Hospital Punta Pacifica

BACKGROUND: In the Trastuzumab for GAstric cancer (ToGA) study, trastuzumab plus chemotherapy improved median overall survival by 2.7 months in patients with human epidermal growth factor receptor 2 (HER2)-positive [immunohistochemistry (IHC) 3+/fluorescence in situ hybridization-positive] gastric/gastroesophageal junction cancer compared with chemotherapy alone (hazard ratio 0.74). Post hoc exploratory analyses in patients expressing higher HER2 levels (IHC 2+/fluorescence in situ hybridization-positive or IHC 3+) demonstrated a 4.2-month improvement in median overall survival with trastuzumab (hazard ratio 0.65). The ToGA study provides the largest screening dataset available on HER2 overexpression/amplification in this indication. We further analyzed correlation(s) of HER2 overexpression/amplification with clinical and epidemiological factors. METHODS: HER2-positivity was analyzed by histological subtype, tumor location, geographic region, and specimen type. Exploratory efficacy analyses were performed. RESULTS: The HER2-positivity rate was 22.1 % across analyzed tumor samples. Rates were similar between European and Asian patients (23.6 % vs. 23.9 %), but higher in intestinal- vs. diffuse-type (31.8 % vs. 6.1 %), and gastroesophageal junction cancer versus gastric tumors (32.2 % vs. 21.4 %). Across all IHC scores, variability in HER2 staining (≤30 % stained cells) was observed in almost 50 % of cases, with increasing rates in lower IHC categories, and did not affect treatment outcome. The polysomy rate was 4 %. CONCLUSIONS: HER2 expression varies by tumor location and type. All patients with advanced gastric or gastroesophageal junction cancer should be tested for HER2 status, preferably using IHC initially. Due to the unique characteristics of gastric cancer, specific testing/scoring guidelines should be adhered to.

Importance: The incidence of early-onset colorectal cancer (younger than 50 years) is rising globally, the reasons for which are unclear. It appears to represent a unique disease process with different clinical, pathological, and molecular characteristics compared with late-onset colorectal cancer. Data on oncological outcomes are limited, and sensitivity to conventional neoadjuvant and adjuvant therapy regimens appear to be unknown. The purpose of this review is to summarize the available literature on early-onset colorectal cancer. Observations: Within the next decade, it is estimated that 1 in 10 colon cancers and 1 in 4 rectal cancers will be diagnosed in adults younger than 50 years. Potential risk factors include a Westernized diet, obesity, antibiotic usage, and alterations in the gut microbiome. Although genetic predisposition plays a role, most cases are sporadic. The full spectrum of germline and somatic sequence variations implicated remains unknown. Younger patients typically present with descending colonic or rectal cancer, advanced disease stage, and unfavorable histopathological features. Despite being more likely to receive neoadjuvant and adjuvant therapy, patients with early-onset disease demonstrate comparable oncological outcomes with their older counterparts. Conclusions and Relevance: The clinicopathological features, underlying molecular profiles, and drivers of early-onset colorectal cancer differ from those of late-onset disease. Standardized, age-specific preventive, screening, diagnostic, and therapeutic strategies are required to optimize outcomes.

OBJECTIVE: To assess the feasibility and effectiveness of the International Nosocomial Infection Control Consortium (INICC) multidimensional hand hygiene approach in 19 limited-resource countries and to analyze predictors of poor hand hygiene compliance. DESIGN: An observational, prospective, cohort, interventional, before-and-after study from April 1999 through December 2011. The study was divided into 2 periods: a 3-month baseline period and a 7-year follow-up period. SETTING: Ninety-nine intensive care unit (ICU) members of the INICC in Argentina, Brazil, China, Colombia, Costa Rica, Cuba, El Salvador, Greece, India, Lebanon, Lithuania, Macedonia, Mexico, Pakistan, Panama, Peru, Philippines, Poland, and Turkey. PARTICIPANTS: Healthcare workers at 99 ICU members of the INICC. METHODS: A multidimensional hand hygiene approach was used, including (1) administrative support, (2) supplies availability, (3) education and training, (4) reminders in the workplace, (5) process surveillance, and (6) performance feedback. Observations were made for hand hygiene compliance in each ICU, during randomly selected 30-minute periods. RESULTS: A total of 149,727 opportunities for hand hygiene were observed. Overall hand hygiene compliance increased from 48.3% to 71.4% ([Formula: see text]). Univariate analysis indicated that several variables were significantly associated with poor hand hygiene compliance, including males versus females (63% vs 70%; [Formula: see text]), physicians versus nurses (62% vs 72%; [Formula: see text]), and adult versus neonatal ICUs (67% vs 81%; [Formula: see text]), among others. CONCLUSIONS: Adherence to hand hygiene increased by 48% with the INICC approach. Specific programs directed to improve hand hygiene for variables found to be predictors of poor hand hygiene compliance should be implemented.

Individuals with autism spectrum disorder (ASD) suffer from developmental disabilities that impact communication, behavior, and social interaction. Immune dysregulation and inflammation have been linked to children with ASD, the latter manifesting in serum levels of macrophage-derived chemokine (MDC) and thymus, and activation-regulated chemokine (TARC). Mesenchymal stem cells derived from umbilical cord tissue (UC-MSCs) have immune-modulatory and anti-inflammatory properties, and have been safely used to treat a variety of conditions. This study investigated the safety and efficacy of UC-MSCs administered to children diagnosed with ASD. Efficacy was evaluated with the Autism Treatment Evaluation Checklist (ATEC) and the Childhood Autism Rating Scale (CARS), and with measurements of MDC and TARC serum levels. Twenty subjects received a dose of 36 million intravenous UC-MSCs every 12 weeks (four times over a 9-month period), and were followed up at 3 and 12 months after treatment completion. Adverse events related to treatment were mild or moderate and short in duration. The CARS and ATEC scores of eight subjects decreased over the course of treatment, placing them in a lower ASD symptom category when compared with baseline. MDC and TARC inflammatory cytokine levels also decreased for five of these eight subjects. The mean MDC, TARC, ATEC, and CARS values attained their lowest levels 3 months after the last administration. UC-MSC administration in children with ASD was therefore determined to be safe. Although some signals of efficacy were observed in a small group of children, possible links between inflammation levels and ASD symptoms should be further investigated. Stem Cells Translational Medicine 2019;8:1008-1016.

OBJECTIVE: The dimensions of oral health-related quality of life (OHRQoL) Oral Function, Orofacial Pain, Orofacial Appearance, and Psychosocial Impact are the major areas where patients are impacted by oral diseases and dental interventions. The aim of this study was to evaluate whether dental patients' reasons to visit the dentist fit the 4 OHRQoL dimensions. METHODS: Dentists (N = 1580) from 32 countries participated in a web-based survey. For their patients with current oral health problems, dentists were asked whether these problems were related to teeth, mouth, and jaws' function, pain, appearance, or psychosocial impact or whether they do not fit the aforementioned 4 categories. Dentists were also asked about their patients who intended to prevent future oral health problems. For both patient groups, the proportions of oral health problems falling into the 4 OHRQoL dimensions were calculated. RESULTS: For every 100 dental patients with current oral health problems, 96 had problems related to teeth, mouth, and jaws' function, pain, appearance, or psychosocial impact. For every 100 dental patients who wanted to prevent future oral health problems, 92 wanted to prevent problems related to these 4 OHRQoL dimensions. Both numbers increased to at least 98 of 100 patients when experts analyzed dentists' explanations of why some oral health problems would not fit the four dimension. For the remaining 2 of 100 patients, none of the dentist-provided explanations suggested evidence against the OHRQoL dimensions as the concepts that capture dental patients' suffering. CONCLUSION: Oral Function, Orofacial Pain, Orofacial Appearance, and Psychosocial Impact capture dental patients' oral health problems worldwide. These 4 OHRQoL dimensions offer a psychometrically sound and practical framework for patient care and research, identifying what is important to dental patients.

Introduction: Stroke is one of the leading causes of death in Latin America, a region with countless gaps to be addressed to decrease its burden. In 2018, at the first Latin American Stroke Ministerial Meeting, stroke physician and healthcare manager representatives from 13 countries signed the Declaration of Gramado with the priorities to improve the region, with the commitment to implement all evidence-based strategies for stroke care. The second meeting in March 2020 reviewed the achievements in 2 years and discussed new objectives. This paper will review the 2-year advances and future plans of the Latin American alliance for stroke. Method: In March 2020, a survey based on the Declaration of Gramado items was sent to the neurologists participants of the Stroke Ministerial Meetings. The results were confirmed with representatives of the Ministries of Health and leaders from the countries at the second Latin American Stroke Ministerial Meeting. Results: In 2 years, public stroke awareness initiatives increased from 25 to 75% of countries. All countries have started programs to encourage physical activity, and there has been an increase in the number of countries that implement, at least partially, strategies to identify and treat hypertension, diabetes, and lifestyle risk factors. Programs to identify and treat dyslipidemia and atrial fibrillation still remained poor. The number of stroke centers increased from 322 to 448, all of them providing intravenous thrombolysis, with an increase in countries with stroke units. All countries have mechanical thrombectomy, but mostly restricted to a few private hospitals. Pre-hospital organization remains limited. The utilization of telemedicine has increased but is restricted to a few hospitals and is not widely available throughout the country. Patients have late, if any, access to rehabilitation after hospital discharge. Conclusion: The initiative to collaborate, exchange experiences, and unite societies and governments to improve stroke care in Latin America has yielded good results. Important advances have been made in the region in terms of increasing the number of acute stroke care services, implementing reperfusion treatments and creating programs for the detection and treatment of risk factors. We hope that this approach can reduce inequalities in stroke care in Latin America and serves as a model for other under-resourced environments.

Abstract.— In March 2000, 104 wild caught Litopenaeus wannamei broodstock, captured off the Pacific coast of Panama, were screened for the following penaeid viruses: infectious hypodermal and hematopoietic necrosis virus (IHHNV) and white spot syndrome virus (WSSV). The purpose of this study was to determine the prevalence of IHHNV and WSSV in wild shrimp in this area of the Western Hemisphere and to acquire specific pathogen free (SPF) L. vannamei for inclusion into the Oceanic Institute's genetic breeding program. The prevalence of the viruses was determined using the dot blot hybridization format, which is a commercially available molecular method for detecting these viruses. Dot blot hybridization assays can be used as an initial screening method to detect moderately to highly infected shrimp. The results from the dot blot assays indicated the prevalence of IHHNV in 28% and WSSV in 2% of the 104 hemolyrnph samples tested. Results from this study were used to establish the initial candidate SPF status of the animals that were assessed and to determine the prevalence of two serious pathogens of penaeid shrimp captured from the wild of the Pacific Ocean in the Central American region off the coast of Panama.

BACKGROUND: A cesarean scar pregnancy is an iatrogenic consequence of a previous cesarean delivery. The gestational sac implants into a niche created by the incision of the previous cesarean delivery, and this carries a substantial risk for major maternal complications. The aim of this study was to report, analyze, and compare the effectiveness and safety of different treatments options for cesarean scar pregnancies managed in the first trimester through a registry. OBJECTIVE: This study aimed to evaluated the ultrasound findings, disease behavior, and management of first-trimester cesarean scar pregnancies. STUDY DESIGN: We created an international registry of cesarean scar pregnancy cases to study the ultrasound findings, disease behavior, and management of cesarean scar pregnancies. The Cesarean Scar Pregnancy Registry collects anonymized ultrasound and clinical data of individual patients with a cesarean scar pregnancy on a secure, digital information platform. Cases were uploaded by 31 participating centers across 19 countries. In this study, we only included live and failing cesarean scar pregnancies (with or without a positive fetal heart beat) that received active treatment (medical or surgical) before 12+6 weeks' gestation to evaluate the effectiveness and safety of the different management options. Patients managed expectantly were not included in this study and will be reported separately. Treatment was classified as successful if it led to a complete resolution of the pregnancy without the need for any additional medical interventions. RESULTS: Between August 29, 2018, and February 28, 2023, we recorded 460 patients with cesarean scar pregnancies (281 live, 179 failing cesarean scar pregnancy) who fulfilled the inclusion criteria and were registered. A total of 270 of 460 (58.7%) patients were managed surgically, 123 of 460 (26.7%) patients underwent medical management, 46 of 460 (10%) patients underwent balloon management, and 21 of 460 (4.6%) patients received other, less frequently used treatment options. Suction evacuation was very effective with a success rate of 202 of 221 (91.5%; 95% confidence interval, 87.8-95.2), whereas systemic methotrexate was least effective with only 38 of 64 (59.4%; 95% confidence interval, 48.4-70.4) patients not requiring additional treatment. Overall, surgical treatment of cesarean scar pregnancies was successful in 236 of 258 (91.5%, 95% confidence interval, 88.4-94.5) patients and complications were observed in 24 of 258 patients (9.3%; 95% confidence interval, 6.6-11.9). CONCLUSION: A cesarean scar pregnancy can be managed effectively in the first trimester of pregnancy in more than 90% of cases with either suction evacuation, balloon treatment, or surgical excision. The effectiveness of all treatment options decreases with advancing gestational age, and cesarean scar pregnancies should be treated as early as possible after confirmation of the diagnosis. Local medical treatment with potassium chloride or methotrexate is less efficient and has higher rates of complications than the other treatment options. Systemic methotrexate has a substantial risk of failing and a higher complication rate and should not be recommended as first-line treatment.

BACKGROUND: The results and benefits of Robotic-assisted Radical Prostatectomy (RARP) are already established in the literature. However, new robotic platforms have been released recently in the market and their outcomes are still unknown. In this scenario, our objective is to describe our experience implementing the HugoTM RAS robot and report the clinical data of patients who underwent Robotic-assisted Radical Prostatectomy. MATERIAL AND METHODS: We retrospectively analyzed fifteen consecutive patients who underwent RARP with HugoTM RAS System (Medtronic, Minneapolis, USA) from June to October 2021. The patients underwent transperitoneal RARP on lithotomy position, using six trocars (4 robotic trocars and 2 for the assistant). We reported the clinical feasibility and safety of this platform, assessing perioperative data, including complications and early outcomes. Continuous variables were reported as median and interquartile ranges, categorical variables as frequencies and proportions. RESULTS AND LIMITATIONS: All procedures were safe and feasible with no major complications or conversion. Median operative time was 235 minutes (213-271), and median estimated blood loss was 300ml (100-310). Positive surgical margins were reported in 5 patients (33%). The median hospitalization time was 2 days (2-2), and the median time to remove the foley was 7 days (7-7). On the first appointment four weeks after surgery, all patients had undetectable PSA values, and 61% were continent. CONCLUSIONS: We described preliminary results with safe and feasible procedures performed with HugoTM RAS System robotic platform. The surgeries were successfully executed with acceptable perioperative outcomes, without conversions or major complications. However, as this technology is very recent, further studies with a long-term follow-up are awaited to access postoperative functional and oncological outcomes.

Formation of the Panama Isthmus, that had global oceanographic and biotic effects in the Neogene, is generally associated with tectonic uplift during collision of the Panama volcanic arc with South America. However, new field, geochemical and geochronological data from the Culebra Cut of the Panama Canal suggest that volcanism also contributed to the Isthmus emergence in the Early Miocene. This volcanism is recorded in a newly-recognised Central Panama volcanic field that includes several phases of development. Early activity of this field along the Panama Canal was associated with proximal effusive to explosive felsic products during formation of subaerial stratovolcanoes and possible domes ca. 21 Ma. This was followed by a period of marine transgression ca. 21-18 Ma, with more distal volcanism documented by tuffs that deposited in marine to terrestrial environments. Finally, proximal mafic volcanism formed tephra cones in a monogenetic field ca. 18(-?) Ma. This was associated with phreatomagmatic processes in a coastal environment, with remarkable kilometre-wide subvolcanic peperitic intrusions. We propose based on these observations that formation of the Central Panama volcanic field was critical in shaping regional topography, and that this could have actively contributed to obstruction and closure of an interoceanic strait in Central Panama.

OBJECTIVE: To compare efficacy, tolerability, and safety of two concentrations of topical SB204 and vehicle twice daily for 12 weeks in the treatment of acne vulgaris. DESIGN: Randomized, double-blind, placebo-controlled, three-arm, Phase 2 study. SETTING: Dominican Republic, Panama, and Honduras. PARTICIPANTS: Subjects with acne, age 12 to 40, with 25 to 70 noninflammatory lesions, 20 to 40 inflammatory lesions, and a baseline Investigator's Global Assessment score of mild, moderate, or severe. MEASUREMENTS: The primary efficacy assessment was the absolute change in noninflammatory lesion counts. Other assessments included inflammatory lesion counts, success on dichotomized Investigator's Global Assessment, reported adverse events, physical examinations, laboratory testing, and tolerability. RESULTS: One hundred fifty-three subjects were randomized to vehicle (n=52), SB204 1% (n=51), or SB204 4% (n=50). When compared to vehicle, subjects treated with SB204 1% and SB204 4% had significantly greater mean percent reduction in noninflammatory lesions from baseline and subjects treated with SB204 4% had a significantly greater mean percent reduction in inflammatory lesion count from baseline at Week 12. There were no significant differences in the IGA success rates between groups. Both concentrations of SB204 were safe and well-tolerated. CONCLUSIONS: When compared to vehicle, both SB204 1% and SB204 4% significantly decreased the percentage of noninflammatory lesions and SB204 4% also significantly decreased the percentage of inflammatory lesions in subjects with acne vulgaris treated for 12 weeks. Treatment with SB204 1% and SB204 4% was safe and well-tolerated. Registry: clinicaltrials.gov (NCT01844752).

BACKGROUND: Published empirical data have increasingly suggested that using near-infrared fluorescence cholangiography during laparoscopic cholecystectomy markedly increases biliary anatomy visualization. The technology is rapidly evolving, and different equipment and doses may be used. We aimed to identify areas of consensus and nonconsensus in the use of incisionless near-infrared fluorescent cholangiography during laparoscopic cholecystectomy. METHODS: A 2-round Delphi survey was conducted among 28 international experts in minimally invasive surgery and near-infrared fluorescent cholangiography in 2020, during which respondents voted on 62 statements on patient preparation and contraindications (n = 12); on indocyanine green administration (n = 14); on potential advantages and uses of near-infrared fluorescent cholangiography (n = 18); comparing near-infrared fluorescent cholangiography with intraoperative x-ray cholangiography (n = 7); and on potential disadvantages of and required training for near-infrared fluorescent cholangiography (n = 11). RESULTS: Expert consensus strongly supports near-infrared fluorescent cholangiography superiority over white light for the visualization of biliary structures and reduction of laparoscopic cholecystectomy risks. It also offers other advantages like enhancing anatomic visualization in obese patients and those with moderate to severe inflammation. Regarding indocyanine green administration, consensus was reached that dosing should be on a milligrams/kilogram basis, rather than as an absolute dose, and that doses >0.05 mg/kg are necessary. Although there is no consensus on the optimum preoperative timing of indocyanine green injections, the majority of participants consider it important to administer indocyanine green at least 45 minutes before the procedure to decrease the light intensity of the liver. CONCLUSION: Near-infrared fluorescent cholangiography experts strongly agree on its effectiveness and safety during laparoscopic cholecystectomy and that it should be used routinely, but further research is necessary to establish optimum timing and doses for indocyanine green.

Purpose: Little is known about oncofertility practice in developing countries that usually suffer from a shortage of health services, especially those related to cancer care. Materials and Methods: To learn more about oncofertility practice in developing countries, we generated a survey to explore the barriers and opportunities associated with oncofertility practice in five developing countries from Africa and Latin America within our Oncofertility Consortium Global Partners Network. Responses from Egypt, Tunisia, Brazil, Peru, and Panama were collected, reviewed, and discussed. Results: Common barriers were identified by each country, including financial barriers (lack of insurance coverage and high out-of-pocket costs for patients), lack of awareness among providers and patients, cultural and religious constraints, and lack of funding to help to support oncofertility programs. Conclusion: Despite barriers to care, many opportunities exist to grow the field of oncofertility in these five developing countries. It is important to continue to engage stakeholders in developing countries and use powerful networks in the United States and other developed countries to aid in the acceptance of oncofertility on a global level.

OBJECTIVE: To describe the effect of the coronavirus disease 2019 (COVID-19) pandemic on Latin American rheumatologists from a professional, economic, and occupational point of view. METHODS: We conducted an observational cross-sectional study using an online survey sent to rheumatologists of each non-English-speaking country member of the Pan American League of Rheumatology Associations (PANLAR). A specific questionnaire was developed. RESULTS: Our survey included 1097 rheumatologists from 19 Latin American countries. Median (IQR) age of respondents was 48 (40-59) years and 618 (56.3%) were female. Duration of practice since graduation as a rheumatologist was 17 years, and 585 (53.3%) were aged < 50 years. Most rheumatologists worked in private practice (81.8%) and almost half worked in institutional outpatient centers (55%) and inpatient care (49.9%). The median number of weekly hours (IQR) of face-to-face practice before the pandemic was 27 (15-40) hours, but was reduced to 10 (5-20) hours during the pandemic. Telehealth was used by 866 (78.9%) respondents during the pandemic. Most common methods of communication were video calls (555; 50.6%), telephone calls (499; 45.5%), and WhatsApp voice calls (423; 38.6%). A reduction in monthly wages was reported by 946 (86.2%) respondents. Consultation fees also were reduced and 88 (8%) rheumatologists stated they had lost their jobs. A reduction in patient adherence to medication was reported by nearly 50% of respondents. Eighty-one (7.4%) rheumatologists received a COVID-19 diagnosis and 7 (8.6%) of them were hospitalized. CONCLUSION: The COVID-19 pandemic has reshaped rheumatology practice in Latin America and has had a profound effect on rheumatologists' behaviors and clinical practice.

Novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the etiologic agent of the ongoing coronavirus disease 2019 (COVID-19) pandemic, which has reached 28 million cases worldwide in 1 year. The serological detection of antibodies against the virus will play a pivotal role in complementing molecular tests to improve diagnostic accuracy, contact tracing, vaccine efficacy testing, and seroprevalence surveillance. Here, we aimed first to evaluate a lateral flow assay's ability to identify specific IgM and IgG antibodies against SARS-CoV-2 and second, to report the seroprevalence estimates of these antibodies among health care workers and healthy volunteer blood donors in Panama. We recruited study participants between April 30th and July 7th, 2020. For the test validation and performance evaluation, we analyzed serum samples from participants with clinical symptoms and confirmed positive RT-PCR for SARS-CoV-2, and a set of pre-pandemic serum samples. We used two by two table analysis to determine the test positive and negative percentage agreement as well as the Kappa agreement value with a 95% confidence interval. Then, we used the lateral flow assay to determine seroprevalence among serum samples from COVID-19 patients, potentially exposed health care workers, and healthy volunteer donors. Our results show this assay reached a positive percent agreement of 97.2% (95% CI 84.2-100.0%) for detecting both IgM and IgG. The assay showed a Kappa of 0.898 (95%CI 0.811-0.985) and 0.918 (95% CI 0.839-0.997) for IgM and IgG, respectively. The evaluation of serum samples from hospitalized COVID-19 patients indicates a correlation between test sensitivity and the number of days since symptom onset; the highest positive percent agreement [87% (95% CI 67.0-96.3%)] was observed at ≥15 days post-symptom onset (PSO). We found an overall antibody seroprevalence of 11.6% (95% CI 8.5-15.8%) among both health care workers and healthy blood donors. Our findings suggest this lateral flow assay could contribute significantly to implementing seroprevalence testing in locations with active community transmission of SARS-CoV-2.

BACKGROUND: The burden of antimicrobial resistance (AMR) in Latin America is high. Little is known about healthcare workers' (HCWs) knowledge, attitudes, and perceptions of antimicrobial stewardship (AS), AMR, and antibiotic use (AU) in the region. METHODS: HCWs from 42 hospitals from 5 Latin American countries were invited to take an electronic, voluntary, anonymous survey regarding knowledge, attitudes, and perceptions of AS, AMR, and AU between March-April 2023. FINDINGS: Overall, 996 HCWs completed the survey (52% physicians, 32% nurses, 11% pharmacists, 3% microbiologists, and 2% "other"). More than 90% of respondents indicated optimizing AU was a priority at their healthcare facility (HCF), 69% stated the importance of AS was communicated at their HCF, and 23% were unfamiliar with the term "antibiotic stewardship". Most (> 95%) respondents acknowledged that appropriate AU can reduce AMR; however, few thought AU (< 30%) or AMR (< 50%) were a problem in their HCF. Lack of access to antibiogram and to locally endorsed guidelines was reported by 51% and 34% of HCWs, respectively. Among prescribers, 53% did not consider non-physicians' opinions to make antibiotic-related decisions, 22% reported not receiving education on how to select antibiotics based on culture results and 60% stated patients and families influence their antibiotic decisions. CONCLUSIONS: Although HCWs perceived improving AU as a priority, they did not perceive AU or AMR as a problem in their HCF. AS opportunities include improved access to guidelines, access to AMR/AU data, teamwork, and education on AS for HCWs and patients and families.

Medical oncology is a relatively young specialty. However, it is old enough to have a history. That history is one of diversity between countries in the speed with which medical oncology has been recognised as a distinct specialty and in the provision made for specialist education. As part of the multidisciplinary team that cares for patients with cancer, medical oncologists have a key role in treatment, comprising the antitumour therapy and the management of symptoms and side-effects, and follow-up, as well as in clinical and translational research to promote therapeutic innovation.1.Popescu R.A. Schäfer R. Califano R. et al.The current and future role of the medical oncologist in the professional care for cancer patients: a position paper by the European Society for Medical Oncology (ESMO).Ann Oncol. 2014; 25: 9-15doi:10.1093/annonc/mdt522Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar In an era of dramatically expanding knowledge and correspondingly rapid advances in the complexity and individualisation of therapy, ensuring that all patients receive optimum care requires ever-increasing attention to training and continuing medical education.1.Popescu R.A. Schäfer R. Califano R. et al.The current and future role of the medical oncologist in the professional care for cancer patients: a position paper by the European Society for Medical Oncology (ESMO).Ann Oncol. 2014; 25: 9-15doi:10.1093/annonc/mdt522Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar, 2.Schrijvers D. Vermorken J.B. Bokemeyer C. et al.Continuing medical education: a must for every medical oncologist.Ann Oncol. 2003; 14: 1455-1459doi:10.1093/annonc/mdg421Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar, 3.Ciardiello F. Arnold D. Casali P.G. et al.Delivering precision medicine in oncology today and in future—the promise and challenges of personalised cancer medicine: a position paper by the European Society for Medical Oncology (ESMO).Ann Oncol. 2014; 25: 1673-1678doi:10.1093/annonc/mdu217Abstract Full Text Full Text PDF PubMed Scopus (89) Google Scholar Within Europe, there has been considerable variability, particularly in the duration of initial training required in internal medicine and in the duration of specific training in medical oncology. This issue is increasingly relevant in the era of multidisciplinary team working. There are also major differences between countries in the way the means are used to establish the competence of those who complete a programme, and in the recognition of medical oncology as distinct from training in a ‘mixed’ specialty such as clinical or haemato-oncology, and in the way training programmes are certified. In this context, the joint ESMO/ASCO Global Curriculum for Training in Medical Oncology has already served as a useful tool in the past 10 years. The European Commission took the recommendations of the Global Curriculum Task Force (GC TF) into account in 2011 when it endorsed (for the first time) the independent nature of medical oncology and agreed on the requirement for a minimum of 5 years for specialisation in this specialty.4.Casali P.G. Medical oncology: the long-awaited prize of recognition.Ann Oncol. 2011; 22: 1695-1697doi:10.1093/annonc/mdr314Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar Indeed, the GC has been an instrument for change in convincing many countries to move towards 5-year training programmes in medical oncology. However, the GC TF has received only occasional feedback on the extent to which the Curriculum as a whole (originally published simultaneously in the Annals of Oncology5.Hansen H.H. Bajorin D.F. Muss H.B. et al.Recommendations for a global core curriculum in medical oncology.Ann Oncol. 2004; 15: 1603-1612doi:10.1093/annonc/mdh447Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar and Journal of Clinical Oncology6.Hansen H.H. Bajorin D.F. Muss H.B. et al.Recommendations for a global core curriculum in medical oncology.J Clin Oncol. 2004; 22: 4616-4625doi:10.1200/JCO.2004.08.134Crossref PubMed Scopus (33) Google Scholar) and now in its second edition7.ESMO/ASCO Recommendations for a Global Curriculum in Medical Oncology 2010. http://www.esmo.org/content/download/8171/168764/file/ESMO-ASCO-Revised-Recommenations-for-a-Global-Curriculum-in-Medical-Oncology.pdf (accessed 15 Sep 2014).Google Scholar and available in several languages has been adopted in individual countries or employed in adapted form. This uncertainty applied also to the use of the associated Log Book, in which the progress of trainees in the educational programmes undertaken is recorded. To obtain more comprehensive information, the GC TF recently undertook an online survey of the landscape of medical oncology training in Europe. Questions were developed by the GC TF and sent to persons nominated by each ESMO National Representative as being involved at a national level in their country's medical oncology training. Where no such person could be identified, the TF sent the survey to a colleague whom they considered to have the relevant expertise. Between December 2012 and June 2013, data were obtained from 35 countries. Two-thirds of EU countries now recognise medical oncology as a distinct specialty (figure 1). In the Netherlands, it was described as a subspecialty, as it was in Turkey. In Germany and Austria, medical oncology training is conducted along with training in haematology, and in the Nordic countries, Estonia, Moldova and Albania, it is taught along with radiation oncology. In Russia, Belarus and the Ukraine, medical oncology is not recognised as a specialty distinct from general oncology, and the training is of very short duration. Iceland's medical oncologists are trained in other European countries or the USA. In a majority of the countries (22 of 35; 63%), approval of medical oncology training was the legal responsibility of ministries of health. In four countries, it was said to be the sole responsibility of the national medical association; in two countries, it was the responsibility of the national medical oncology society, and in an additional two countries it was the responsibility of both the national medical and medical oncology societies. In 21 countries (60%), medical oncology training was reported as being standardised across all teaching institutions. In 50%, there is an annual quota for those entering training. The total duration of training (general internal medicine plus specialisation) that medical oncologists needed ranged from 2 years in Russia to 6–8 years in Austria, Belgium, Bosnia–Herzegovina, Denmark, Germany, Greece, Ireland, Luxembourg, Moldova, the Netherlands, Romania, Slovenia, Switzerland and the UK. The mean of 5.5 years is consistent with GC recommendations. Of central interest in the survey was the number of countries which had adopted or adapted the GC (figure 2). The 12 countries which reported that they had adopted the curriculum were Albania, Belgium, Bosnia–Herzegovina, Bulgaria, the Czech Republic, Hungary, Ireland, Lithuania, Romania, Russia, Slovenia, and Turkey. However, the fact that medical oncology is not considered a fully independent specialty in Albania, Russia and Turkey suggests that in these three instances at least the GC must have been adapted to local circumstances. Austria (where a change in national legislation will be considered) and France were said to be in the process of adapting the training according to the GC recommendations. In Denmark and Finland, the GC has apparently been adopted within the clinical oncology training programme; in Latvia and Spain, applicable components have been taken into account during revision of the national training programme. Its overall influence therefore has been considerable. However, the GC has neither been adopted nor adapted in 12 countries. These included Germany, Greece, Italy, the Netherlands, Switzerland and the UK. Training in these countries nevertheless seems to be highly compatible in duration and content with GC provisions. It is encouraging that respondents from Cyprus, Estonia, Greece, Italy, Moldova, Montenegro, the Netherlands and Switzerland have reported that GC might be applicable in their countries. Furthermore, it seems that there are a lot of similarities between GC recommendations and the current medical oncology training programme in Italy; however, any potential application should require a change in law at the national level. The status of the GC was not known in 5 countries. Six countries said that the GC Log Book had been adopted and 26 (74%) that it had not, although only 5 said that it was not applicable. In 19 countries, a national Log Book of some form was in use, and in 16 it was mandatory. Continuous assessment of trainees is required in 24 (69%) countries, and a formal examination is a necessary part of the qualification in 8 countries. A final examination is foreseen in 20 of 35 countries at the exit of the specialisation programme in medical oncology. The ESMO examination is a mandatory part of the process of the medical oncology specialty qualification in only Switzerland and Slovenia. It should also be noted that questions for the ESMO examination are distributed in the Examination's Blueprint based on topics included in the GC. Despite more than 1 year of effort to collect, collate and clarify uncertainties in the data provided, it has to be admitted that the reliability of the information obtained in this survey is not assured. In part, this is due to the fact that survey respondents in certain countries tended to report their perceptions rather than facts. Also, there was no provision in the survey for information supplied to be checked by national authorities, since the survey represents a voluntary initiative of dedicated persons without legal European power. However, these data provide the most comprehensive and recent information available about the state of medical oncology training in Europe. Conducting the survey has encouraged interest in the sharing of experiences and best practices across countries. Its main findings suggest that medical oncology is now more generally recognised as an independent specialty than it was at the time of the MOSES surveys of 20068.The ESMO MOSES Task Force. Medical Oncology Status in Europe Survey (MOSES)—Phase II. 2006. http://www.esmo.org/Policy/Recognition-and-Status-of-Medical-Oncology/Status-of-Medical-Oncology-in-Europe (accessed 15 Sep 2014).Google Scholar and 2008,9.The ESMO MOSES Task Force. Medical Oncology Status in Europe Survey (MOSES)—Phase III. 2008. http://www.esmo.org/Policy/Recognition-and-Status-of-Medical-Oncology/Status-of-Medical-Oncology-in-Europe (accessed 15 Sep 2014).Google Scholar that efforts are being made to extend the duration of specialist training required for certification in some countries for homogenisation in Europe, and that the ESMO/ASCO GC is increasingly influential. This is particularly evident in countries which have joined or which wish to join the EU and have adjusted their training systems accordingly. An additional benefit of the survey is that GC TF is now in a better position to identify the training institutes and teaching staff responsible for medical oncology education across Europe. This should allow us to further improve the dissemination of the GC and recognition of the status of medical oncology as an independent discipline. ASCO and ESMO are considering a global survey of medical oncology recognition, training and certification along the lines of the survey recently conducted in Europe, in order to promote optimal training in medical oncology worldwide. The ESMO/ASCO GC TF would like to thank Dr Razvan Popescu, Chair of the ESMO National Representatives and Membership Committee (2010–2014), all ESMO National Representatives and individual respondents to the European GC Landscape Survey for their help in collecting the data. The GC TF would also like to thank Dr Svetlana Jezdic, Marina Cogo and Katharine Fumasoli from the ESMO Head Office for their valuable assistance in various phases of the GC Landscape Survey.

OPINION article Front. Cardiovasc. Med., 30 November 2020Sec. Cardiovascular Epidemiology and Prevention Volume 7 - 2020 | https://doi.org/10.3389/fcvm.2020.562708

PURPOSE: Little is known about oncofertility practice in developing countries that usually suffer from a shortage of health services, especially those related to cancer care. MATERIALS AND METHODS: To learn more about oncofertility practice in developing countries, we generated a survey to explore the barriers and opportunities associated with oncofertility practice in five developing countries from Africa and Latin America within our Oncofertility Consortium Global Partners Network. Responses from Egypt, Tunisia, Brazil, Peru, and Panama were collected, reviewed, and discussed. RESULTS: Common barriers were identified by each country, including financial barriers (lack of insurance coverage and high out-of-pocket costs for patients), lack of awareness among providers and patients, cultural and religious constraints, and lack of funding to help to support oncofertility programs. CONCLUSION: Despite barriers to care, many opportunities exist to grow the field of oncofertility in these five developing countries. It is important to continue to engage stakeholders in developing countries and use powerful networks in the United States and other developed countries to aid in the acceptance of oncofertility on a global level.

Background: Despite substantial declines in burden over time, stroke remains a public health threat in the Americas. This study aimed to assess the current magnitude, trends, and disparities in the estimates of stroke burden by sex and age in the Americas from 1990 to 2021. Methods: Estimates from the Global Burden of Disease, Injuries and Risk Factors Study 2021 were used to analyze incidence, prevalence, mortality, years of life lost due to premature death, years lived with disabilities, and disability-adjusted life years (DALYs) caused by stroke and its major subtypes stratified by age, and sex in the Americas from 1990 to 2021. We used Joinpoint regression analysis to estimate the average annual percent change (AAPC) of stroke mortality and disease burden outcomes and assessed trends. Findings: In 2021, there were 1.1 million (95% uncertainty interval: 1.0-1.2) new cases, 12.9 million (12.3-13.7) prevalent cases, 0.5 million (0.5-0.6) deaths, and 11.4 million (10.6-12.1) DALYs due to stroke in the Americas. The absolute number of stroke burden outcomes increased from 1990 to 2021, but their corresponding age-standardized rates significantly declined. A deceleration in reduction rates of burden outcomes for all strokes and most stroke subtypes occurred over the last decade, with pronounced difference between sexes mainly in incidence among younger groups. From 2015 to 2021, trends in incidence rates from all stroke and stroke subtypes reversed to increase in most age groups, and strikingly, trends in mortality and DALY rates from ischemic stroke among younger populations reversed to upward with AAPC over 1.4%. A substantial number of countries contributed to these increasing trends. Interpretation: Regionally, the annual number of stroke cases and deaths significantly increased from 1990 to 2021, despite reductions in age-standardized rates. The declining pace in age-standardized stroke rates has decelerated in recent years, while trends in incidence, and ischemic stroke mortality and DALY among middle-aged adults and adults, reversed towards upward in the period 2015-2021. Further studies are needed to understand the determinants of this recent pattern and identify the most cost-effective interventions to stem this alarming trend. Funding: There was no funding source for this study.