Summary Patterns of cancer incidence across the world have undergone substantial changes as a result of industrialisation and economic development. However, the economies of most countries remain at an early or intermediate stage of development—these stages are characterised by poverty, too few health-care providers, weak health systems, and poor access to education, modern technology, and health care because of scattered rural populations. Low-income and middle-income countries also have younger populations and therefore a larger proportion of children with cancer than high-income countries. Most of these children die from the disease. Chronic infections, which remain the most common causes of disease-related death in all except high-income countries, can also be major risk factors for childhood cancer in poorer regions. We discuss childhood cancer in relation to global development and propose strategies that could result in improved survival. Education of the public, more and better-trained health professionals, strengthened cancer services, locally relevant research, regional hospital networks, international collaboration, and health insurance are all essential components of an enhanced model of care.

https://www.thelancet.com/pdfs/journals/lanonc/PIIS1470-2045(13)70008-1.pdf

Paediatric cancer in low-income and middle-income countries

Sepsis is a major contributor to the global burden of disease. The majority of sepsis cases and deaths are estimated to occur in low and middle-income countries. Barriers to reducing the global burden of sepsis include difficulty quantifying attributable morbidity and mortality, low awareness, poverty and health inequity, and under-resourced and low-resilience public health and acute health care delivery systems. Important differences in the populations at risk, infecting pathogens, and clinical capacity to manage sepsis in high and low-resource settings necessitate context-specific approaches to this significant problem. We review these challenges and propose strategies to overcome them. These strategies include strengthening health systems, accurately identifying and quantifying sepsis cases, conducting inclusive research, establishing data-driven and context-specific management guidelines, promoting creative clinical interventions, and advocacy.

/pdf/the-global-burden-of-sepsis-barriers-and-potential-solutions-1mae5vmd5e.pdf

The global burden of sepsis: barriers and potential solutions

© 2018, Journal of Health Global. Background Non-communicable diseases (NCDs) are the leading cause of death globally. Eighty-two percent of premature NCD deaths occur within low- and lower middle-income countries (LLMICs). Research to date, largely drawn from high-income countries, suggests that disadvantaged and marginalized groups have a higher NCD burden, but there has been a dearth of research studying this relationship within LLMICs. The purpose of this systematic review is to map the literature on evidence from LLMICs on the socio-economic status (SES) gradient of four particular NCDs: cardiovascular disease, cancer, diabetes, and chronic respiratory diseases. Methods We conducted a comprehensive literature search for primary research published between 1 January 1990 and 27 April 2015 using six bibliographic databases and web resources. We included studies that reported SES and morbidity or mortality from cardiovascular disease, cancer, diabetes and chronic respiratory diseases within LLMICs. Results Fifty-seven studies from 17 LLMICs met our inclusion criteria. Fourteen of the 18 papers that reported significant associations between cancer and SES suggested that low SES groups had the highest cancer risk. Eleven of 15 papers reporting significant relationships between CVD and SES suggested that low SES groups have higher risk. In contrast, seven of 12 papers reporting significant findings related to diabetes found that higher SES groups had higher diabetes risk. We identified just three studies on the relationship between chronic respiratory diseases and SES; none of them reported significant findings. Conclusions Only 17 of the 84 LLMICs were represented, highlighting the need for more research on NCDs within these countries. The majority of studies were medium to high quality cross-sectional studies. When we restricted our analyses to high quality studies only, for both cancer and cardiovascular disease more than half of studies found a significantly higher risk for those of lower SES. The opposite was true for diabetes, whilst there was a paucity of high quality research on chronic respiratory disease. Development programmes must consider health alongside other aims and NCD prevention interventions must target all members of the population. Systematic review registration number: Prospero: CRD42015020169.

/pdf/a-systematic-review-of-associations-between-non-communicable-4n3kyejhr1.pdf

A systematic review of associations between non-communicable diseases and socioeconomic status within low- and lower-middle-income countries.

Over the last few decades, maternal health has been a major focus of the international community and this has resulted in a substantial decrease in maternal mortality globally Although, compared with maternal illness, medical and surgical emergencies account for far more morbidity and mortality, there has been less focus on global efforts to improve comprehensive emergency systems The thoughtful and specific application of the concepts used in the effort to decrease maternal mortality could lead to major improvements in global emergency health services The so-called three-delay model that was developed for maternal mortality can be adapted to emergency service delivery Adaptation of evaluation frameworks to include emergency sentinel conditions could allow effective monitoring of emergency facilities and further policy development Future global emergency health efforts may benefit from incorporating strategies for the planning and evaluation of high-impact interventions

/pdf/applying-the-lessons-of-maternal-mortality-reduction-to-23sspi9p5m.pdf

Applying the lessons of maternal mortality reduction to global emergency health

In high-income countries (HICs), the annual incidence of childhood cancer is approximately 140 per 1 million children younger than age 15 years, although estimates vary between and within countries (Parkin and others 1998). Incidence rates from low- and middle-income country (LMIC) registries are generally significantly lower, as annual rates per 1 million children of 45.6 in Namibia and 64.4 in India, respectively, illustrate (Parkin and others 1998). Some of this variation may relate to differences in environmental exposures or to biologic susceptibility. However, deficiencies in diagnosis and registration likely contribute significantly to differences in the reported incidence of cancer, both overall and of particular subtypes, such as acute leukemias (Howard and others 2008).

Treating Childhood Cancer in Low- and Middle-Income Countries

Background 
Infection remains the most common cause of death from toxicity in children with cancer in low- and middle-income countries. Rapid administration of antibiotics when fever develops can prevent progression to sepsis and shock, and serves as an important indicator of the quality of care in children with acute lymphoblastic leukemia and acute myeloid leukemia. We analyzed factors associated with (1) Longer times from fever onset to hospital presentation/antibiotic treatment and (2) Sepsis and infection-related mortality.


Method 
This prospective cohort study included children aged 0–16 years with newly diagnosed acute leukemia treated at Benjamin Bloom Hospital, San Salvador. We interviewed parents/caregivers within one month of diagnosis and at the onset of each new febrile episode. Times from initial fever to first antibiotic administration and occurrence of sepsis and infection-related mortality were documented.


Findings 
Of 251 children enrolled, 215 had acute lymphoblastic leukemia (85.7%). Among 269 outpatient febrile episodes, median times from fever to deciding to seek medical care was 10.0 hours (interquartile range [IQR] 5.0–20.0), and from decision to seek care to first hospital visit was 1.8 hours (IQR 1.0–3.0). Forty-seven (17.5%) patients developed sepsis and 7 (2.6%) died of infection. Maternal illiteracy was associated with longer time from fever to decision to seek care (P = 0.029) and sepsis (odds ratio [OR] 3.06, 95% confidence interval [CI] 1.09–8.63; P = 0.034). More infectious deaths occurred in those with longer travel time to hospital (OR 1.36, 95% CI 1.03–1.81; P = 0.031) and in families with an annual household income <US$2,000 (OR 13.90, 95% CI 1.62–119.10; P = 0.016).


Interpretation 
Illiteracy, poverty, and longer travel times are associated with delays in assessment and treatment of fever and with sepsis and infectious mortality in pediatric leukemia. Providing additional education to high-risk families and staying at a nearby guest house during periods of neutropenia may decrease sepsis and infectious mortality.

/pdf/low-socioeconomic-status-is-associated-with-prolonged-times-1m9cszax2q.pdf

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

STUDY OBJECTIVES
Concerns regarding the risk of positive airway pressure (PAP)-associated respiratory infection (RI) have shaped consumer views toward PAP device use and maintenance. However, data regarding temporal associations between PAP use and risk for RIs are limited. The purpose of the present study was to examine longitudinal associations between PAP use and risk of clinically significant RIs in a cohort of patients with obstructive sleep apnea (OSA).


METHODS
The frequency of clinically-reported respiratory RIs pre- and post-PAP use were compared in a sample of 482 adult patients with OSA who underwent PAP titration at a large academic sleep center between 2011-2014. RIs were identified by clinical record review beginning two years before and ending two years after the participants' PAP titration. Presence of longitudinal standard PAP data download reports identified PAP users from non-users. PAP adherence was defined as at least four hours of use per day, 5 days per week for at least 70% of days. Poisson regression models, adjusted for age, gender, body mass index (BMI), and the number of pre-PAP use RIs were utilized to examine associations between PAP use and subsequent RIs.


RESULTS
Poisson regression models adjusted for age, gender, BMI, and the number of pre-PAP use RIs did not show associations between PAP therapy use and rate of post-PAP use RIs (RR=1.27, 95% CI: 0.86, 1.86). A sensitivity analysis that included only PAP users with difference in PAP adherence showed similar results (RR=0.65, 95% CI: 0.32, 1.30).


CONCLUSIONS
Among adults with OSA, we did not find evidence for association between PAP use/adherence and increased RI frequency. These data offer new information that could assuage patients with OSA who are considering PAP deferral based on RI concerns.

Respiratory infection risk in positive airway pressure therapy users: a retrospective cohort study.

STUDY OBJECTIVES
Head and neck squamous cell carcinoma (HNSCC) or its treatment may be associated with an increased risk of obstructive sleep apnea (OSA). However, reported relationships between OSA risk factors and HNSCC are inconsistent. This study examined associations between tumor variables and risk of OSA at least one year after completion of treatment for HNSCC.


METHODS
This cross-sectional study included HNSCC patients of a large academic medical center. Inclusion criteria were age ≥18 years, cancer free for at least one year, with absence of tracheostomy or mental impairment. The STOP-BANG questionnaire, with a threshold ≥3, was used to classify HNSCC patients into elevated and low OSA risk. Tumor characteristics and treatment types were obtained from medical records. Descriptive statistics were used to compare characteristics between OSA risk groups. Unadjusted and age-adjusted logistic and linear regression models were used to explore associations between exposures and OSA risk.


RESULTS
Among 67 participants, 85% were males, mean age was 62.0 years (8.0 SD), mean body mass index was 28.7 kg/m2 (4.6 SD), and mean neck circumference was 16.3 inches (1.2 SD). Three-quarters of participants received chemoradiation only. Elevated OSA risk was observed in 60% of the participants. Tumor location, tumor stage, and type of cancer treatment were not different between OSA risk groups. Hyperlipidemia was more common in the elevated OSA risk group vs. the low risk (n=16, 40% vs. n=2, 7%, p=0.004). Age-adjusted analysis showed a trend toward twofold increased odds of elevated OSA risk in patients with tumors at the base of the tongue in comparison to other locations (OR=2.3, 95% CI 0.9, 6.4). No associations between tumor stage, cancer treatment, and elevated OSA risk were observed.


CONCLUSIONS
Elevated OSA risk was common after HNSCC treatment. However, measured HNSCC characteristics generally were not different between elevated and low OSA risk groups. Given the high frequency of OSA that appears likely to exist in HNSCC patients, clinicians should inquire about OSA features in patients with a history of HNSCC.

Risk of obstructive sleep apnea after treatment of head and neck squamous cell carcinoma: a cross-sectional study.

STUDY OBJECTIVES
Transgender or gender nonconforming (TGNC) identity is associated with higher burden of sleep disorders relative to cisgender identity. However, the role of gender-affirming therapy (GAT) in sleep disorders is poorly understood. This study examined relationships between TGNC identity, transition, and sleep disorders among TGNC and cisgender youth.


METHODS
This retrospective cross-sectional study utilized a large US-based administrative claims database (de-identified Optum Clinformatics Data Mart Database) to identify youth aged 12-25 years who obtained a diagnosis of TGNC identity and those who pursued GAT. Descriptive statistics estimated distributions of demographic and health characteristics by gender identity. Unadjusted and age-adjusted logistic regression models were used to examine associations between TGNC identity, GAT, and sleep disorders.


RESULTS
This study included 1,216,044 youth, of which 2,603 (0.2%) were identified as TGNC. Among the 1,387 TGNC who pursued GAT, 868 and 519 were identified as transmasculine and transfeminine, respectively. Adjusted analysis showed increased odds of insomnia (OR=5.4, 95% CI 4.7, 6.2), sleep apnea (OR=3.0, 95% CI 2.3, 4.0), and other sleep disorders (OR=3.1, 95% CI 2.5, 3.9) in TGNC relative to cisgender youth. Decreased odds of any sleep disorder were observed in the TGNC youth on GAT (OR=0.5, 95% CI 0.4, 0.7) relative to those not on GAT.


CONCLUSIONS
This study demonstrated a high burden of sleep disorders in TGNC youth in comparison to cisgender. However, GAT may confer a protective effect on sleep disorders among TGNC youth. Longitudinal assessments of sleep disorders prior to and post-GAT are needed to uncover their temporal relationships.

Gender identity and transition: relationships with sleep disorders in US youth.

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Papers

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

Respiratory infection risk in positive airway pressure therapy users: a retrospective cohort study.

Risk of obstructive sleep apnea after treatment of head and neck squamous cell carcinoma: a cross-sectional study.

Gender identity and transition: relationships with sleep disorders in US youth.