Neutralizing antibodies from naturally infected individuals against SARS-CoV-2 Gamma and Delta variants in the Paraguayan population.

INTRODUCTION: Severe Acute Respiratory Syndrome-Coronavirus-2 Virus (SARS-CoV-2) is responsible for Coronavirus Disease 2019 (COVID-19). A substantial number of SARS-CoV-2 infection cases have been reported during the pandemic, and vaccination coverage in some regions, particularly in developing countries, remains very low. SARS-CoV-2 variants of concern (VOCs) have also emerged as some of the most pressing public health issues. In this scenario, it is crucial to know whether COVID-19 convalescent antibodies have cross-neutralizing action against VOCs to contribute to the analysis of the future progress of the pandemic. METHODOLOGY: The plasma of individuals infected with SARS-CoV-2 from June to November 2020 in Paraguay (before the first recorded infections associated with VOCs in the country) was selected. Anti-spike antibodies were determined in plasma samples (n = 626) obtained from this convalescent and unvaccinated group. Using a pseudotyped virus neutralization assay, we then investigated the neutralizing response against D614G variant and Gamma, and Delta VOCs. RESULTS: IgG antibodies against spike were detected in 85.6% of convalescent individuals. Samples from individuals previously infected by a non-VOC showed a 6.6- and 8.1-fold reduction in neutralizing capacity to the Gamma and Delta variants, respectively, when compared to the D614G variant. CONCLUSIONS: Our findings show that antibodies generated by non-VOC infection have reduced neutralizing capabilities against Gamma and Delta variants that appeared subsequently and might have implications for immunity strategies.

Retrospective analysis of outcomes for pediatric acute lymphoblastic leukemia in South American centers.

Introduction: Acute lymphoblastic Leukemia (ALL) is the most common pediatric malignancy. While the survival rate for childhood ALL exceeds 90% in high-income countries, the estimated survival in low-and middle-income countries ranges from 22-79%, depending on the region and local resources. Methods: This study retrospectively reviewed demographic, biological, and clinical parameters of children under 18 years of age with newly diagnosed ALL presenting between 2013-2017 across five pediatric centers in 4 countries in South America. Survival analyses were estimated using the Kaplan-Meier method. Results: Across the five centers, 752 patients were analyzed (Bolivia [N=9], Ecuador [N=221], Paraguay [N=197], Peru [N=325]) and 92.1% (n=690) patients were diagnosed with B-cell and 7.5% (n= 56) with T-cell ALL. The median age was 5.5 years old (IQR 7.29). At diagnosis, 47.8% of patients were categorized as standard and 51.9% as high risk per their institutional regimen. Advanced diagnostics availability varied between modalities. MRD was evaluated in 69.1% of patients; molecular testing was available for ETV6-RUNX, BCR-ABL1, TCF3-PBX1, and KMT2A-rearranged ALL in 75-81% of patients; however, karyotyping and evaluation for iAMP21 were only performed in 42-61% of patients. Central nervous system (CNS) involvement was evaluated at diagnosis in 57.3% (n=429) patients; of these, 93.7% (n=402) were CNS 1, 1.6% (n=7) were CNS 2, 0.7% (n=11) were CNS3, 1.9% (n=8) had cranial nerve palsy, and 2.1% (n=9) results unavailable. Chemotherapy delays >2 weeks were reported in 56.0% (n=421) patients during treatment. Delays were attributed to infection in 63.2% (n=265), drug-related toxicities in 47.3% (n=198), and resource constraints, including lack of bed availability in 23.2% (n=97) of patients. The 3-year Abandonment-sensitive EFS and OS were 61.0±1.9% and 67.2±1.8%, respectively. The 3-year EFS and OS were 71.0±1.8% and 79.6±1.7%, respectively. Discussion: This work reveals opportunities to improve survival, including addressing severe infections, treatment interruptions, and modifications due to drug shortages. In 2018, healthcare professionals across South America established the Pediatric Oncology Latin America (POLA) group in collaboration with St. Jude Children's Research Hospital. POLA collaborators developed an evidence-based, consensus-derived, adapted treatment guideline, informed by preliminary results of this evaluation, to serve as the new standard of care for pediatric ALL in participating institutions.

Factores de riesgo asociados a mortalidad en pacientes pediátricos oncológicos ingresados a cuidados intensivos de un Hospital Universitario en Paraguay: una experiencia de 3 años / Risk factors associated with mortality in pediatric oncology patients admitted to intensive care at a University Hospital in Paraguay: a 3-year experience

RESUMEN Introducción. La supervivencia de los pacientes con neoplasia infantil ha mejorado considerablemente gracias al progreso en el diagnóstico y el tratamiento multidisciplinario. Objetivo. determinar los factores de riesgo de mortalidad de los pacientes ingresados a cuidados intensivos (UCIP) de un hospital de enseñanza en Asunción, Paraguay. Metodología. Se realizó una revisión retrospectiva de las historias clínicas de los pacientes oncológicos ingresados a la UCIP del Hospital de Clínicas de enero 2014 a diciembre 2016. Resultados. De 874 pacientes que ingresaron a la UCIP, 150 (17,2%) fueron pacientes oncológicos. La edad media fue de 9,8 ± 5,2 años; 51% del sexo femenino. Tuvieron reingreso (12%), otra comorbilidad (48%), admisión de urgencia (67,3%). Los días previos de internación en sala fue en promedio 6,5 ± 10,9 y en la unidad de terapia intensiva 6,9 ± 13,7 días. El tipo de cáncer fue en el 52% hematológico. El 82% de los pacientes presentaron falla de uno o más órganos y la mortalidad fue de 19,3%. Varios factores de riesgo para mortalidad se identificaron por el análisis bivariado, pero, por el análisis multivariado solo cinco variables quedaron asociadas con óbito: edad ≥10 años (p=0,047), PIM2 ≥10 (p=0,001), mucositis (p= 0,004), falla neurológica (p= 0,001) y falla renal (p= 0,001). Conclusión. La mortalidad global fue menor a la reportada en otras series, la cual fue mayor en los mayores de 10 años, con mucositis, falla orgánica neurológica y renal.

ABSTRACT Introduction. The survival of patients with childhood neoplasia has improved considerably thanks to the progress in diagnosis and multidisciplinary treatment. Objective. to determine the mortality risk factors in patients admitted to intensive care (PICU) at a teaching hospital in Asunción, Paraguay. Methodology. A retrospective review of the medical charts of cancer patients admitted to the PICU of the Hospital de Clínicas from January 2014 to December 2016 was carried out. Results. 874 patients admitted to the PICU, 150 (17.2%) patients had cancer. Mean age was 9.8 ± 5.2 years; 51% female. They had readmission (12%), other comorbidity (48%), emergency admission (67.3%). Previous days of hospitalization in the ward was an average 6.5 ± 10.9 and in the intensive care unit 6.9 ± 13.7 days. The type of cancer was 52% hematological. 82% of patients presented failure of one or more organs and mortality was 19.3%. Several risk factors for mortality were identified by bivariate analysis, but by multivariate analysis only five variables were associated with death: age ≥10 years (p=0.047), PIM2 ≥10 (p=0.001), mucositis (p= 0.004), neurological failure (p= 0.001) and renal failure (p= 0.001). Conclusion. Overall mortality was lower than that reported in other series, which was higher in those older than 10 years, with mucositis, neurological and renal organ failure.

C/Can City Engagement Process: An Implementation Framework for Strengthening Cancer Care in Cities in Low- and Middle-Income Countries.

The effective implementation of locally adapted cancer care solutions in low- and middle-income countries continues to be a challenge in the face of fragmented and inadequately resourced health systems. Consequently, the translation of global cancer care targets to local action for patients has been severely constrained. City Cancer Challenge (C/Can) is leveraging the unique value of cities as enablers in a health systems response to cancer that prioritizes the needs of end users (patients, their caregivers and families, and health care providers). C/Can's City Engagement Process is an implementation framework whereby local stakeholders lead a staged city-wide process over a 2- to 3-year period to assess, plan, and execute locally adapted cancer care solutions. Herein, the development and implementation of the City Engagement Process Framework (CEPF) is presented, specifying the activities, outputs, processes, and indicators across the process life cycle. Lessons learned on the application of the framework in the first so-called Key Learning cities are shared, focusing on the early outputs from Cali, Colombia, the first city to join C/Can in 2017. Creating lasting change requires the creation of a high-trust environment to engage the right stakeholders as well as adapting to local context, leveraging local expertise, and fostering a sustainability mindset from the outset. In the short term, these early learnings inform the refinement of the approach in new cities. Over time, the implementation of this framework is expected to validate the proof-of-concept and contribute to a global evidence base for effective complex interventions to improve cancer care in low- and middle-income countries.

Apoyo social autopercibido en estudiantes de medicina de la Universidad Nacional de Asunción (Paraguay) / Self-perceived social support in medical students of the National University of Asunción, Paraguay

INTRODUCCIÓN: En los estudiantes de medicina, la falta de apoyo emocional y social puede generar bajo rendimiento académico y predisponer al desarrollo de estrés psicológico. El apoyo social es un mecanismo de supervivencia frente al estrés, puesto que aquellos estudiantes de medicina que se encuentran satisfechos con su vida y con su red de apoyo muestran baja percepción al estrés y alta resiliencia. Asimismo, el poco apoyo social puede influir en la generación de bajos niveles de empatía, lo cual repercutirá de manera negativa en la futura práctica profesional. El objetivo del presente trabajo fue describir el apoyo social autopercibido en estudiantes de medicina de la Universidad Nacional de Asunción. MATERIALES Y MÉTODOS: Estudio descriptivo con muestreo no probabilístico que incluyó a 76 estudiantes de medicina de la Universidad Nacional de Asunción (Paraguay). La red de apoyo se estudió con las escalas APGAR familiar y APGAR de amistad. RESULTADOS: Se incluyó a 76 estudiantes, de los cuales el 60,5% fue del sexo femenino. El 22,4% reporta una importante disfuncionalidad familiar y el 17,1% no se siente apoyado por sus amigos. CONCLUSIONES: Existen bajos niveles de apoyo social autopercibido por los estudiantes de medicina y esto se manifiesta por el poco apoyo que refieren recibir tanto de sus familias como de sus amigos

INTRODUCTION: The lack of emotional and social support in medical students can lead to low academic performance and predispose to the development of psychological stress. Social support is a survival mechanism for stress, since those medical students who are satisfied with their life and support network show low perception of stress and high resilience. Likewise, the lack of social support can influence the generation of low levels of empathy, which will have a negative impact on future professional practice. The objective of the present study was to describe self-perceived social support in medical students of the National University of Asunción. MATERIAL AND METHODS: A descriptive study with non-probabilistic sampling was conducted on 76 medical students of the National University of Asunción, Paraguay. The support network was studied with the family APGAR and the friendship APGAR scales. RESULTS: Of the 76 students included, 60.5% were female. Significant family dysfunction was reported by 22.4%, and 17.1% did not feel supported by their friends. CONCLUSION: There are low levels of self-perceived social support expressed by medical students, and this is manifested by the little support they received from both their families and their friends

The My Child Matters programme: effect of public-private partnerships on paediatric cancer care in low-income and middle-income countries.

In low-income and middle-income countries, an excess in treatment failure for children with cancer usually results from misdiagnosis, inadequate access to treatment, death from toxicity, treatment abandonment, and relapse. The My Child Matters programme of the Sanofi Espoir Foundation has funded 55 paediatric cancer projects in low-income and middle-income countries over 10 years. We assessed the impact of the projects in these regions by using baseline assessments that were done in 2006. Based on these data, estimated 5-year survival in 2016 increased by a median of 5·1%, ranging from -1·5% in Venezuela to 17·5% in Ukraine. Of the 26 861 children per year who develop cancer in the ten index countries with My Child Matters projects that were evaluated in 2006, an estimated additional 1343 children can now expect an increase in survival outcome. For example, in Paraguay, a network of paediatric oncology satellite clinics was established and scaled up to a national level and has managed 884 patients since initiation in 2006. Additionally, the African Retinoblastoma Network was scaled up from a demonstration project in Mali to a network of retinoblastoma referral centres in five sub-Saharan African countries, and the African School of Paediatric Oncology has trained 42 physicians and 100 nurses from 16 countries. The My Child Matters programme has catalysed improvements in cancer care and has complemented the efforts of government, civil society, and the private sector to sustain and scale improvements in health care to a national level. Key elements of successful interventions include strong and sustained local leadership, community engagement, international engagement, and capacity building and support from government.

Knowledge of the Guarani language in medical students at a university hospital in Paraguay. / Grado de conocimiento del idioma guaraní en estudiantes de medicina en un hospital universitario de Paraguay.

INTRODUCTION: Paraguay is a bilingual country and knowledge of the guarani language is an important communication tool for the doctor- patient relationship. OBJECTIVE: To determine the degree of and the factors that influence the knowledge of the Guaraní language in medical students at a University Hospital in Paraguay. METHODS: Observational, cross-sectional, analytical study in which an anonymous questionnaire was applied to the final year medical students of a University Hospital of Paraguay. The baseline characteristics of the medical students and their degree of knowledge of the Guarani language were described. The association between the characteristics of the students and the degree of knowledge of the Guarani language was evaluated with the Chi square association test and the logistic regression model. RESULTS: We included 264 students in the survey. Eighty two percent come from the capital, 72% made their pre-university studies in the capital; 92% studied Guaraní in primary and secondary education; 67.9% do not interpret Guarani correctly; 8.5% understand and express themselves totally in Guaraní. Of these, 86% refer to have the greater learning of the language in their home; 75.2% of respondents believe that primary and secondary education did not help in learning the language. The degree of knowledge of the language (speaks and understands the Guarani language correctly) varies according to: the origin of the student, the inland regions or the capital (31.25% vs. 2.5%, adjusted OR = 0.24, 95% confidence interval: 0.06 to 0.92, p = 0.003); the location of primary and secondary school: inland versus capital (25.6% vs. 1%, adjusted OR: 0.08, 95% confidence interval: 0.01 to 0.53, p = 0.009). CONCLUSIONS: The degree of knowledge of the Guaraní language of the students is lower compared to the general population; those who best understand and express themselves were born or studied in the interior of the country. The majority considers that primary and secondary education contribute little in the learning of Guaraní. Since language is an important communication tool in the patient-doctor relationship and knowing that Guarani is the most spoken language in the country, strategies for its learning should be implemented.

INTRODUCCIÓN: Paraguay es un país bilingüe, y el conocimiento del idioma guaraní constituye una herramienta importante de comunicación en la relación médico-paciente. OBJETIVO: Dar cuenta del grado y los factores que determinan el conocimiento del idioma guaraní, en estudiantes de medicina de último año en un hospital universitario de Paraguay. MÉTODOS: Estudio observacional, transversal y analítico. En él se aplicó una encuesta anónima con cuestionario a los alumnos de último año de medicina de un hospital universitario de Paraguay. Se realizó un estudio descriptivo de las características basales de los estudiantes de medicina y de su grado de conocimiento del idioma guaraní. Se efectuó la prueba de Chi-cuadrado para comparar variables categóricas, y se aplicó un estudio de regresión logística para determinar factores que determinan el grado de conocimiento del idioma. RESULTADOS: Fueron encuestados 264 estudiantes. El 82% provenía de la capital, 72% realizó sus estudios preuniversitarios en Asunción. El 92% estudió guaraní en la educación primaria y secundaria; 67,9% no lo interpreta correctamente. El 8,5% entienden y se expresan totalmente en guaraní; de ellos el 86% refirió que su mayor aprendizaje del idioma fue en el hogar familiar. El 75,2% de los encuestados consideró que la educación primaria y secundaria no ayudó en el aprendizaje. El grado de conocimiento del idioma (habla y entiende el idioma guaraní correctamente), varía si el estudiante proviene del interior o de la capital (31,25% versus 2,5%; OR ajustado: 0,24, intervalo de confianza 95% de 0,06 a 0,92; p=0,003); y según la localidad de la escuela primaria y secundaria: interior versus capital (25,6 y 1% respectivamente; OR ajustado: 0,08; intervalo de confianza 95% de 0,01 a 0,53; p=0,009). CONCLUSIONES: El grado de conocimiento de los estudiantes del guaraní es menor, comparado con población general. Los que mejor se expresan y comprenden el idioma, nacieron o lo estudiaron en el interior del país. La mayoría considera de poco aporte la educación primaria y secundaria para el aprendizaje del guaraní. Siendo el idioma una herramienta importante de comunicación en la relación médico–paciente, y sabiendo que el guaraní es el idioma más hablado del país; se deberían implementar estrategias para su aprendizaje.

Conocimiento sobre métodos básicos de estadística, epidemiología e investigación de médicos residentes de la Universidad Nacional de Asunción, Paraguay / Knowledge of basic statistical, epidemiological and research methodology by medical residents from the National University of Asunción, Paraguay

INTRODUCCIÓN: La estadística médica es considerada un elemento importante de la medicina basada en la evidencia. El objetivo de este estudio fue evaluar el conocimiento de métodos básicos de estadística, epidemiología e investigación en médicos residentes de la Universidad Nacional de Asunción, y evaluar el efecto de las características individuales sobre el nivel de conocimientos. MATERIALES Y MÉTODOS: Estudio observacional, analítico de corte transverso y muestreo no probabilístico, en el que se incluyeron 50 médicos residentes. Se utilizó una versión adaptada del cuestionario de Novack et al. sobre conocimientos de epidemiología y estadística. Para establecer asociaciones se usaron las pruebas de correlación de Pearson, «t» de Student y ANOVA, estableciendo una significación de p < 0,05. RESULTADOS: El 52% de los residentes era de sexo masculino y el 36% era residente de medicina familiar. El 4% de los participantes realizó una puntuación superior o igual al 60% (considerado aprobado). La media de respuestas correctas fue de 2,76±1,66. Se encontró asociación significativa entre la lectura de las secciones «Metodología» y «Discusión» de los artículos científicos y número de respuestas correctas, al igual que entre el sexo y la puntuación obtenida. Asimismo, se encontró correlación positiva entre el año de residencia y cantidad de artículos científicos leídos. CONCLUSIONES: Es preocupante el bajo conocimiento que los médicos residentes participantes de este estudio tienen sobre los principales elementos de la epidemiología, la estadística y la metodología de la investigación, lo que pone de manifiesto la necesidad de una urgente revisión del currículo académico

INTRODUCTION: Medical statistics is considered an important element of evidence-based medicine. The objective of this study was to evaluate the knowledge of basic statistical, epidemiological and research methods among medical residents of the National University of Asunción, and to evaluate the effect of individual characteristics on the knowledge of those methods. MATERIALS AND METHODS: This was a cross sectional and observational study, of analytical prevalence, and non-probability sampling, which included 50 medical residents. An adapted version of the questionnaire on knowledge of epidemiology and statistics by Novack et al. was used, with permission of the authors. Pearson's correlation test, t test and ANOVA was used to establish relationships between the variables. Significance was established at P??.05. RESULTS: The sample population included 52% males, and 36% were Family Medicine residents. A score greater than or equal to 60% (score considered as approved) was achieved by 4% of the participants. The mean of correct answers was 2.76±1.66. A significant association was found between the reading of the "methodology" and "discussion" sections of scientific articles and the number of correct responses, as well as between gender and the score obtained. A positive correlation was also found between the year of residence and the number of scientific articles read. CONCLUSIONS: The low level of knowledge that the medical residents, who participated in this study, have on the main elements of epidemiology, statistics and research methodology, is worrying, and highlights the need for an urgent review of the academic curriculum

Actitudes y desafíos percibidos de médicos residentes de medicina familiar hacia la investigación: un estudio piloto de Paraguay, 2016 / Attitudes and perceived challenges towards research of medical residents of family medicine: a pilot study from Paraguay, 2016

Las competencias en investigación han sido reconocidas como parte esencial de la educación médica en el postgrado. El objetivo de este estudio piloto fue evaluar las actitudes y desafíos percibidos de médicos residentes de Medicina Familiar hacia la investigación. Estudio piloto, observacional, descriptivo, de corte transverso y muestreo no probabilístico, en el que se incluyeron 20 médicos residentes. Se utilizó un cuestionario sobre actitudes y desafíos percibidos sobre la investigación. Se realizó estadística descriptiva para todas las variables. Los resultados se expresaron en frecuencias, porcentajes, medias y desvíos estándar. Del total de participantes, sólo 7 (35%) participaron en algún proyecto de investigación durante la residencia, principalmente, en estudios descriptivos (30%) y reportes de casos (15%). El 60% respondió que en la residencia no desarrollaban un programa específico de formación en investigación, aunque la mayoría estuvo de acuerdo con que la investigación es esencial para el desarrollo de una carrera académica (95%), que mejora la atención sanitaria del paciente (75%) y que su estudio debe ser obligatorio en el currículo académico (70%). Los médicos residentes paraguayos presentan actitudes positivas y reconocen la importancia de la investigación, no obstante, sólo el 35% ha realizado investigaciones durante su programa de residencia, siendo el principal desafío al que se enfrentan, la falta detiempo protegido. Se considera necesario el rediseño del currículo del programa de residencia en Medicina Familiar de la Universidad Nacional de Asunción a fin de incluir de manera trasversal la formación en investigación de médicos residentes.

Research skills have been recognized as an essential part of medical education at thepostgraduate level. The objective of this pilot study was to evaluate the attitudes andperceived challenges of family medicine residents toward research. This was anobservational, descriptive and cross-sectional pilot study, of non-probabilistic sampling, which included 20 medical residents. A questionnaire on attitudes and perceived challengeson research was used. Descriptive statistics were performed for all variables. The resultswere expressed as frequencies, percentages, means and standard deviations. Of the totalparticipants, only 7 (35%) participated in a research project during residency, mainly indescriptive studies (30%) and case reports (15%). Sixty percent of participants respondedthat their residency did not develop a specific program of research training, although mostagreed that research was essential for the development of an academic career (95%),improved patient healthcare (75%) and that the study of research techniques should bemandatory in the academic curriculum (70%). Paraguayan medical residents have positiveattitudes and recognize the importance of research. However, only 35% have conductedresearch during their residency program; being the main challenge they face, the need for aprotected time for research. It is considered necessary to redesign the curriculum of theFamily Medicine residency program of the National University of Asuncion, in order toinclude research training in a transversal way.

Building a National Pediatric Cancer Center and Network in Paraguay: Lessons for Addressing Challenges in a Low-income Country.

In Paraguay, cancer is among the leading causes of death among children. We report challenges and solutions for building the country's first pediatric cancer center at the National University School of Medicine (PCC-SM) and describe the outcomes of the National Network for Pediatric Cancer. We found that children with acute lymphoblastic leukemia treated between 2008 and 2012 had higher 3-year survival rates and lower treatment abandonment rates than did children treated between 2000 and 2007 before the network was established. This improvement directly coincided with the increased treatment capacity of the PCC-SM. Herein, we describe the role of local, national, and international contributors in improving the health care at Paraguay's PCC-SM and discuss how expediting access to specialized cancer diagnosis and care and implementing a system for referral and follow-up visits can improve cancer outcomes in other low-resource countries.

Management of children with brain tumors in Paraguay.

BACKGROUND: Cure rates among children with brain tumors differ between low-income and high-income countries. To evaluate causes of these differences, we analyzed aspects of care provided to pediatric neuro-oncology patients in a low middle-income South American country. METHODS: Three methods were used to evaluate treatment of children with brain tumors in Paraguay: (1) a quantitative needs assessment questionnaire for local treating physicians, (2) site visits to assess 3 tertiary care centers in Asunción and a satellite clinic in an underdeveloped area, and (3) interviews with health care workers from relevant disciplines to determine their perceptions of available resources. Treatment failure was defined as abandonment of therapy, relapse, or death. RESULTS: All 3 tertiary care facilities have access to chemotherapy and pediatric oncologists but lack training and tools for neuropathology and optimal neurosurgery. The 2 public hospitals also lack access to appropriate radiological tests and timely radiotherapy. These results demonstrate disparities in Paraguay, with rates of treatment failure ranging from 37% to 83% among the 3 facilities. CONCLUSIONS: National and center-specific deficiencies in resources to manage pediatric brain tumors contribute to poor outcomes in Paraguay and suggest that both national and center-specific interventions are warranted to improve care. Disparities in Paraguay reflect different levels of governmental and philanthropic support, program development, and socio-economic status of patients and families, which must be considered when developing targeted strategies to improve management. Effective targeted interventions can serve as a model to develop pediatric brain tumor programs in other low- and middle-income countries.

Protocol-based treatment for children with cancer in low income countries in Latin America: a report on the recent meetings of the Monza International School of Pediatric Hematology/Oncology (MISPHO)--part II.

Pediatric cancer programs in low-income countries (LIC) can improve outcomes. However, treatment must be tailored to the patient's living conditions and the availability of supportive care. In some cases, a more intense regimen will decrease survival since the increase in death from toxicity may exceed any decrease in relapse. Attempts to practice evidence-based pediatric oncology are thwarted by the lack of evidence derived from local experience in LIC to determine optimal therapy. This report summarizes treatment regimens used by pediatric oncologists from 15 countries of the Caribbean, Central and South America who participate in the Monza International School of Pediatric Hematology/Oncology (MISPHO). Patients with hepatoblastoma, Wilms tumor, and histiocytosis treated on unmodified published protocols had outcomes comparable to those in high-income countries (HIC). Those with rhabdomyosarcoma, osteosarcoma, Hodgkin lymphoma, and acute myeloid leukemia treated with unmodified regimens had event-free survival estimates 10%-20% lower than those reported in HIC due to higher rates of toxic death, abandonment of therapy, and relapse. Treatment of retinoblastoma is complicated by advanced stages and extraocular disease at diagnosis; improved outcomes depend on education of pediatricians and the public to recognize early signs of this disease. Use of unmodified protocols for Burkitt lymphoma and acute lymphoblastic leukemia have been associated with unacceptable toxicity in LIC, so MISPHO centers have modified published regimens by giving lower doses of methotrexate and reducing use of anthracyclines. Despite the use of all-trans-retinoic acid during induction for acute promyelocytic leukemia, the incidence of fatal hemorrhage remains unacceptably high.

Sindrome de Evans: a proposito de un caso

Se presenta el caso de una niña de 12 años diagnosticada de anemia hemolítica y púrpura trombocitopénica autoinmunes, lo que constituye el Síndrome de Evans. La naturaleza autoinmune de la anemia hemolítica fue demostrada por la positividad del test de Coombs directo. No pudo demostrarse la destrucción autoinmune de las plaquetas por carcererse de exámenes de laboratório específicos. Se comentan algunos aspectos fisiopatológicos de esta entidad, así como la buena respuesta terapéutica bajo tratamiento corticoideo del caso presentado