Survival analysis was conducted using semi-parametric Cox proportional hazards models. Results: Of the study population (n = 670), 35.2% were female with a mean age of 58.3 ± 12.6 years. On admission, high-altitude patients were more likely to be younger (57.2 vs. 60.5 years old), presented with less comorbidities such as hypertension (25.9% vs. 54.9% with p-value <.001) and diabetes mellitus (20.5% vs. 37.2% with p-value <.001), less probability of having a capillary refill time > 3 sec (13.7% vs. 30.1%, p-value <.001), and less severity-of-illness condition (APACHE II score, 17.5 ± 8.1 vs. 20 ± 8.2, p < .01). After adjusting for key confounders high altitude is associated with significant higher probabilities of ICU survival/discharge (HR: 1.74 [95% CI: 1.46-2.08]) and hospital survival/discharge (HR: 1.35 [95% CI: 1.18-1.55]) than patients treated at sea level. Conclusions: Patients treated at high altitude at any time point during the study period were 74% more likely to experience ICU survival/discharge and 35% more likely to experience hospital survival/discharge than to the sea-level group. Possible reasons for these findings are genetic and physiological adaptations due to exposure to chronic hypoxia. Keywords: COVID-19; ICU; SARS-CoV-2; high altitude; sea level; survival.
Essential Emergency and Critical Care: a consensus among global clinical experts
(2021) Schell, Carl Otto; Khalid, Karima; Wharton-Smith, Alexandra; Oliwa, Jacquie; Sawe, Hendry R; Roy, Nobhojit; Sanga, Alex; Marshall, John C; Rylance, Jamie; Hanson, Claudia; Kayambankadzanja, Raphael K; Wallis, Lee A; Jirwe, Maria; Baker, Tim; EECC Collaborators; EECC Collaborators*
Background: Globally, critical illness results in millions of deaths every year. Although many of these deaths are potentially preventable, the basic, life-saving care of critically ill patients are often overlooked in health systems. Essential Emergency and Critical Care (EECC) has been devised as the care that should be provided to all critically ill patients in all hospitals in the world. EECC includes the effective care of low cost and low complexity for the identification and treatment of critically ill patients across all medical specialties. This study aimed to specify the content of EECC and additionally, given the surge of critical illness in the ongoing pandemic, the essential diagnosis-specific care for critically ill patients with COVID-19. Methods: In a Delphi process, consensus (>90% agreement) was sought from a diverse panel of global clinical experts. The panel iteratively rated proposed treatments and actions based on previous guidelines and the WHO/ICRC's Basic Emergency Care. The output from the Delphi was adapted iteratively with specialist reviewers into a coherent and feasible package of clinical processes plus a list of hospital readiness requirements. Results: The 269 experts in the Delphi panel had clinical experience in different acute medical specialties from 59 countries and from all resource settings. The agreed EECC package contains 40 clinical processes and 67 requirements, plus additions specific for COVID-19. Conclusion: The study has specified the content of care that should be provided to all critically ill patients. Implementing EECC could be an effective strategy for policy makers to reduce preventable deaths worldwide. Keywords: COVID-19; health policy; health services research; health systems; surgery.
Evaluación de los conocimientos generales de los profesionales de la salud ecuatorianos acerca del cáncer renal
(Práctica Fam Rural, 2018) Torres, Fausto Gady; Soria, Tannia; Moreno, Andrea; Ruilova, Erika; Irigoyen Paulina
Introducción: el cáncer renal, como toda patología oncológica, tiene un mejor pronostico si es diagnosticada tempranamente, de manera general los médicos especialistas no son la puerta de entrada de esta enfermedad al sistema de salud, por lo que es indispensable tener ciertos indicios clínicos en médicos no especialistas o de diferentes especialidades. Objetivo: Evaluar el nivel de conocimientos de los Médicos Ecuatorianos sobre el Cáncer Renal. Metodología: Se realizó un estudio de corte transversal, la información fue recolectada a través de una encuesta diseñada para esta investigación. se calcula la muestra en base a prevalencias de conocimientos regionales con un nivel de confianza de 95%. Resultados: en general los aciertos a las preguntas de conocimientos fueron elevados (61%), el puntaje fue más alto en especialidades directamente relacionadas. El componente más afectado fue el de tratamiento (38%). El 78% de los médicos percibe que no existe medicación adecuada en el mercado ecuatoriano y más de la mitad piensa que la tecnología es aún insuficiente. Un 15% de profesionales aún cree que el manejo de Cáncer Renal debe hacerse exclusivamente por un médico oncólogo. Conclusiones: Existen vacíos de conocimiento en los profesionales de la salud, éstos se dan en todos los componentes evaluados, es necesario fortalecer los esfuerzos de Educación continua para evitar retrasos en el diagnóstico de patologías cuyo pronóstico depende de un manejo temprano.
Evaluation of DNA damage through cytogenetic approach in smokers and vapers with and without nicotine compared with control group
(2024) Paz-y-Miño, César; Ocampo, Ligia; Sánchez, María-Eugenia; Leone, Paola E
The use of tobacco and electronic cigarettes is harmful to health and can cause genetic damage, increasing the risk of cancer and other serious diseases. Although e-cigarettes contain fewer toxic chemicals than conventional tobacco, recent studies have shown that the vapor caused by burning produced by e-cigarettes can also be toxic and carcinogenic. Various studies have found that those exposed to tobacco and vaping have significantly higher levels of damage to their DNA in different types of cells and tissues. Evidence has accumulated that e-cigarette vaping can alter cellular functions and DNA itself, increasing the risk of cancer and aging. The present work evaluates the cytogenetic damage in individuals exposed to conventional cigarette vapors by burning with nicotine and vapors without nicotine, compared with a non-smoking population. The study included participants with an average age of 30 years (+/-10), with a majority of men representing 70% of the sample. The Chi-square test found no significant statistical differences between the men and women exposed (p<0.05). The results of chromosomal fragility found in the four groups studied (control group, conventional smokers, vapers with nicotine and vapers without nicotine) showed breaks and gaps in one or both of the chromatids in all exposed individuals, with highly significant statistical differences (p<0.001) compared to the unexposed control group. No statistically significant differences were found between the group of conventional smokers and the vapers with and without nicotine, nor between the two types of vapers (p>0.05). In conclusion, cytogenetic evidence of DNA damage produced by vaping is shown in the same proportions as a normal cigarette. This will significantly impact public health, which must be considered in preventive actions.
Global Cancer Institute multidisciplinary tumor boards as a tool to improve patterns of clinical practice for breast and gynecologic cancer in resource-limited settings.
(J Clin Oncol [Internet], 2017) Louis, Jessica St.; Bukowski, Alexandra; Rodrigues, Angelica Noguelra; Moreno, Joel; Ferreyra, Mayra; Lopes, Andre; De La Serna, Frances; Tindwa, Chakou Halfani; Baki Mollah, Obayedullah; Villarreal-Garza, Cynthia; Duarte, Carlos; Hambardzumyan, Vahagn; Salman, Pamela; Soria, Tannia; Goss, Paul E.
Background: Multidisciplinary tumor boards (MTBs) are commonly practiced in high-income countries (HICs) to ensure adherence to guidelines through a team approach to patient care. The Global Cancer Institute (GCI) established online MTBs in 2012 to facilitate live telemedicine discussions of breast and gynecologic case scenarios between specialists in low- and middle-income countries (LMICs) and expert specialists in HICs. GCI MTBs aim to improve clinical knowledge and patterns of practice for specialists in LMICs through an interactive online forum. Methods: In each monthly MTB, three patient case scenarios are presented by specialists in LMICs for live discussion with an expert panel of specialists based in HICs. Guideline or clinical trial-based discussions are held for each case scenario. Best practices for clinical care in limited resource settings are also discussed. Links to clinical practice guidelines, clinical trials, and resources are provided to all MTB attendees. For educational purposes, each MTB is live streamed and uploaded to a private YouTube channel for viewing by community oncologists and trainees worldwide. Results: The GCI MTBs program has recruited over 500 LMIC participants from 48 hospitals in 24 countries across Latin America, Eastern Europe, Africa, and Asia. 17 expert breast cancer specialists and 13 expert gynecologic cancer specialists provide multidisciplinary guidance. To date, 130 breast cancer case scenarios and 80 gynecologic cancer case scenarios have been presented. For breast MTBs, 73% of case scenarios were invasive ductal carcinomas. Common subtypes presented were ER/PR+ (63%), HER2+ (30%), and triple negative disease (28%). 56 cases involved advanced disease management (43%). For gynecologic MTBs, common gynecologic cancer case scenarios were cervical (74%) and ovarian (15%). 37 cases involved advanced disease management (46%). Conclusions: GCI MTBs are a useful educational tool for specialists in LMICs to improve patterns of clinical practice and engage in multidisciplinary discussions. GCI continues to expand its MTBs to cancer facilities in LMICs.
Global surveillance of trends in cancer survival 2000-14 (CONCORD-3)
(The Lancet, 2019-03) Allemani, Claudia; Matsuda, Tomohiro; Di Carlo, Veronica; Harewood, Rhea; Matz, Melissa; Nikšić, Maja; Bonaventure, Audrey; Valkov, Mikhail; Johnson, Christopher J; Estève, Jacques; Ogunbiyi, Olufemi J; Chen, Wan-Qing; Eser, Sultan; Engholm, Gerda; Stiller, Charles; Monnereau, Alain; Woods, Ryan; Visser, Otto; Hsiang Lim, Gek; Aitken, Joanne; Weir, Hannah K; Coleman Michel P.; CONCORD Working Group
Background—In 2015, the second cycle of the CONCORD programme established global surveillance of cancer survival, as a metric of the effectiveness of health systems and to inform global policy on cancer control. Methods—CONCORD-3 updates the world-wide surveillance of cancer survival to 2014, with individual data for 37.5 million patients diagnosed with cancer during the 15-year period 2000–2014. Data were provided by 322 population-based cancer registries in 71 countries and territories, of which 47 provided data with 100% population coverage. The study includes 18 cancers or groups of cancers: oesophagus, stomach, colon, rectum, liver, pancreas, lung, breast (women), cervix, ovary, prostate and melanoma of the skin in adults, and brain tumours, leukaemias and lymphomas in both adults and children. Standardised quality control procedures were applied; errors were rectified by the registry concerned. We estimated five-year net survival. Estimates were age-standardised with the International Cancer Survival Standard weights. Findings—For most cancers, five-year net survival remains among the highest in the world in the US and Canada, in Australia and New Zealand, and in Finland, Iceland, Norway and Sweden. For many cancers, Denmark is closing the survival gap with the other Nordic countries. Survival trends are generally increasing, even for some of the more lethal cancers: in some countries, survival has increased by up to 5% for cancers of the liver, pancreas and lung. For women diagnosed during 2010–2014, the predicted five-year survival for breast cancer is now close to 90% in the US and in Australia, but international differences remain very wide, with levels as low as 40% in South Africa. For gastrointestinal cancers, the highest levels of five-year survival are seen in South-East Asia, in Korea for cancers of the stomach (69%), colon (72%) and rectum (71%), in Japan for oesophageal cancer (36%) and in Taiwan for liver cancer (28%). By contrast, in the same world region, survival is generally lower than elsewhere for melanoma of the skin (60% in Korea, 52% in Taiwan, 50% in China), and for both lymphoid malignancies (53% in Korea, 51% in Taiwan, 38% in China) and myeloid malignancies (46% in Korea, 33% in Taiwan, 25% in China). For children diagnosed during 2010–2014, five-year survival for acute lymphoblastic leukaemia ranged from 66% in Thailand to 95% in Finland. Five-year survival from brain tumours in children is higher than for adults, and the global range is very wide (from 45% in Thailand to 80% in Sweden and Denmark). Interpretation—The CONCORD programme enables timely comparisons of the overall effectiveness of health systems in providing care for 18 cancers that collectively represent 75% of all cancers diagnosed world-wide every year. It contributes to the evidence base for global policy on cancer control. From 2017, the Organisation for Economic Co-operation and Development will use findings from the CONCORD programme as the official benchmark of cancer survival, among their indicators of the quality of health care in 48 countries world-wide. It is crucial for governments to recognise population-based cancer registries as key policy tools that can be used to evaluate both the impact of cancer prevention strategies and the effectiveness of health systems for all patients diagnosed with cancer
Global survival trends for brain tumors, by histology: analysis of individual records for 556,237 adults diagnosed in 59 countries during 2000–2014 (CONCORD-3)
(2022) Girardi, Fabio; Matz, Melissa; Stiller, Charles; You, Hui; Gragera, Rafael Marcos; Valkov, Mikhail Y.; Bulliard, Jean-Luc; De, Prithwish; Morrison, David; Wanner, Miriam; O’Brian, David K.; Saint-Jacques, Nathalie; Coleman, Michel P.; Allemani, Claudia; CONCORD Working Group
Abstract Background. Survival is a key metric of the effectiveness of a health system in managing cancer. We set out to provide a comprehensive examination of worldwide variation and trends in survival from brain tumors in adults, by histology. Methods. We analyzed individual data for adults (15–99 years) diagnosed with a brain tumor (ICD-O-3 topography code C71) during 2000–2014, regardless of tumor behavior. Data underwent a 3-phase quality control as part of CONCORD-3. We estimated net survival for 11 histology groups, using the unbiased nonparametric Pohar Perme estimator. Results. The study included 556,237 adults. In 2010–2014, the global range in age-standardized 5-year net survival for the most common sub-types was broad: in the range 20%–38% for diffuse and anaplastic astrocytoma, from 4% to 17% for glioblastoma, and between 32% and 69% for oligodendroglioma. For patients with glioblastoma, the largest gains in survival occurred between 2000–2004 and 2005–2009. These improvements were more noticeable among adults diagnosed aged 40–70 years than among younger adults. Conclusions. To the best of our knowledge, this study provides the largest account to date of global trends in population-based survival for brain tumors by histology in adults. We have highlighted remarkable gains in 5-year survival from glioblastoma since 2005, providing large-scale empirical evidence on the uptake of chemoradiation at population level. Worldwide, survival improvements have been extensive, but some countries still lag behind. Our findings may help clinicians involved in national and international tumor pathway boards to promote initiatives aimed at more extensive implementation of clinical guidelines.
Hospital Mortality and Effect of Adjusting PaO2/FiO2 According to Altitude Above the Sea Level in Acclimatized Patients Undergoing Invasive Mechanical Ventilation. A Multicenter Study
(2019) Jibaja, Manuel; Ortiz-Ruiz, Guillermo; García, Fernanda; Garay-Fernández, Manuel; Montelongo, Felipe de Jesús; Martinez, Jorge; Viruez, José Antonio; Baez-Pravia, Orville; Salazar, Santiago; Villacorta-Cordova, Francisco; Morales, Freddy; Tinoco-Solórzano, Amilcar; Ibañez Guzmán, Carlos; Valle Pinheiro, Bruno; Zubia-Olaskoaga, Felix; Dueñas, Carmelo; Lara Garcia, Antonio; Cardinal-Fernández, Pablo
Objective: (i) Analyze the effect of altitude above the sea level on the mortality rate in patients undergoing invasive mechanical ventilation. (ii) Validate the traditional equation for adjusting PaO2/FiO2 according to the altitude. Design: A prospective, observational, multicenter and international study conducted during August 2016. Patients: Inclusion criteria: (i) age between 18 and 90 years old, (ii) admitted to intensive care unit (ICU) situated at the same altitude above the sea level (AASL) in which the patients has stayed, at least, during the previous 40 days and (iii) received invasive MV for at least 12h. Material and methods: All variables were registered the day of intubation (day 0). Patients were followed until death, ICU discharge or day 28. PaO2/FiO2 ratio was adjusted by the AASL according to: PaO2/FiO2*(barometric pressure/760). Categorical variables were compared with χ2 and Cochran-Mantel-Haenszel test. Continuous variables with Mann-Whitney. Correlation between continuous variables was analyzed graphically and analytically. Logistic regression model was constructed to identify factors associated to mortality. Kapplan-Meier method was used to estimate the probability of survival according to the altitude. A 2-side p value <0.05 was consider significant. Results: 249 patients (<1500m n=55; 1500 to <2500m n=20; 2500 to <3500m n=155 and ≥3500m n=19) were included. Adjusted and non-adjusted PaO2/FiO2 were correlated with several respiratory and non respiratory variables. None discordances between non adjusted and adjusted PaO2/FiO2 were identified. However, several correlations were appreciated only in patients situated <1500m or in >1500m. Seventy-nine patients died during the ICU stayed (32%). The mortality curve was not affected by the altitude above the sea level. Variables independently associated to mortality are: PEEP, age, systolic arterial blood pressure, and platelet count. Auroc: 0.72. Conclusion: In acclimatized patients undergoing invasive mechanical ventilation, the traditional equation for adjusting PaO2/FiO2 according the elevation above the sea level seems to be inaccurate and the altitude above the sea level does not affect the mortality risk. Keywords: Altitud; Altitud elevada; Altitude; Fallo respiratorio; High altitude; Mechanical ventilation; Mortalidad; Mortality; Respiratory failure; Ventilación mecánica.
Ibero-American Expert Consensus on Squamous Cell Carcinoma of the Head and Neck Treatment in Patients Unable to Receive Cisplatin: Recommendations for Clinical Practice
(Cancer Management and Research, 2021) Falco, Agustín; De Oliveira, Thiago Bueno; Cacicedo Jon; Ospina, Aylen Vanessa; Ticona, Miguel Ángel; Galindo, Héctor; Pereira, Marcos David; Aguilar-Ponce, José Luis; Rueda-Domínguez, Antonio; Soria, Tannia; Taberna, Miren; Iglesias, Lara; Sowley, Taysser; Mesía, Ricard; TTCC group (Spanish Group for the Treatment of the Head and Neck Cancer)
Abstract: Cisplatin is the standard of treatment for squamous cell carcinoma of the head and neck (SCCHN) that has demonstrated efficacy, either in locally advanced disease when combined with radiotherapy at high doses, or in metastatic/recurrent disease when combined with other agents. However, the usual toxicities related to cisplatin, such as neurotoxicity, nephrotoxicity, ototoxicity, and hematologic toxicities, especially when high doses have been administered, have important implications in the patients’ quality of life. The decision to administer cisplatin depends on several patient factors, such as age, performance status, weight loss, comorbidities, previous toxicities, chronic viral infection, or even the current SARS-CoV-2 pandemic. In order to establish recommendations for the management of patients with SCCHN, a group of experts in medical and radiation oncology from Spain and Latin-American discussed how to identify patients who are not candidates for cisplatin to offer them the most suitable therapeutic alternative. Keywords: age, cisplatin, comorbidities, contraindication, frailty, toxicity
Limited Education as a Risk Factor in Cervical Cancer
(Bull Pan Am Health Organ, 1996-12) Corral, Fabián; Cueva, Patricia; Yépez, José; Montes, Elizabeth
Lung cancer: EGFR-ALK mutation in the high lands
(Journal of Clinical Oncology, 2018) Villacrés, Leonardo David; Villarroel, Nelson; Moreno, Pablo; Carrasco, Edison A.; Castillo, José; Muñoz, María José; Caballero, Henry; Soria, Tannia
Background: It has been shown that oxygen is a driver of damage forming free radicals, at higher areas of altitude the risk of developing lung cancer decreases, the primary endpoint was to identify the incidence of EGFR-ALK mutation in the high lands and as a secondary endpoint was to determine the relationship among a pulmonary lobe location, EGFR-ALK mutation and tobacco use. Methods: All patients with lung cancer living at an altitude between 2500( meters above sea level) masl to 3000 masl treated at the Hospital Solon Espinosa Ayala "Quito-Ecuador" between the year 2010 and 2015. The characteristics of the patients included in this study were: living in the high lands for more than 30 years, to have a EGFR and ALK mutation reported. All this data were collected from the electronic medical records. A descriptive analysis of the EGFR and ALK mutation were performed in our city, the Fisher test was used to compare the mutation of EGFR with the location of a pulmonary lobe in a physiological way, whether the tumor is located in superior or inferior lobe and also with tobacco use. Results: Among 191 individuals, 154 individuals were excluded as the did not meet the inclusion criteria, with a total of 37 individuals, with an EGFR mutation in 48.6% (18/37) and an ALK mutation in 3% ( 1/37) of patients. Although 50% of the EGFR mutations belonged to a superior lobe location, this was not significant statistically OR = 2.25 IC 95% (0.61 - 8.18); p = 0.15, the EGFR mutation was not affected by tobacco consumption in our data, presented in the non-smoker individuals OR = 1.47 IC 95% (0.80 - 2.71); p = 0.21. Conclusions: The incidence of EGFR mutation is high, practically presenting a 1: 1 ratio, while the incidence of ALK mutation was very low; Although the EGFR mutation was higher in the upper lobe tumor location, it was not significant, and it was a finding that tobacco consumption was not related to the EGFR mutation present.
Management of an Unusual Central Nervous System Metastasis With Linear Accelerator Radiosurgery in a Low-Middle Income Country
(Cureus, 2021-11-22) Mosquera, Martín; Leon Rojas, Jose; Puente Vallejo, Raúl
Large cell neuroendocrine carcinoma, a type of non-small cell lung cancer, is quite rare and has been associated with brain metastasis, mainly to the cerebral hemispheres. However, the rate of cerebellar metastasis is underreported in the literature and appears to be quite rare. Despite the rarity of this metastasis, treatment guidelines for both supratentorial and cerebellar lesions have been established by using either radiosurgery or whole-brain radiation therapy. The choice of modality must take into consideration the vicinity of relevant structures such as the brainstem and its multiple nuclei. Here we report the case of a 68-year-old male, resident of a rural community in the Andean region of Ecuador, a lowmiddle income country; with the diagnosis of a large cell neuroendocrine carcinoma of the lung with dual central nervous system metastasis treated with linear particle accelerator radio-surgery due to its versatility and cost-effectiveness in a resource-limited setting. We showcase the rarity of the metastatic lesions as well as the utility of linear accelerators and their versatility to perform precise radiosurgical procedures in two simultaneous locations.
Management of an Unusual Metastasis of Cervical Cancer in the Adrenal Bed With Stereotactic Ablative Body Radiation Therapy
(Cureus, 2022-02-13) Ochoa, Pamela; Nuñez Silva, Cristina; De Los Reyes, Luis; Puente Vallejo, Raúl
Uterine cervical carcinoma is an important type of cancer among Ecuadorian women, especially in adult women. Survival rates have improved with the development of radiotherapy, surgical techniques, and chemotherapy. However, recurrence and/or metastasis are not unusual phenomena. Frequent sites of metastasis are the lungs, regional lymph nodes, and bones. Atypical locations can also occur on solid organs, such as adrenal glands. Treatment for the rare complication that is adrenal metastasis is individualized, it can include surgical resection, chemotherapy, local ablation, or different types of radiotherapy. We aimed to report a case of an Ecuadorian woman from Quito city with a diagnosis of cervical carcinoma diagnosed in 2009, treated surgically and with adjuvant chemotherapy. Her progression was monitored with medical controls with no recurrence until 2018, when she relapsed with a metastatic invasion of the pelvic ganglia and the surroundings of the abdominal aorta, with a histopathologic diagnosis of adenocarcinoma. She was then treated with chemotherapy and radiotherapy until June 2019. In 2020, she went through a splenectomy and left adrenalectomy to treat vascular thrombosis. In 2021, 37 x 15 mm mass was discovered in the surgical bed of the previously removed adrenal gland. It was treated as an oligometastatic carcinoma with stereotactic body radiotherapy (SBRT) by a linear accelerator.
Multilevel impacts of a pediatric early warning system in resource-limited pediatric oncology hospitals
(2022) Mirochnick, Emily; Graetz, Dylan E; Ferrara, Gia; Puerto-Torres, Maria; Gillipelli, Srinithya R; Elish, Paul; Muniz-Talavera, Hilmarie; Gonzalez-Ruiz, Alejandra; Armenta, Miriam; Barra, Camila; Diaz-Coronado, Rosdali; Hernandez, Cinthia; Juarez, Susana; Loeza, Jose de Jesus; Mendez, Alejandra; Montalvo, Erika; Penafiel, Eulalia; Pineda, Estuardo; Agulnik, Asya
Background: Pediatric Early Warning Systems (PEWS) reduce clinical deterioration, improve interdisciplinary communication, and provide cost savings; however, little is known about how these impacts are achieved or related. This study evaluates the multi-level impacts of PEWS in resource-limited pediatric oncology centers. Methods: We conducted 71 semi-structured interviews including physicians (45%), nurses (45%), and administrators (10%) from 5 resource-limited pediatric oncology centers in 4 Latin American countries. Interviews were conducted in Spanish, transcribed, and translated into English. A code book was developed using a priori and inductively derived codes. Transcripts were independently coded by 2 coders, achieving a kappa of 0.8-0.9. Thematic content analysis explored perceived impacts of PEWS at the level of the patient, clinician, healthcare team, and institution. Results: PEWS improved the quality of attention for patients, reducing morbidity and mortality. Clinicians felt more knowledgeable, confident, and empowered providing patient care, resulting in greater job satisfaction. PEWS affected team dynamics by improving interdisciplinary (ward and intensive care unit) and interprofessional (physicians and nurses) relationships and communication. This ultimately led to institutional culture change with emphasis on patient safety, collaboration with other centers, and receipt of institutional awards. Together, these impacts led to hospital-wide support of ongoing PEWS use. Conclusions: In resource-limited hospitals, PEWS use results in multi-level positive impacts on patients, clinicians, teams, and institutions, creating a feedback loop that further supports ongoing PEWS use. These findings can guide advocacy for PEWS to various stakeholders, improve PEWS effectiveness, and inform assessment of other interventions to improve childhood cancer outcomes. Keywords: Latin America; Pediatric Early Warning System (PEWS); global health; pediatric critical care; pediatric oncology; quality improvement; resource-limited. Copyright © 2022 Mirochnick, Graetz, Ferrara, Puerto-Torres, Gillipelli, Elish, Muniz-Talavera, Gonzalez-Ruiz, Armenta, Barra, Diaz-Coronado, Hernandez, Juarez, Loeza, Mendez, Montalvo, Penafiel, Pineda and Agulnik.

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