Bloodstream infection by Rhodococcus corynebacterioides in a pediatric patient diagnosed with high-risk retinoblastoma

Rhodococcus is a pathogen that is known to cause infections in animals and humans, mainly in cases of immunocompromised patients. A case of a pediatric cancer patient suffering from a bloodstream infection caused by Rhodococcus corynebacterioides was described in this work. Gram positive rods were isolated from blood cultures. The target bacterium was identified using a combination of biochemical tests, the MALDI-TOF mass spectrometry technique, and the analysis of the 16S rRNA sequence. Moreover, an antimicrobial susceptibility test was performed using the E-test. The isolated bacterium was identified as R. corynebacterioides. The 3-year-old patient was successfully treated with vancomycin and meropenem. This is the first published report of R. corynebacterioides in a pediatric patient diagnosed with retinoblastoma that developed a bloodstream infection. R. corynebacterioides should be considered among the opportunistic infectious agents affecting pediatric cancer patients.

QOLP-25. PERFORMANCE STATUS OF PEDIATRIC PATIENTS WITH CENTRAL NERVOUS SYSTEM TUMORS TREATED IN A TERTIARY CENTER IN MEXICO, A SINGLE-CENTER EXPERIENCE

BACKGROUND

Central nervous system (CNS) tumors are the most common solid neoplasms in the pediatric age. Despite this, there are no reports of results focused on the performance status of pediatric patients who are treated in a multidisciplinary setting.

OBJECTIVE

Describe the Performance Status of CNS pediatric patients after being treated with a multidisciplinary approach in a tertiary center.

METHODS

We review the chart of the pediatric patients at the Teleton Children Oncology Hospital from December 2014 to December 2019. The performance status was evaluated either using ECOG, Karnofsky, or Lansky scores. The multidisciplinary approach at our hospital includes: A Well-Equipped Diagnostic Center, integrated by a CAP-accredited laboratory, a Molecular Biology Unit, and the Imaging Unit, including a high-quality 2 tesla MRI. The surgical equipment comprises a surgical microscope, bipolar coagulation equipment, microsurgical instruments, and craniotomy equipment. For deep biopsies or functional surgery, we use Frame-Based Stereotactic Systems (FBSS) and neuronavigation systems. We provide first-line chemotherapy protocols and have a radiotherapy unit that can start treatment within a week. We have an Intensive Care Unit for oncologic patients with a 93% of overall survival. We provide ludic therapy and cognitive behavioral therapy, as well as emotional support. The Physical Rehabilitation Clinic uses the Bobath concept, proprioceptive and neuromuscular techniques as well as follow-up visits according to needs.

RESULTS

Of the 56 patients treated, 35 were evaluated with ECOG/Lansky performance status scale during the last follow up visit, resulting in 74.2% with a fully active performance, able to carry on all pre-disease activities without restriction.

CONCLUSION

A multidisciplinary approach is essential in the management of pediatric patients with CNS tumors. Efforts should be aimed at reducing post-surgical morbidity and early rehabilitation to reintegrate patients into society in the long term as we described many of them have an excellent performance status.

Acute Lymphoblastic Leukaemia Survival in Children Covered by Seguro Popular in Mexico: A National Comprehensive Analysis 2005-2017

The aim of the study was to measure survival of children with acute lymphoblastic leukemia (ALL) under Mexico's public health insurance for the population treated under Seguro Popular. A retrospective cohort study using claims data from Mexico's Seguro Popular program, covering cancer treatment from 2005 to 2015 was conducted. Overall 5-year national and state-specific survival for children with ALL across Mexico who initiated cancer treatment under this program was estimated. From 2005 to 2015, 8,977 children with ALL initiated treatment under Seguro Popular. Under this financing scheme, the annual number of treated children doubled from 535 in 2005 to 1,070 in 2015. The estimates for 5-year overall survival of 61.8% (95%CI 60.8, 62.9) remained constant over time. We observed wide gaps in risk-standardized 5-year overall survival among states ranging from 74.7% to 43.7%. We found a higher risk of mortality for children who received treatment in a non-pediatric specialty hospital (Hazards Ratio, HR = 1.18; 95%CI 1.09, 1.26), facilities without a pediatric oncology/hematology specialist (HR = 2.17; 95%CI 1.62, 2.90), and hospitals with low patient volume (HR = 1.22; 95%CI 1.13, 1.32). In a decade Mexico's Seguro Popular doubled access to ALL treatment for covered children and by 2015 financed the vast majority of estimated ALL cases for that population. While some progress in ALL survival may have been achieved, nationwide 5-year overall survival did not improve over time and did not achieve levels found in comparable countries. Our results provide lessons for Mexico's evolving health system and for countries moving toward universal health coverage.

LINC-40. VERY YOUNG PATIENTS AND CENTRAL NERVOUS SYSTEM TUMORS: A SINGLE-CENTER EXPERIENCE IN AN UPPER-MIDDLE-INCOME COUNTRY

Tumors of the central nervous system comprise nearly a quarter of all childhood cancers and are the most frequent solid tumor in the pediatric population. Primary central nervous system tumors (PCNST) are a rare and heterogeneous group of tumors responsible for high mortality and morbidity. Around 10% of primary CNS tumors occur during the first year of life with almost half of them during the first six months. About 18% of these tumors appear before the age of two years. Very young children differ from older children and adolescents regarding the incidence and location of different histological entities of CNS tumors. We aimed at providing descriptive epidemiological data and report the outcome in a tertiary center from December 2013 to January 2020 for all histological subtypes of primary central nervous system tumors in very young patients, defined as patients younger than three years. We collect data from 19 patients treated in an oncology exclusive tertiary center in Mexico between 2013 and 2020. This study aims to relate factors such as age, radiotherapy, surgery, chemotherapy with Lansky Performance Scale and determine the impact, not only in the overall survival but also in the quality of life.

LINC-39. PERFORMANCE STATUS OF PEDIATRIC PATIENTS WITH CENTRAL NERVOUS SYSTEM TUMORS TREATED IN MEXICO, A SINGLE-CENTER EXPERIENCE

BACKGROUND

Central nervous system (CNS) tumors are the most common solid neoplasms in the pediatric age, they comprise about a quarter of all cancers at this age. Little is known about the specific epidemiology of this group in Mexico and there are no reports of results focused on the Performance Status of patients who are treated in a multidisciplinary setting.

OBJECTIVE

To describe the Performance Status of CNS pediatric patients after being treated with a multidisciplinary approach in a tertiary center.

METHODS

We report a retrospective chart review of all pediatric patients who presented to the Neuro-Oncology Clinic at Teleton Pediatric Oncology Hospital in Queretaro, Mexico, from December 2014 to January 2020. We analyzed age, gender, the extent of surgical resection and histopathology. Performance Status was assessed using ECOG and Karnofsky/Lansky scores during every patient’s last follow-up visit.

RESULTS

A total of 56 patients were treated, epidemiology and histopathology variants are similar to those described in the international literature. With a median follow-up of 33 months, 35 patients are alive (62.5%), 28 of them (74.2%) have an excellent Performance Status (ECOG score 0 or Lansky/Karnofsky ≥ 90), 5 (14.2%) scored ECOG 1–2 and only 4 (11.4%) scored ECOG 3–4.

CONCLUSIONS

A multidisciplinary approach with a focus on Performance Status and the potential for neurological recovery is essential in the management of pediatric patients with CNS tumors. Efforts should be aimed at reducing post-surgical morbidity and early rehabilitation to reintegrate patients into society in the long term.

Patient and health service factors associated with delays in cancer treatment for children without social security in Mexico

BACKGROUND

The objective was to investigate factors associated with patient-related timing (PRT) to seek healthcare and health service-related timing (HSRT) to diagnose cancer and provide treatment to children without social security in Mexico.

PROCEDURE

A cross-sectional survey was conducted in 13 Ministry of Health hospitals in the states of Chihuahua, Jalisco, Mexico City, Morelos, Oaxaca, Puebla, Queretaro, State of Mexico, and Tlaxcala. Study participants were parents of recently diagnosed pediatric cancer patients (≤ 17 years of age). Three groups of factors were investigated: (1) patients (child and parent characteristics); (2) healthcare providers (HCPs) (first-contact HCP, institution, perceptions of barriers to healthcare, etc.); and (3) disease factors (cancer type/site, stage/risk at diagnosis). PRT and HSRT-associated factors were identified using multiple negative binomial regressions.

RESULTS

The study included 265 children; 49% sought care when symptoms first appeared. The median PRT was seven days, and the median HSRT was 40 days. Parents' perceptions of long wait times for appointments were associated with longer PRT and HSRT. Residing in the lowest or highest socioeconomic regions and persistent or worsening symptoms increased the probability of longer PRT. Older patient age, HCP requests for imaging tests or prescription for steroids, a higher number of doctors consulted, having a urinary tract cancer, and having an advanced stage or high-risk cancer increased the probability of longer HSRT.

CONCLUSION

Strategies to shorten lag time from symptom onset to diagnosis and treatment are urgently needed for childhood cancers in Mexico.

Identifying and Prioritizing Family Education Needs at Pediatric Oncology Centers in Central America and Mexico

The educational needs of parents at the time of their child’s cancer diagnosis are often unclear, and research on this topic in low- and middle-income countries is limited. This study evaluated the educational needs of families at major pediatric oncology centers in Central America and Mexico.

Case Discussion As a Strategic Planning Tool: Exploring Medical Tourism at Hospital Infantil Telethon De Oncología

Background: As medical tourism rises globally, healthcare leaders are required to make strategic decisions about accepting international patients, as a means to diversify income, increase access to cancer care, and optimize patient experience. Hospital Infantil Teletón de Oncología (HITO), a free-standing pediatric oncology hospital in Mexico, currently has no international patients. Aim: We posed a hypothetical case to a group of HITO's senior leaders to understand the strategic priorities, examine the decision-making process around allocating beds for self-paying patients, and explore how changes in hospital governance influence the healthcare system. Methods: A literature review and prediscussion interviews were conducted, and IRB exemption was obtained. Two facilitators led the discussion using a structured case guide. Participants (N=13) were randomly assigned to teams supporting or opposing the decision to accept international patients. Thirty minutes were allocated for team discussion, thirty minutes for team presentation and group discussion. Session was recorded and transcribed. Results: Four themes emerged around ethics and equity, finance, operations, and community. Ethical considerations included concerns that this possibility disrupted HITO's mission to serve the Mexican population. Financial considerations focused on the creation of a new billing system and cost-efficiency questions. Operational issues included new processes and systems in care delivery to accommodate international patients such as transfer of records and hiring of translators. Community topics covered HITO's reputation and the impact on local economy. Conclusion: Our study revealed the importance of a multidisciplinary approach to complex decision-making and the need for systematic strategic planning that lead to system strengthening and improvement of childhood cancer outcomes. The use of a hypothetical case as a learning and consensus-building tool in exploring team dynamics and mapping strategies was also highlighted. With medical tourism as a potentially realistic scenario, healthcare leaders must be prepared to evaluate its impact on their organization, healthcare system, and society.

Delivery of Pediatric Cancer Care in Mexico: A National Survey

Purpose Limited data describe the delivery of pediatric cancer care in Mexico. We report a nationwide survey of pediatric cancer units. Methods An electronic survey was distributed to 74 pediatric cancer units in Mexico to describe case volumes; organization of care; and availability of medical/surgical specialists, supportive care, complex therapies, and diagnostic services. Centers were classified as low (< 30 new patients/year), medium (30 to 59/year) and high (≥ 60/year). Results Sixty-two centers completed the survey (response rate, 84%). The median annual new case volume per center was 50 (interquartile range [IQR], 23 to 81). Thirty-four percent (n = 21), 26% (n = 16), and 40% (n = 25) of units were low-, medium-, and high-volume centers, respectively. Treatment units reported a median of two pediatric oncologists (IQR, 2) and one pediatric hematologist (IQR, 1 to 2). Availability of medical and surgical subspecialists varied by center size, with substantially more specialist support at higher-volume centers ( P < .01). Multidisciplinary tumor boards are available at 29% (six of 21), 56% (nine of 16), and 76% (19 of 25) of low- to high-volume centers, respectively ( P = .005). Radiation and palliative care services are available at 42% (n = 26) and 63% (n = 36) of all centers, which did not vary by center volume. Educational support for hospitalized children and school reintegration programs are available at 56% (n = 36) and 58% (n = 36) of centers, respectively. One third (38% [n = 23]) of centers reported that at least one half of patients were lost to follow-up during the transition from pediatric to adult programs. Conclusion A large variation exists in annual case volumes across Mexican pediatric cancer centers. Additional efforts to increase access to multidisciplinary, supportive, and palliative care across all pediatric cancer units in Mexico are required.

A multicentre report from the Mexican Retinoblastoma Group

BACKGROUND

Retinoblastoma (RB) is a relatively uncommon tumour in childhood. The incidence of retinoblastoma in Mexico is probably higher than the incidence reported worldwide, however there is not enough information about the characteristics of this illness in Mexico. This report aims to present the results of a multicentre clinical survey of RB in Mexico.

METHODS

A retrospective study was carried out on all RB cases treated in 16 institutions during the last six years. The variables analysed were age at diagnosis, sex, affected eyes, treatment modalities, and pathological staging. Overall survival was obtained.

RESULTS

The authors analysed 500 cases; age range was 0-182 months. There were 364 unilateral cases (72.8%). Enucleation was performed in 84.9% of the patients. The St Jude's staging was: 7.4% stage I, 52.8% stage II, 18.0% stage III, 11.4% stage IV, 7.2% not evaluated, and 3.2% missing data. Chemotherapy was used in 74.4% of the patients. Disease free survival was 89% at 73 months follow up.

CONCLUSIONS

The paper presents a great number of cases and pioneers multicentre studies in paediatric ophthalmology and oncology in this country. Given the great number of patients in advanced stages and the variability on treatment schemes, it is evident that it is mandatory to work in a cooperative group and develop a national early detection programme as well as a treatment protocol which include all specialists involved in the care of patients with RB.

B-lineage acute lymphoblastic leukemia of childhood. An institutional experience

A total of 119 children (1990-95) with acute lymphoblastic leukemia (ALL) B-lineage either CD10+ or CD10- were registered into a single non-randomized chemotherapy protocol. Only untreated patients with standard risk were included in the study. Their ages ranged from 1.8-10 years with a mean of 5.1 years. There were 82 (68%) children with early pre B-All, 35 (29%) with pre B-ALL and 2(1.6%) with transitional pre B-ALL (p < 0.00001). The patients were divided according to CD10 reactivity, either + (94 children) or -(25 patients). The event-free survival (EFS) at 60 months for the CD10+ children was of 78% (alive 73/94), while for the CD10- was 71% (alive 18/25) (p = 0.6) and 74% for both groups. The factors that influenced favorably the survival in the CD10+ group were the age between 3 to 5.99 years (p < 0.00001), sex (either male or female), leukocyte count between 10-24.9 x 10(9)/l (p < 0.00001), LDH under 300 U/I (p < 0.00001) and L1 bone marrow cytomorphology (p < 0.00001). In the CD10- patients, the EFS was favorably influenced by the female sex (p = 0.04), leukocyte count under 10 x 10(9)/l (p = 0.05) and LDH < 300 U/l (p = 0.02). CNS infiltration was documented in 4.2% (5/119). Mortality secondary to chemotherapy was seen in 7%. In conclusion, this is the first large series in Mexican children with B-lineage ALL published. Because of the relatively small number of patients in each group (pre B and transitional pre B), all the patients in the current series were treated alike. When the 119 patients were divided only on the basis of CD10 reactivity, the EFS for both groups (CD10+ and-) was similar; therefore, the reactivity to CD10 has no prognostic value in this type of ALL.

Arsenic-cadmium interaction in rats

Simultaneous exposure to cadmium and arsenic is highly probable in the urban area of San Luis Potosi, Mexico due to common localization of copper and zinc smelters. Therefore, in this work, rats were intraperitoneally exposed either to cadmium or arsenic alone, or simultaneously to both metals. The effects of these treatments on three different toxicological parameters were studied. Cadmium modified the LD50 of arsenic and conversely arsenic modified the LD50 for cadmium. At the histopathological level, arsenic appeared to protect against the cadmium effects, especially on testes. This protective effect seemed to be related to the glutathione levels found in this tissue: rats exposed to both arsenic and cadmium, presented glutathione values intermediate to those observed after exposure to either metal alone; arsenic had the highest value and cadmium the lowest. In liver, rats exposed to arsenic, cadmium or arsenic and cadmium, presented glutathione values below those in the saline group, with the lowest value corresponding to the arsenic and cadmium treatment. The results appear to support the proposed interaction between arsenic and cadmium and coexposure to both metals seems to alter certain effects produced by either metal alone.