Improving outcomes for children with cancer in low-income countries in Latin America: a report on the recent meetings of the Monza International School of Pediatric Hematology/Oncology (MISPHO)-Part I

The difference in survival for children diagnosed with cancer between high- and low-income countries (LIC) continues to widen as curative therapies are developed in the former but not implemented in the latter. In 1996, the Monza International School of Pediatric Hematology/Oncology (MISPHO) was founded in an attempt to narrow this survival gap. During its sixth and seventh meetings, members recognized the problem of lack of affordability of essential drugs to treat childhood cancer in many LIC, and initiated an advocacy program. In 1998, MISPHO spawned a collaboration of Central American pediatric oncology centers: the Asociación de Hemato-Oncología Pediátrica Centroamericana (AHOPCA). AHOPCA members reported preliminary findings from several of the 10 cooperative protocols that are currently in progress. In 2003, a second regional collaborative group was formed that includes seven centers in South America. Twinning programs between MISPHO centers and centers in high-income countries (HIC) have proven invaluable to harness the resources of these centers to improve pediatric oncology care in LIC. MISPHO educational efforts include oncology nursing, supportive care, cancer-specific updates, epidemiology, and clinical research methods. Educational efforts are facilitated by educational content and online conferencing via www.cure4kids.org. Identifying preventable causes of abandonment of therapy and documenting the nutritional status of patients treated at MISPHO centers are areas of active research.     

Treatment for children with severe aplastic anemia and sickle cell disease in low income countries in Latin America: a report on the recent meetings of the Monza International School of Pediatric Hematology/Oncology (MISPHO): Part III

Treatment of hematologic disorders in low-income countries (LIC) is difficult. This report summarizes treatment of sickle cell disease and aplastic anemia by pediatric hematologists from 15 LIC who participate in the Monza International School of Pediatric Hematology/Oncology (MISPHO). Patients with severe sickle cell disease were treated with low dose hydroxyurea, which safely reduced vaso-occlusive crises. Patients with severe aplastic anemia fared poorly due to lack of availability and high cost of anti-thymocyte globulin and cyclosporine and lack of access to stem cell transplantation. Appropriate therapy was most likely to occur in MISPHO centers with an active twinning program with a center in a high-income country.     

Protocol-based treatment for children with cancer in low income countries in Latin America: a report on the recent meetings of the Monza International School of Pediatric Hematology/Oncology (MISPHO)--part II

Pediatric cancer programs in low-income countries (LIC) can improve outcomes. However, treatment must be tailored to the patient's living conditions and the availability of supportive care. In some cases, a more intense regimen will decrease survival since the increase in death from toxicity may exceed any decrease in relapse. Attempts to practice evidence-based pediatric oncology are thwarted by the lack of evidence derived from local experience in LIC to determine optimal therapy. This report summarizes treatment regimens used by pediatric oncologists from 15 countries of the Caribbean, Central and South America who participate in the Monza International School of Pediatric Hematology/Oncology (MISPHO). Patients with hepatoblastoma, Wilms tumor, and histiocytosis treated on unmodified published protocols had outcomes comparable to those in high-income countries (HIC). Those with rhabdomyosarcoma, osteosarcoma, Hodgkin lymphoma, and acute myeloid leukemia treated with unmodified regimens had event-free survival estimates 10%-20% lower than those reported in HIC due to higher rates of toxic death, abandonment of therapy, and relapse. Treatment of retinoblastoma is complicated by advanced stages and extraocular disease at diagnosis; improved outcomes depend on education of pediatricians and the public to recognize early signs of this disease. Use of unmodified protocols for Burkitt lymphoma and acute lymphoblastic leukemia have been associated with unacceptable toxicity in LIC, so MISPHO centers have modified published regimens by giving lower doses of methotrexate and reducing use of anthracyclines. Despite the use of all-trans-retinoic acid during induction for acute promyelocytic leukemia, the incidence of fatal hemorrhage remains unacceptably high.     

Quality control in mutation analysis: the European Molecular Genetics Quality Network (EMQN)

 The demand for clinical molecular genetics testing has steadily grown since its introduction in the 1980s. In order to reach and maintain the agreed quality standards of laboratory medicine, the same internal and external quality assurance (IQA/EQA) criteria have to be applied as for “conventional” clinical chemistry or pathology. In 1996 the European Molecular Genetics Quality Network (EMQN) was established in order to spread QA standards across Europe and to harmonise the existing national activities. EMQN is operated by a central co-ordinator and 17 national partners from 15 EU countries; since 1998 it is being funded by the EU commission for a 3-year period. EMQN promotes QA by two tools: by providing disease-specific best practice meetings (BPM) and EQA schemes. A typical BPM is focussed on one disease or group of related disorders. International experts report on the latest news of gene characterisation and function and the state-of-the-art techniques for mutation detection. Disease-specific EQA schemes are provided by experts in the field. DNA samples are sent out together with mock clinical referrals and a diagnostic question is asked. Written reports must be returned which are marked for genotyping and interpretation. So far, three BPMs have been held and six EQA schemes are in operation at various stages. Although mutation types and diagnostic techniques varied considerably between schemes, the overall technical performance showed a high diagnostic standard. Nevertheless, serious genotyping errors have been occurred in some schemes which underline the necessity of quality assurance efforts. Conclusion The European Molecular Genetics Quality Network provides a necessary platform for the internal and external quality assurance of molecular genetic testing. Received: 5 April 2001 / Accepted: 12 April 2001     

MR imaging in Guillain-Barré syndrome

MRI in a 5-year-old girl with Guillain-Barré syndrome showed marked enhancement of nerve roots in the region of the conus medullaris and cauda equina. This enhancement gradually disappeared after high-dose immunoglobulin therapy. This characteristic finding of MRI may have diagnostic utility and represent the clinical course of the disease. Received: 11 December 1995 Accepted: 10 January 1996     

The role of maternal education in the 15‐year trajectory of malnutrition in children under 5 years of age in Bangladesh

Malnutrition in children under 5 years of age (U5s) is a serious public health problem in low‐ and middle‐income countries including Bangladesh. Improved maternal education can contribute effectively to reduce child malnutrition. We examined the long‐term impact of maternal education on the risk of malnutrition in U5s and quantified the level of education required for the mothers to reduce the risk. We used pooled data from five nationwide demographic and health surveys conducted in 1996–1997, 1999–2000, 2004, 2007 and 2011 in Bangladesh involving 28 941 U5s. A log‐binomial regression model was used to examine the association between maternal education (no education, primary, secondary or more) and malnutrition in children, measured by stunting, underweight and wasting controlling for survey time, maternal age, maternal body mass index, maternal working status, parity, paternal education and wealth quintile. An overall improvement in maternal educational attainment was observed between 1996 and 2011. The prevalence of malnutrition although decreasing was consistently high among children of mothers with lower education compared with those of mothers with higher education. In adjusted models incorporating time effects, children of mothers with secondary or higher education were at lower risk of childhood stunting [risk ratio (RR): 0.86, 95% confidence interval (CI): 0.81, 0.89], underweight (RR: 0.83, 95% CI: 0.78, 0.88) and wasting (RR: 0.82, 95% CI: 0.74, 0.91) compared with children of mothers with no education. We demonstrated the importance of promoting women's education at least up to the secondary level as a means to tackle malnutrition in Bangladesh.     

Does disadvantage start at home? Racial and ethnic disparities in health-related early childhood home routines and safety practices

BACKGROUND: Little is known about whether racial/ethnic differences exist in household family activities, safety practices, and educational opportunities known to impact young children's healthy development and school success. OBJECTIVE: To examine whether racial/ethnic disparities exist in early childhood home routines, safety measures, and educational practices/resources. METHODS: The 2000 National Survey of Early Childhood Health is a telephone survey of a nationwide sample of parents of 2608 children aged 4 to 35 months. Differences in family activities, safety measures, and educational practices/resources were examined for white, black, and Hispanic children. RESULTS: Minority children are less likely than white children to have consistent daily mealtimes and bedtimes, and more frequently never eat lunch or dinner with their family. Minority parents are less likely to install stair gates or cabinet safety locks and to turn down hot water settings. Minority parents less often read daily to their child, Hispanic parents more often never read to their child, and minority households average fewer children's books. Black children average more hours watching television daily. Disparities persisting in multivariate analyses included: minority children having increased odds of never eating lunch or dinner with their family, black children not having regular mealtimes (odds ratio, 1.8; 95% confidence interval, 1.2-2.7) and watching 1 more hour of television daily, black parents not installing cabinet locks, minority parents having twice the odds of not installing stair gates and not reading to their child daily, and minority homes having fewer children's books (black homes, -30; and Hispanic homes, -20). Children whose parents completed surveys in Spanish also experienced several disparities. CONCLUSIONS: Young minority children experience multiple disparities in home routines, safety measures, and educational practices/resources that have the potential to impede their healthy development and future school success. Such disparities might be reduced or eliminated through targeted education and intervention by pediatric providers.     

Review of the Circumstances Among Children in Immigrant Families in Australia

Australia has always had a very high level of immigration. There were about 1.5 million children 0 to 17 years of age in immigrant families in Australia in 2001. This represented almost 33% of all children. More than a quarter of these children were in families from the most consistent countries of immigrant origin, Ireland and the United Kingdom. Another 17% were in families from other parts of Europe, while 10% were in families from New Zealand, and 3% were in families from other countries in Oceania. Compared with most other OECD countries, there is a dearth of research on children in immigrant families in Australia, and relatively limited administrative data that might allow us to compare immigrant families to other families in the general population. No recent studies track the educational, health, or employment trajectories of children in families in various immigrant groups. Research on children in immigrant families undertaken since the 1970s has been sporadic and fragmentary. None of the flagship studies on child well-being provides specific information about culturally and linguistically diverse children or children in immigrant families. There are no national studies on the involvement of these children with the child welfare, juvenile justice, or out-of-home care systems, and it is therefore not known if they are overrepresented or underrepresented. Studies tend to compare two or three ethnic or language groups, group all immigrants together, or classify immigrant children according to English-speaking or non-English speaking backgrounds. Australians pride themselves on the harmony and the relative lack of racial tension in their society, but hard data on indicators of racial harmony are scarce. We examine the limited evidence base below, and supplement an analysis of census data and data from the Longitudinal Study of Australian Children (LSAC). The findings are rather paradoxical. On the one hand the research confirms the serious disadvantages in well-being that children in certain immigrant groups face, relative to the overall population. The disadvantages include poorer educational outcomes, exposure to racism, the trauma of separation from the cultural and social networks of their countries of origin, challenges to adjusting to the Australian culture and life style, identity problems and less access to services and social support. These issues are heightened among immigrants who have come to Australia with fewer skills and fewer resources, as well as less knowledge of English. On the other hand the wellbeing of migrant children appears to be relatively good compared to the general Australian population and also compared to migrants in other OECD countries.     

Growth monitoring and diagnostic work-up of short stature: an international inventorization

BACKGROUND/AIMS: Growth monitoring is almost universally performed, but few data are available on which referral criteria and diagnostic work-up are used worldwide for children with short stature. METHODS: A short questionnaire, containing questions on auxological screening and on diagnostic criteria for short stature, was sent to all members of the European Society of Paediatric Endocrinology (ESPE) and to several pediatric endocrinologists outside Europe. RESULTS: Responses were received from 36 countries. In 27 (75%) a child health care program existed and in 14 (39%) there was a protocol for referral of children with growth retardation. Height for age was mostly used as a referral criterion. Sixteen countries (45%) reported having a guideline in secondary health care for diagnostic work-up. Although all countries agreed on having biochemical, radiological and/or genetic tests in the diagnostic work-up, there was a wide variety of recommended tests. CONCLUSIONS: There is little consensus on referral criteria and diagnostic work-up of children with short stature among industrialized countries. There is a need to establish evidence-based guidelines.     

Visually impaired (VI) education in Romania and the United Kingdom: special education in Romania since 1990 for blind and partially sighted children and young people, with comparisons drawn from similar experiences of legislative and educational changes in England and Wales since 1981

This article reviews the educational facilities available in the last decades of the 20th century for blind and partially sighted children and young people in Romania and the UK. A turning point in England and Wales came with the Education (Special Educational Needs) Act 1981. For Romania, the turning point came in 1990 with the overthrow of the Ceaucescu regime in late 1989. Romania is seeking entry to the European Union in 2007. This has provided an incentive to bring special educational philosophy and facilities quickly into line with other countries in the European Union. Similar problems regarding inclusion are encountered in both countries. Differentiating features are their different demographic characteristics and the educational resources and assets available at the time of the major changes. Finally, there is a brief review of the number of people with sight loss in paid employment as the next logical focal point for a national inclusion strategy. The UK has been able to develop and advance further than Romania in this sphere, but the legal framework is in place in Romania. The generic terms visually impaired (VI) and sight loss are both used throughout when referring to blind and partially sighted people.     

Diagnosis of bacterial enteric infections in children in Zambia

Abstract Background: The bacterial pathogens commonly responsible for diarrhea in children under the age of 5 in Zambia were identified and the most effective methods of diagnosis of such infections in laboratories with limited resources, such as those in developing countries, are recommended.
Methods: Stool samples were collected from children under the age of 5 years who visited the Diarrhoea Training Unit (DTU) of Zambia University Teaching Hospital in Lusaka, Zambia, between May 1992 and May 1993. A total of 639 children were evaluated for the presence of bacterial infection using standard culture media. The prevalence of bacterial pathogens was compared with that reported from other developing countries
Results: Pathogenic strains of Escherichia coli were isolated from 95 (14.9%) children, Shigella species from 65 (10.2%) children, and Vibrio cholerae from 21 (3.3%) children. The presence of visible blood in the feces was an early indicator of the presence of shigellosis.
Conclusions: E. coli, Shigella species and Vibrio cholerae were the major causes of bacterial diarrhea in the Zambian children studied. Research is required to determine the prevalence of such enteropathogenic strains. The use of adequate diagnostic procedures is indispensable to appropriate management. The recommendations have been prepared as a manual for the identification of enteropathogenic bacteria to be used in laboratories with limited resources, such as in developing countries.     

Children''s bicycle helmet use and injuries in Hillsborough County, Florida before and after helmet legislation

The purpose of this research was to explore the changes in children's bicycle helmet use and motor vehicle bicycle related injuries in Hillsborough County, Florida before and after passage of the Florida's bicycle helmet law for children under the age of 16. The results show a significant increase in bicycle helmet use among children, ages 5-13, in the post-law years compared with the pre-law years. Also, there has been a significant decline in the rates of bicycle related motor vehicle injuries among children in the post-law years compared with the pre-law years. Although there have been complementary educational and outreach activities in the county to support helmet use, it appears that the greatest increase in use occurred after the passage of the helmet law. It is recommended that educational efforts continue to sustain helmet use rates and decreases in injuries.     

Burden of disease in hospitalized RSV-positive children in Germany

BACKGROUND: In spite of a large amount of data from other countries, those on the burden of disease attributed to respiratory syncytial virus (RSV) in Germany are lacking and are urgently needed. METHOD: In a population-based cross-sectional study from July 1996 to June 1999 150 children from birth to 16 years of age hospitalized in Kiel and tested positive for RSV by polymerase chain reaction were investigated. Stepwise linear and logistic regression models were applied to predict a bacterial co-infection as well as the duration of hospitalization. RESULTS: Pneumonia (54 %) and wheezing bronchitis (including bronchiolitis, 27 %) were the predominating diagnoses; 25 % had an underlying condition. Four patients needed nasal continuous airway pressure and one intermittent mandatory ventilation; none died. According to the surrogate markers CRP and immature neutrophil fraction, 20 % to 30 % were suspected to have a bacterial co-infection on admission; antibiotics were prescribed in 65 % of the patients. The average duration of hospitalization was 9 days and was best predicted by young age, the presence of an underlying condition, intercostal retractions and high CRP on admission. CONCLUSIONS: Bacterial co-infection is the major confounder in burden of disease analyses in RSV. The decision not to administer antibiotics to children hospitalized with RSV can be risky, particularly when there is considerable diagnostic uncertainty. Within the realm of current clinical practice, complications and deaths related to RSV are rare in Germany.     

Neonatal bacterial meningitis: an update

Meningitis is associated with significant mortality and morbidity in infants in the first 3 months of life. The most recent national surveillance study (1996–7) identified an overall mortality of 10% with 50% of cases having some form of disability at 5 year follow-up (24% serious); a risk of serious disability 16-fold higher than that of GP-matched controls. The mortality has declined over the last two decades but there has been no change in the long term morbidity. Despite this there have been no attempts to assess the quality of current diagnostic and management strategies. It seems likely that improved recognition, evaluation and treatment of bacterial meningitis in infants could lead to a reduction in mortality and morbidity. Similar analyses undertaken in the areas of paediatric meningococcal disease and adult meningitis have revealed deficiencies in healthcare delivery and suggested that these may play a part in adverse outcomes.     

Drowning in Finland: "external cause" and "injury" codes.

BACKGROUND: The International Classification of Diseases (ICD) external codes (E codes) for drowning assist in determining the primary event leading to drowning, but do not alone allow the precise determination of the overall drowning rates. AIMS: To analyze the sensitivity of the ICD E codes for drowning. To describe the pattern and trend of drowning deaths that are classified with E codes other than for drowning. SETTING: Finland, 1969-2000. METHODS: Mortality files of Statistics Finland were searched electronically using the injury codes (I codes) and E codes for drowning. Cross analysis of I and E coded drownings was performed to determine the rate and pattern of drowning cases classified with E codes other than for drowning. Time trends were calculated using the Poisson regression model. RESULTS: Of 13 705 drowning deaths, 644 (4.7%) were not identified with the E codes for drowning. The great majority (n=547, 84.9%) of these cases were traffic accidents resulting in drowning. No significant time trends were found even after the introduction, in 1996, of the ICD 10th revision. CONCLUSIONS: In Finland, underestimation of overall drowning rates using the E code alone is less pronounced than in countries where similar studies have been performed. The relatively high rate of transport accidents resulting in drowning indicates a specific target for preventive countermeasures.     

Childhood cancer in Ireland: a population-based study.

BACKGROUND: Population-based studies of childhood cancer incidence, survival and mortality make an important contribution to monitoring the successful implementation of new treatment guidelines and to understanding the epidemiology of these diseases. METHODS: We analysed incidence and survival data for cancers diagnosed in children under 15 years of age in the Republic of Ireland during 1994-2000 (the first 7 years of National Cancer Registry coverage), and longer term mortality trends. RESULTS: World age-standardised incidence rates in Ireland averaged 142 cases per million children per year, slightly higher than the European average and slightly lower than the US average, although differences varied by diagnostic group. Observed 5-year survival in Ireland (79% overall) was slightly higher than European and US averages, and was significantly higher for acute non-lymphocytic leukaemia (67%) and (compared with the USA) significantly lower for Hodgkin lymphoma (83%). No significant increases in incidence rates were evident from the available 7 years' data, either overall or for particular diagnostic groups. Rates of childhood cancer mortality have declined markedly since the 1950s. CONCLUSIONS: Data presented here are in line with other developed countries and suggest major improvements in treatment and consequent survival.     

Time spent in different sedentary activity domains across adolescence: a follow-up study

ObjectiveThis longitudinal study aimed to verify possible changes in the time spent in sedentary activities occurring as screen-time, educational, cultural, social, and transportation domains in a sample of Brazilian adolescents between 2015 and 2017.MethodsIt is a longitudinal prospective study with 586 adolescents from 12 to 15 years old at the Baseline (2015) enrolled in 14 public schools from Curitiba, Brazil. The Adolescent Sedentary Activity Questionnaire assessed the time spent in sedentary activities in five domains (recreational screen-time, educational, cultural, social, and transportation). A series of linear random effects regressions analyzed changes in the sedentary time between 2015 and 2017, with p < .05.ResultsOverall, 323 adolescents dropped out of the study resulting in a retention rate of 44.9%. The overall sedentary time remained stable from 2015 to 2017 (-3.98 min/day, 95%CI: -15.39; 7.42). The screen-time decreased (-22.22 min/day, 95%CI: -30.30; -14.15), and educational (8.29 min/day, 95% CI: 3.52; 13.06), cultural (3.41 min/day, 95% CI: 0.66; 6.15) and social sedentary activities (8.20 min/day, 95% CI: 2.06; 14.34) increased from 2015 to 2017.ConclusionSignificant reductions in screen-time were evidenced along with increases in time spent on other sedentary activities of educational, cultural, and social nature. KeywordsSedentary behavior, Adolescent health, Longitudinal studies     

Immigration and changes in the epidemiology of hemoglobin disorders in Italy : an emerging public health burden

ABSTRACT: BACKGROUND: In the last years Italy is confronting with massive migratory movements from developing countries where hemoglobinopathies are widespread. This is causing a large diffusion and a changing spectrum in the epidemiology of hemoglobinic disorders in our Nation. METHODS: Investigations recently published in Italy on hemoglobinopathies among immigrants were revised in order to appreciate the impact of immigration from developing countries on epidemiology of these pathologies and to outline adequate guidelines of prevention. RESULTS: Although in Italy there is a limited number of investigations regarding the relation between immigration and hemoglobin disorders, published data show that in our Nation there is a changing and increasing spectrum of hemoglobinopathies linked to immigration. CONCLUSIONS: Prospective and retrospective actions of public healthy preventive policy are requested, based upon information ( health educational programs for immigrants and caregivers), screenings among immigrants (school screening, pre-marital, preconception and early pregnancy screening, newborn screening ), counseling for foreign at-risk couples and healthy carriers.     

Organization of health practices and vulnerability to childhood diarrhea

OBJECTIVES: This study aimed to characterize, the organization of health practices related to the reduction of vulnerability to childhood diarrhoea. METHODS: A longitudinal study was carried out, with two interconnected transversal cuts, in 14 health services (11 health centres and 3 hospitals), located in six municipalities of Pernambuco that participated of the Diarrhoea Control Implementation Project coordinated by the Health State Department. The data collection was performed through observation, interviews with professionals and mothers of the children, and clinic histories revision. RESULTS: Overall, there was a high proportion of patients who either did not get consulted or had to wait for a long time after their arrival at the health service. No orientation was given on the use of oral rehydration salts at home; little advice on the signs and symptoms of an aggravating episode was given, an elevated number of drugs were prescribed to the children with diarrhoea; and there was high degree of omission to record the patient? hydration status and the treatment offered. The educational practice is systematic only in 3 services, and only in these services there is delegation of activities to the nursing team and articulation with community health agents. On the 2nd phase of the study, one of the few changes identified was a discrete increase in weight measurement and its recording on a Chart. However, in the intervention period 69.6% of the health team members noticed an improvement on the pediatric assistance. CONCLUSIONS: The results reveal the great deficiency of the evaluated services in operating educational and healing activities related to diarrhoea control. So the observed practices concerning the attention to the children have contributed to increase childhood vulnerability, which shows the need to reorganize disease control actions, among the myriad of other actions related to this social group.     

Radiologic-Pathologic Conference of Children's Hospital Boston: Liver nodules after heart transplantation

We report the case of a 16-year-old boy who presented 1¹/₂ years after heart transplantation with multiple lesions throughout the liver as demonstrated by ultrasonography and CT. Results of analyses revealed features diagnostic for post-transplant lymphoproliferative disorder, which rarely involves the liver. Received: 17 January 1996 Accepted: 7 February 1996