title: Treatment-related mortality in children with acute myeloid leukaemia in Central America: incidence, timing and predictors.
abstract: BACKGROUND
  Cure rates in paediatric acute myeloid leukaemia in low-income countries lag behind those in high-income countries, in part secondary to higher rates of treatment-related mortality. Patterns of treatment-related mortality are likely to differ between low and high-income centres. Understanding low-income setting patterns is necessary before effective interventions aimed at decreasing treatment-related mortality can be designed. Our aim was to describe the incidence, timing and predictors of treatment-related mortality among Central American children with acute myeloid leukaemia.
  
  
  METHODS
  We evaluated patients younger than 21 years diagnosed with acute myeloid leukaemia from 2000 to 2008 in El Salvador, Honduras or Guatemala. Biologic, socioeconomic and nutritional variables collected prospectively were examined as potential predictors of treatment-related mortality.
  
  
  RESULTS
  Among 279 patients, treatment-related mortality occurred in 65 (23%). Of 65 deaths, 51 (78.5%) occurred before or during induction, resulting in an early death rate of 18.3%. The most common causes of treatment-related mortality were infection (29/65; 45%) and haemorrhage (13/65; 20%). Infection accounted for 33% of treatment-related mortality before remission induction therapy versus 40% during induction and 77% after induction (P = 0.03). Rates of treatment-related mortality did not vary between time periods 1 and 2 (24.8% versus 21.4%; P = 0.32). Only lower initial platelet count predicted early death (odds ratio per 10 × 10(9)/L = 0.88, 95% Confidence Interval (CI) 0.79-0.97; P < 0.001).
  
  
  CONCLUSIONS
  Treatment-related mortality remains a significant cause of treatment failure. Supportive care interventions are needed. Children presenting with low initial platelet counts were at highest risk of induction death, suggesting that transfusion practices should be evaluated.
authors.affiliation: Division of Haematology/Oncology and Program in Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Canada.
authors.forename: Sumit
authors.initials: S
authors.lastname: Gupta
authors.forename: Miguel
authors.initials: M
authors.lastname: Bonilla
authors.forename: Patricia
authors.initials: P
authors.lastname: Valverde
authors.forename: Ligia
authors.initials: L
authors.lastname: Fu
authors.forename: Scott C
authors.initials: SC
authors.lastname: Howard
authors.forename: Raul C
authors.initials: RC
authors.lastname: Ribeiro
authors.forename: Lillian
authors.initials: L
authors.lastname: Sung
mesh_terms: D002489:Central America; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D019049:Developed Countries; D004544:El Salvador / Q000453:epidemiology; D005260:Female; D006166:Guatemala / Q000453:epidemiology; D006721:Honduras / Q000453:epidemiology; D006801:Humans; D015994:Incidence; D015470:Leukemia, Myeloid, Acute / Q000401:mortality* / Q000628:therapy*; D008297:Male; D017063:Outcome Assessment, Health Care / Q000379:methods; D012189:Retrospective Studies; D012959:Socioeconomic Factors