RESUMEN
OBJECTIVE: To evaluate the association between deficiency of vitamin A or D at diagnosis of pediatric acute lymphoblastic leukemia (ALL) and subsequent infectious complications during induction therapy. STUDY DESIGN: We conducted an institutional review board-approved, retrospective cohort study of children with newly diagnosed ALL from 2007 to 2017 at St. Jude Children's Research Hospital. We measured vitamin D, vitamin D binding protein, retinol binding protein as a surrogate for vitamin A, and immunoglobulin isotypes in serum obtained at ALL diagnosis, and we assessed the association between vitamin deficiencies or levels and infection-related complications during the 6-week induction phase using Cox regression models. RESULTS: Among 378 evaluable participants, vitamin A and D deficiencies were common (43% and 17%, respectively). Vitamin D deficiency was associated with higher risks of febrile neutropenia (adjusted hazard ratio [aHR], 1.7; P = .0072), clinically documented infection (aHR, 1.73; P = .025), and likely bacterial infection (aHR, 1.86; P = .008). Conversely, vitamin A deficiency was associated solely with a lower risk of sepsis (aHR, 0.19; P = .027). CONCLUSIONS: In this retrospective study, vitamin D deficiency was associated with an increased risk of common infection-related complications during induction therapy for ALL. Additional studies are warranted to evaluate whether vitamin D supplementation could mitigate this effect.
Asunto(s)
Leucemia-Linfoma Linfoblástico de Células Precursoras , Deficiencia de Vitamina A , Deficiencia de Vitamina D , Humanos , Leucemia-Linfoma Linfoblástico de Células Precursoras/tratamiento farmacológico , Leucemia-Linfoma Linfoblástico de Células Precursoras/complicaciones , Estudios Retrospectivos , Masculino , Femenino , Niño , Preescolar , Deficiencia de Vitamina A/complicaciones , Deficiencia de Vitamina D/complicaciones , Quimioterapia de Inducción/efectos adversos , Lactante , Adolescente , Estudios de CohortesRESUMEN
OBJECTIVE: To evaluate the diagnostic yield of baseline chest radiographs (CXRs) of children with acute lymphoblastic leukemia (ALL). STUDY DESIGN: We reviewed the CXR findings at diagnosis for 990 patients aged 1-18 years with ALL treated during the Total XV and XVI studies at St. Jude Children's Research Hospital and evaluated the associations of these findings with clinical characteristics and initial management. RESULTS: Common findings were peribronchial/perihilar thickening (n = 187 [19.0%]), pulmonary opacity/infiltrate (n = 159 [16.1%]), pleural effusion/thickening (n = 109 [11.1%]), mediastinal mass (n = 107 [10.9%]), and cardiomegaly (n = 68 [6.9%]). Portable CXRs provided results comparable with those obtained with 2-view films. Forty of 107 patients with a mediastinal mass (37.4%) had tracheal deviation/compression. Mediastinal mass, pleural effusion/thickening, and tracheal deviation/compression were more often associated with T-cell ALL than with B-cell ALL (P < .001 for all). Pulmonary opacity/infiltrate was associated with younger age (P = .003) and was more common in T-cell ALL than in B-cell ALL (P = .001). Peribronchial/perihilar thickening was associated with younger age (P < .001) and with positive central nervous system disease (P = .012). Patients with cardiomegaly were younger (P = .031), more often black than white (P = .007), and more often categorized as low risk than standard/high risk (P = .017). Patients with a mediastinal mass, pleural effusion/thickening, tracheal deviation/compression, or pulmonary opacity/infiltrate were more likely to receive less invasive sedation and more intensive care unit admissions and respiratory support (P ≤ .001 for all). Cardiomegaly was associated with intensive care unit admission (P = .008). No patients died of cardiorespiratory events during the initial 7 days of management. CONCLUSIONS: The CXR can detect various intrathoracic lesions and is helpful in planning initial management.
Asunto(s)
Manejo de la Enfermedad , Pulmón/diagnóstico por imagen , Leucemia-Linfoma Linfoblástico de Células Precursoras/diagnóstico , Radiografía Torácica/métodos , Adolescente , Niño , Preescolar , Femenino , Humanos , Lactante , Masculino , Estudios RetrospectivosAsunto(s)
Secuenciación de Nucleótidos de Alto Rendimiento , Leucemia-Linfoma Linfoblástico de Células Precursoras/genética , Leucemia-Linfoma Linfoblástico de Células Precursoras/terapia , Análisis de Secuencia de ADN , Antineoplásicos/uso terapéutico , Biomarcadores de Tumor/genética , Niño , Análisis Mutacional de ADN/métodos , Predisposición Genética a la Enfermedad , Variación Genética , Humanos , Inmunoterapia , Terapia Molecular Dirigida , Neoplasia Residual , Medicina de Precisión , Leucemia-Linfoma Linfoblástico de Células Precursoras/diagnóstico , Medición de RiesgoRESUMEN
OBJECTIVE: To identify the most effective sedation regimen for bone marrow aspiration and lumbar puncture procedures with a prospective trial of 3 combinations of sedation/analgesia. STUDY DESIGN: In this double-blind crossover study, we randomly assigned 162 children with acute lymphoblastic leukemia or lymphoblastic lymphoma to receive fentanyl 1 mcg/kg, fentanyl 0.5 mcg/kg, or placebo, in addition to propofol and topical anesthetic for 355 procedures. RESULTS: We found no significant differences among the 3 regimens in the frequency of pain (pain score > 0) or severe pain (pain score ≥ 5) during recovery, or a >20% increase in hemodynamic/respiratory variables during anesthesia. Treatment with fentanyl 1 mcg/kg was associated with a lower frequency of movement during procedure compared with treatment with fentanyl 0.5 mcg/kg (P = .0476) or treatment with placebo (P = .0545). The placebo group required longer time to recover (median, 18 minutes) compared with the fentanyl 0.5 mcg/kg group (median, 9 minutes) (median difference 2.0, P = .007) and the fentanyl 1 mcg/kg (median 8 minutes), (median difference 2.0, P = .15). The placebo group also required larger total dose of propofol (median 5 mg/kg) compared with that of the fentanyl 1 mcg/kg group (median, 3.5 mg/kg) and the fentanyl 0.5 mcg/kg group (median 3.5 mg/kg) (median differences 1.5, P < .00005, in both comparisons). CONCLUSION: The addition of fentanyl 1 mcg/kg to propofol for brief painful procedures reduces movement, propofol dose, and recovery time.
Asunto(s)
Anestesia , Anestésicos Intravenosos/administración & dosificación , Examen de la Médula Ósea , Sedación Profunda , Fentanilo/administración & dosificación , Hipnóticos y Sedantes/administración & dosificación , Dolor/prevención & control , Propofol/administración & dosificación , Punción Espinal , Adolescente , Examen de la Médula Ósea/efectos adversos , Niño , Preescolar , Estudios Cruzados , Método Doble Ciego , Femenino , Humanos , Masculino , Neoplasias , Dolor/etiología , Estudios Prospectivos , Punción Espinal/efectos adversosRESUMEN
We report a case of BK virus-induced tubulointerstitial nephritis in a child with acute lymphoblastic leukemia. Primary BK virus infection was exacerbated by chemotherapy-induced immunodeficiency. Careful administration of chemotherapy and anti-viral therapy prevented further damage. This diagnosis should be considered in children who experience renal dysfunction during cancer treatment.
Asunto(s)
Virus BK/aislamiento & purificación , Nefritis Intersticial/virología , Infecciones por Polyomavirus/diagnóstico , Leucemia-Linfoma Linfoblástico de Células Precursoras/diagnóstico , Infecciones Tumorales por Virus/diagnóstico , Protocolos de Quimioterapia Combinada Antineoplásica/efectos adversos , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Antivirales/uso terapéutico , Biopsia con Aguja , Preescolar , Femenino , Estudios de Seguimiento , Humanos , Inmunohistoquímica , Pruebas de Función Renal , Nefritis Intersticial/complicaciones , Nefritis Intersticial/tratamiento farmacológico , Infecciones por Polyomavirus/complicaciones , Infecciones por Polyomavirus/terapia , Leucemia-Linfoma Linfoblástico de Células Precursoras/complicaciones , Leucemia-Linfoma Linfoblástico de Células Precursoras/tratamiento farmacológico , Medición de Riesgo , Resultado del Tratamiento , Infecciones Tumorales por Virus/complicaciones , Infecciones Tumorales por Virus/terapiaRESUMEN
INTRODUCTION: Pediatric cancer units in low-income countries lack data on which to base quality improvement initiatives. We implemented a data management program in the oncology unit of the children's hospital of Tegucigalpa, Honduras, and then we assessed training and supervision of data managers, data accuracy, and completeness as well as obstacles encountered. METHODS: Training included 2 days of off-site hands-on instruction in the use of an online database, daily on-site supervision by physicians, periodic online meetings for education and problem-solving, and continuous e-mail support. RESULTS: Of the 652 patients diagnosed with acute leukemia between July 1995 and June 2005, 150 (23%) had not yet been registered in the database at the time of audit and 65 (10%) had missing medical records. The remaining 437 charts (67%) were reviewed by an external auditor and compared to the data entered previously by the two trained data managers. Protocol information was incomplete in 30% of cases, and the cause of death was inaccurate in 18%. All other data were 99% accurate and 93%-100% complete. Obstacles included a limited medical records system, poor organization of the charts, missing records, inconsistently documented protocol information, data managers who lack a medical background, and slow or unreliable internet connections. CONCLUSION: Data managers can be trained to effectively collect basic pediatric oncology data in a low-income country. Addressing inadequacies in the medical record system while providing specific training in protocol-based care and determination of cause of death for both physicians and data managers will improve data quality.
Asunto(s)
Implementación de Plan de Salud/organización & administración , Hospitales Pediátricos/organización & administración , Leucemia/terapia , Área sin Atención Médica , Servicio de Oncología en Hospital/organización & administración , Protocolos Clínicos , Recolección de Datos , Honduras , Hospitales Pediátricos/estadística & datos numéricos , Humanos , Equipos de Administración Institucional , Sistemas de Registros Médicos Computarizados , Servicio de Oncología en Hospital/estadística & datos numéricos , Evaluación de Procesos y Resultados en Atención de Salud , Tasa de SupervivenciaRESUMEN
BACKGROUND: Pediatric Hodgkin lymphoma (HL) has a cure rate of more than 80% in high-income countries (HIC). However, more than 80% of the world's children live in low-income countries (LIC), where the cure rate is often much lower. PROCEDURE: We compared the outcome of HL of 371 patients treated at two pediatric oncology centers in the US to that of 62 patients treated at one center in Recife, Brazil (IMIP) to determine whether the same treatment strategy should be used in both high-income and LIC. The logrank test was used to compare event-free and overall survival. RESULTS: The percentages of patients with unfavorable disease at each center were similar (P = 0.72). Patients with favorable disease at IMIP had estimated 5-year survival rates comparable to those of the US centers (100% and 99%, respectively). Among patients with unfavorable disease, those treated at IMIP had a 5-year event-free survival (EFS) rate of 60%, compared to 78% at the US centers; (P = 0.08). The 5-year survival estimate after relapse was 25% at IMIP versus 61% at the US centers (P = 0.08). The 5-year overall survival for patients with unfavorable disease was 72% at IMIP versus 90% at the US centers (P = 0.01). CONCLUSIONS: Intensive frontline therapy should be considered for patients with unfavorable HL in LIC where the relapse rate is high and the salvage rate is low, provided that supportive care is adequate.
Asunto(s)
Enfermedad de Hodgkin/terapia , Adolescente , Adulto , Protocolos de Quimioterapia Combinada Antineoplásica/administración & dosificación , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Bleomicina/administración & dosificación , Brasil/epidemiología , Niño , Preescolar , Estudios de Cohortes , Terapia Combinada , Ciclofosfamida/administración & dosificación , Dacarbazina/administración & dosificación , Supervivencia sin Enfermedad , Doxorrubicina/administración & dosificación , Femenino , Enfermedad de Hodgkin/tratamiento farmacológico , Enfermedad de Hodgkin/mortalidad , Enfermedad de Hodgkin/radioterapia , Maternidades/estadística & datos numéricos , Hospitales Pediátricos/estadística & datos numéricos , Hospitales Universitarios/estadística & datos numéricos , Humanos , Lactante , Masculino , Metotrexato/administración & dosificación , Oregon/epidemiología , Prednisona/administración & dosificación , Procarbazina/administración & dosificación , Estudios Retrospectivos , Factores de Riesgo , Terapia Recuperativa , Análisis de Supervivencia , Tasa de Supervivencia , Tennessee/epidemiología , Resultado del Tratamiento , Vinblastina/administración & dosificación , Vincristina/administración & dosificaciónRESUMEN
CONTEXT: The cure rate for childhood acute lymphoblastic leukemia (ALL) differs markedly between developed and developing countries. OBJECTIVE: To assess the effect of a multidisciplinary team approach and protocol-based therapy on the event-free survival of children with ALL in an area with limited resources. DESIGN, POPULATION, AND SETTING: A retrospective cohort study at a pediatric hospital in the resource-poor city of Recife, Brazil. We reviewed medical records of the outcomes of 375 children with ALL diagnosed between 1980 and 2002. Eighty-three children were diagnosed in the early period (1980-1989), in the absence of a dedicated pediatric oncology unit, protocol-based therapy, specially trained nurses, 24-hour on-site physician coverage, and ready access to intensive care. Seventy-eight children were treated (all according to protocol) during the middle period (July 1994 to March 1997). During the recent period (April 1997 to December 2002), 214 children were treated with protocol in a dedicated pediatric oncology unit staffed 24 hours by pediatric oncologists and oncology nurses. Improvements were implemented gradually during the middle period and were completed during the recent period. MAIN OUTCOME MEASURE: Event-free survival was estimated by the Kaplan-Meier method. Events included death from toxicity, disease progression or relapse, and abandonment of treatment. RESULTS: The 5-year event-free survival improved steadily: 32% (95% CI, 21%-43%) in the early period, 47% (95% CI, 36%-58%) in the middle period, and 63% (95% CI, 55%-71%) in the recent period. The probability of cause-specific treatment failure in the early, middle, and late periods, respectively, within 1 year of diagnosis was 14% vs 3.8% vs 3.3% for relapse; 6.0% vs 12% vs 9.8% for death from infection; 2.4% vs 13% vs 4.2% for death from noninfectious toxicity; and 16% vs 1.3% vs 0.5% for abandonment of therapy. CONCLUSION: Treatment of childhood ALL in a dedicated pediatric oncology unit using a comprehensive multidisciplinary team approach, protocol-based therapy, and local support and funding is associated with improved outcomes in a resource-poor area.
Asunto(s)
Hospitales Pediátricos , Área sin Atención Médica , Servicio de Oncología en Hospital , Evaluación de Procesos y Resultados en Atención de Salud , Grupo de Atención al Paciente , Leucemia-Linfoma Linfoblástico de Células Precursoras/mortalidad , Leucemia-Linfoma Linfoblástico de Células Precursoras/terapia , Adolescente , Brasil/epidemiología , Niño , Preescolar , Protocolos Clínicos , Femenino , Hospitales Pediátricos/organización & administración , Hospitales Pediátricos/estadística & datos numéricos , Humanos , Lactante , Masculino , Servicio de Oncología en Hospital/organización & administración , Servicio de Oncología en Hospital/estadística & datos numéricos , Estudios Retrospectivos , Análisis de SupervivenciaRESUMEN
The causes of treatment failure in childhood acute lymphoblastic leukaemia are thought to differ between resource-rich and resource-poor countries. We assessed the records of 168 patients treated for this disease in Honduras. Abandonment of treatment (n=38), the main cause of failure, was associated with prolonged travel time to the treatment facility (2-5 h: hazard ratio 3.1, 95% CI 1.2-8.1 vs >5 h: 3.7, 1.3-10.9) and age younger than 4.5 years (2.6, 1.1-6.3). 35 patients died of treatment-related effects. Outcome could be substantially improved by interventions that help to prevent abandonment of therapy (such as funding for transport, satellite clinics, and support groups), and by prompt treatment of infection.
Asunto(s)
Países en Desarrollo/estadística & datos numéricos , Área sin Atención Médica , Leucemia-Linfoma Linfoblástico de Células Precursoras/terapia , Insuficiencia del Tratamiento , Adolescente , Niño , Preescolar , Países en Desarrollo/economía , Femenino , Accesibilidad a los Servicios de Salud/normas , Accesibilidad a los Servicios de Salud/estadística & datos numéricos , Honduras , Humanos , Lactante , Masculino , Pacientes Desistentes del Tratamiento/estadística & datos numéricos , Pobreza/estadística & datos numéricos , Factores de RiesgoRESUMEN
A efetividade do tratamento modifica a importância da maioria dos fatores associados com o prognóstico. Entre as manifestaçöes clínicas e laboratoriais de rotina, apenas a idade e a contagem leucocitária permanecem independentemente correlacionadas ao resultado do tratamento. A imunofenotipagem é útil para a classificaçäo das LLA, mas, possivelmente, com exceçäo do antígeno CD10, tem muito pouca importância prognóstica no contexto de uma abordagem terapêutica efetiva. Alteraçöes cariotípicas continuam a ter importante valor preditivo. Hiperdiplodia (>50 cromossomos) está associada ao bom prognóstico, enquanto que a t (9;22) e t(4;11), ao insucesso terapêutico. Casos com imunofenótipo pré-B e t(1;19) têm mau prognóstico, se tratados com regimes terapêuticos baseados em antimetabólicos, e, portanto, o tratamento desse grupo de pacientes deve incluir outras classes de drogas. Finalmente, algumas alteraçöes cromossômicas, como a dic(9;12), podem estar associadas ao bom prognóstico. Com exceçäo do tratamento da leucemia de células B, protocolos terapêuticos especificamente direcionados a grupos segregados por análise imunofenotípica ou genotípica näo têm sido bem sucedidos. portanto, a seleçao da melhor opçäo terapêutica para um determinado paciente deverá ser orientada pela probabilidade do insucesso terapêutico. Para pacientes com alto risco de recidivas (i.e. com uma probabilidade>70 por cento) a utilizaçäo de protocolos experimentais é justificável, mesmo em face dos efeitos colaterais agudos e tardios decorrentes do tratamento. Para o grupo de crianças de baixo risco de recidiva (<20 por cento de probabilidade), terapia que evita as medicaçöes mais perigosas deve ser administrada.