Manejo de heridas traumáticas de difícil cicatrización con colgajos microvasculares.

OBJECTIVE: Present different flap alternatives when performing microvascular free-flap reconstruction in acute hard-to-heal wounds. METHOD: A retrospective review of patients whose acute hard-to-heal wounds were treated with microvascular free-flap reconstruction. Data on demographics, wound aetiology, diagnostic, previous treatment, free-flap type, free-flap size, complications and follow up were analysed. RESULTS: A total of 20 patients received microvascular free-flap reconstruction. The median age was 39.5 years. Twenty free-flap reconstructions were performed. These included: 3 cross-leg free flap, 1 cross-leg vascular cable bridge flap, 2 fibula osteocutaneous flap, 6 anterolateral thigh (ALT) flap, 3 thoracodorsal artery perforator (TDAP) flap, 3 fasciomyocutaneous flap, and 2 femoral artery fasciocutaneous flap. A patient required microvascular anastomosis due to hematoma; the rest did not present complications during their postoperative. Previous treatment included negative pressure wound therapy (12 patients) and surgical debridement with silver hydrogel dressings (8 patients). CONCLUSION: Hard-to-heal wounds can be unresponsive to traditional wound healing practices or local flaps. They often require free-flap reconstruction, using tissues similar to those compromised. Microvascular techniques can be an effective alternative.

OBJETIVO: El objetivo de este estudio fue presentar diferentes opciones de manejo de heridas de difícil cicatrización utilizando colgajos libres microvasculares. MÉTODO: Se llevó a cabo una revisión retrospectiva de todos los pacientes con heridas traumáticas de difícil cicatrización, a quienes se les realizó reconstrucción con colgajo libre. Se analizaron datos demográficos, etiología de la herida, diagnóstico, tratamiento previo de la herida, tipo de colgajo utilizado, dimensiones del defecto y del colgajo, vasos receptores, complicaciones, y seguimiento. RESULTADOS: En total, 20 pacientes fueron sometidos a reconstrucciones con colgajos libres. La edad promedio fue de 39,5 años. Se realizaron 20 colgajos libres, entre ellos: 3 de piernas cruzadas, 1 de piernas cruzadas con puente vascular, 2 osteocutáneos de peroné, 6 fasciocutáneos anterolateral del muslo, 3 perforantes de la arteria toracodorsal, 3 miocutáneos dorsal ancho, y 2 fasciocutáneos de la perforante de la arteria femoral profunda. Un paciente requirió revisión de anastomosis microvascular debido a un hematoma. El resto de los pacientes no presentó intercurrencias en el postoperatorio. Respecto al tratamiento previo, 12 pacientes recibieron terapia de presión negativa, mientras que 8 tuvieron desbridamientos quirúrgicos con subsecuente aplicación de hidrogel con plata iónica. CONCLUSIÓN: Las heridas de difícil cicatrización no tienen una buena respuesta al tratamiento convencional con curaciones, injertos o colgajos locales, sino que requieren la transferencia de tejidos similares a los que se han perdido. Las técnicas microvasculares pueden ser una alternativa.

Manejo de heridas traumáticas de difícil cicatrización con colgajos microvasculares.

OBJECTIVE: Present different flap alternatives when performing microvascular free-flap reconstruction in acute hard-to-heal wounds. METHOD: A retrospective review of patients whose acute hard-to-heal wounds were treated with microvascular free-flap reconstruction. Data on demographics, wound aetiology, diagnostic, previous treatment, free-flap type, free-flap size, complications and follow up were analysed. RESULTS: A total of 20 patients received microvascular free-flap reconstruction. The median age was 39.5 years. Twenty free-flap reconstructions were performed. These included: 3 cross-leg free flap, 1 cross-leg vascular cable bridge flap, 2 fibula osteocutaneous flap, 6 anterolateral thigh (ALT) flap, 3 thoracodorsal artery perforator (TDAP) flap, 3 fasciomyocutaneous flap, and 2 femoral artery fasciocutaneous flap. A patient required microvascular anastomosis due to hematoma; the rest did not present complications during their postoperative. Previous treatment included negative pressure wound therapy (12 patients) and surgical debridement with silver hydrogel dressings (8 patients). CONCLUSION: Hard-to-heal wounds can be unresponsive to traditional wound healing practices or local flaps. They often require free-flap reconstruction, using tissues similar to those compromised. Microvascular techniques can be an effective alternative.

OBJETIVO: El objetivo de este estudio fue presentar diferentes opciones de manejo de heridas de difícil cicatrización utilizando colgajos libres microvasculares. MÉTODO: Se llevó a cabo una revisión retrospectiva de todos los pacientes con heridas traumáticas de difícil cicatrización, a quienes se les realizó reconstrucción con colgajo libre. Se analizaron datos demográficos, etiología de la herida, diagnóstico, tratamiento previo de la herida, tipo de colgajo utilizado, dimensiones del defecto y del colgajo, vasos receptores, complicaciones, y seguimiento. RESULTADOS: En total, 20 pacientes fueron sometidos a reconstrucciones con colgajos libres. La edad promedio fue de 39,5 años. Se realizaron 20 colgajos libres, entre ellos: 3 de piernas cruzadas, 1 de piernas cruzadas con puente vascular, 2 osteocutáneos de peroné, 6 fasciocutáneos anterolateral del muslo, 3 perforantes de la arteria toracodorsal, 3 miocutáneos dorsal ancho, y 2 fasciocutáneos de la perforante de la arteria femoral profunda. Un paciente requirió revisión de anastomosis microvascular debido a un hematoma. El resto de los pacientes no presentó intercurrencias en el postoperatorio. Respecto al tratamiento previo, 12 pacientes recibieron terapia de presión negativa, mientras que 8 tuvieron desbridamientos quirúrgicos con subsecuente aplicación de hidrogel con plata iónica. CONCLUSIÓN: Las heridas de difícil cicatrización no tienen una buena respuesta al tratamiento convencional con curaciones, injertos o colgajos locales, sino que requieren la transferencia de tejidos similares a los que se han perdido. Las técnicas microvasculares pueden ser una alternativa.

[Obstructive ictericia by neuroma of amputation of via biliar. Case report]. / Ictericia obstructiva por neuroma de amputación de vía biliar. Reporte de caso.

Neuromas of the bile duct develop from the sympathetic and parasympathetic nerve fibers that surround the wall of the bile duct. A 44-year-old woman with a history of conventional cholecystectomy six months prior to hospital admission attended emergency due to obstructive jaundice that lasted 15 days. In the imaging studies, the presence of a mass at the level of the bile ducts is considered, considering the diagnosis of a malignant neoplasm. Due to the antecedents, the absence of tumor markers, it was decided to perform a percutaneous biopsy without conclusive results, performing later a surgical intervention with anatomopathological study compatible with neuroma of biliary tract amputation. The amputation neuroma at the level of the bile duct is an infrequent tumor. It can manifest clinically as obstructive jaundice and usually simulates a malignant tumor of the bile ducts. Surgical management is the definitive treatment.

Prevalence and associated factors of premature ejaculation and erectile dysfunction in young, single men who have sex with men in Lima, Peru.

Background: While there is literature on erectile dysfunction (ED) and premature ejaculation (PE) in men, conclusive evidence regarding these sexual health issues and potential associated factors in the young, single men who have sex with men (MSM) population is lacking. Aim: The study sought to determine the prevalence and factors associated with PE and ED in young single MSM in the capital of Peru. Methods: This was an analytical cross-sectional study in MSM using an online questionnaire. The presence of ED and PE was assessed using the 5-item International Index of Erectile Function and 5-item Premature Ejaculation Diagnostic Tool questionnaires, respectively. In addition, their association with personal, physical health, and sexual behavior variables was evaluated. Prevalence ratios (PRs) were estimated through regression models. Outcomes: Premature ejaculation and Erectile dysfunction in MSM. Results: Of 315 participants, most were between 20 to 29 years of age (71.8%), 43.5% identified as homosexual, 59.1% had between 2 and 5 sexual partners, and 40.6% reported that the duration of their sexual relationship was between 1 and 12 months. The prevalence of ED was 53.3% (95% confidence interval [CI], 47.66%-58.95%), and PE was present in 8.3% (95% CI, 5.46%-11.86%). Factors associated with a higher prevalence of ED were having between 6 and 9 sexual partners (PR, 1.48; 95% CI, 1.05-2.11) and having a sexual relationship lasting 13 to 24 months (PR, 0.70; 95% CI, 0.50-0.98). Furthermore, for each additional year from the onset of the first sexual encounter with another man, the prevalence of PE increased by 7% (PR, 1.07; 95% CI, 1.02-1.13). Clinical Implications: These findings suggest that there is a relationship between an increased number of sexual partners and a higher prevalence of ED. It also suggests that relationships that last for some time may have a protective effect against ED. Strengths and Limitations: Strengths include the use of validated instruments, adequate sample size, robust multivariate analysis, and being one of the few studies in Latin America assessing PE and ED in the MSM population. Limitations include the cross-sectional design, nonprobability sampling, and access to participants. Conclusion: Having more sexual partners is associated with increased ED, while relationships lasting 13 to 24 months are associated with decreased ED. Each additional year from the onset of the first sexual relationship increases the prevalence of PE. These findings can guide the design of health policies and programs tailored to the MSM community to enhance their well-being and sexual quality of life.

Poor sleep quality and erectile dysfunction in students from a Peruvian University: A cross-sectional study.

Objective: We aimed to evaluate the association between sleep quality and erectile dysfunction in young university students. Methods: A cross-sectional survey was conducted in men aged 18-30 years from Universidad Ricardo Palma, Lima, Peru. The survey comprised the International Index of Erectile Function, Pittsburgh Sleep Quality Index, Berlin questionnaire, and questions related to sociodemographic data. Prevalence ratios were estimated with generalized linear models. Results: Of 381 participants, the median age was 23 years. Half of the students (50.9%) had poor sleep quality, of which 72.7% had mild erectile dysfunction and 20.6% mild to moderate dysfunction. Prevalence of erectile dysfunction was significantly higher in students with poor sleep quality than in students with good sleep quality (aPR = 6.48; 95% CI: 4.58-9.17) after adjusting for age, academic year, nutritional status, and sleep apnea. In a subsequent exploratory analysis, sleep apnea was associated with a higher prevalence of erectile dysfunction (aPR = 1.19; 95% CI: 1.01-1.39), while overweight (aPR = 0.85; 95% CI: 0.76-0.95) and obesity (aPR = 0.65; 95% CI: 0.52-0.82) were associated with a lower prevalence of this condition. Conclusion: Poor sleep quality was independently associated with erectile dysfunction in young university students. This finding suggests that male students are at risk for sexual problems due to possible academic demands and relationship issues.

[Antibiotic prophylaxis for flexible cystoscopy. Perspectives for Latin America and Caribbean.] / Profilaxis antibiótica en la uretrocistoscopia flexible. Perspectivas para latinoamérica y el caribe.

Sr. Editor: Los resultados de Cano-García et al. (1) en el último estudio publicado sobre la profilaxis antibiótica con ciprofloxacino en uretrocistoscopia flexible (UF) son claros y fuertes, si bien la pregunta clínica pudo ser respondida mediante un estudio de intervención (ensayo clínico), el diseño utilizado es bueno y aproximado pero difiriendo de algunos puntos claves: aleatorización, denominación de grupo control y asignación del tratamiento. Que le dan riesgo de sesgo, pero que no invalidan los resultados. Nosotros remarcamos que las conclusiones han sido equivalentes a los resultados de los ensayos clínicos realizados en poblaciones similares como el estudio de Jiménez-Pacheco et al. (2), que encuentran que una población seleccionada y con medidas de asepsia adecuadas, la profilaxis no muestra reducción clínicamente relevante en la incidencia de ITU en pacientes sometidos a UF, así mismo Arrabal et al. (3), quienes añadieron fosfomicina en su diseño, comparando tres grupos (no intervención, fosfomicina y ciprofloxacino) reportan que no disminuye la presencia de infección ni bacteriuria posterior a la UF. Sumándose a esta evidencia, una revisión sistemática con metaanálisis (RSM) publicado por Garcia-Perdomo et al. (4), concluye que la evidencia no es muy fuerte para recomendar profilaxis en UF y la necesidad de realizar ensayos clínicos con mejores diseños. Carey et al. (5), en otra RSM no recomiendan el uso de profilaxis antibiótica en UF de manera rutinaria, llevando a ser más robustos los resultados de Cano-Garcia et al...

Sr. Editor:Los resultados de Cano-García et al. (1) en el último estudio publicado sobre la profilaxis antibióticacon ciprofloxacino en uretrocistoscopia flexible (UF) son claros y fuertes, si bien la pregunta clínica pudo serrespondida mediante un estudio de intervención (ensayo clínico), el diseño utilizado es bueno y aproximado perodifiriendo de algunos puntos claves: aleatorización, denominación de grupo control y asignación del tratamiento.Que le dan riesgo de sesgo, pero que no invalidan los resultados.Nosotros remarcamos que las conclusiones han sido equivalentes a los resultados de los ensayos clínicosrealizados en poblaciones similares como el estudio de Jiménez-Pacheco et al. (2), que encuentran que unapoblación seleccionada y con medidas de asepsia adecuadas, la profilaxis no muestra reducción clínicamenterelevante en la incidencia de ITU en pacientes sometidos a UF, así mismo Arrabal et al. (3), quienes añadieronfosfomicina en su diseño, comparando tres grupos (no intervención, fosfomicina y ciprofloxacino) reportan queno disminuye la presencia de infección ni bacteriuria posterior a la UF. Sumándose a esta evidencia, una revisiónsistemática con metaanálisis (RSM) publicado por Garcia-Perdomo et al. (4), concluye que la evidencia no es muyfuerte para recomendar profilaxis en UF y la necesidad de realizar ensayos clínicos con mejores diseños. Careyet al. (5), en otra RSM no recomiendan el uso de profilaxis antibiótica en UF de manera rutinaria, llevando a sermás robustos los resultados de Cano-Garcia et al...

Case Report: Bladder adenocarcinoma: primary or urachal?

Background: Bladder adenocarcinoma (AC) is a scarce histological variant and there are few studies on its proper management. No previous case reports present the management of a urachal tumor and the incidental finding of bladder adenocarcinoma. Clinical case: We present the case of a young woman with nonspecific symptoms, who presented with a prior history of dysuria, bladder tenesmus, suprapubic pain and urinary urgency for one year, which had been treated as recurrent urinary tract infection. A partial cystectomy plus extended lymphadenectomy was scheduled. We found a bladder tumor with characteristics of a urachal tumor and the pathological report indicated a primary bladder AC. The patient had a complete recovery at one year of follow-up. Conclusions: A patient can present with a tumor with urachal characteristics; however, the pathology report can show primary AC. The decision to perform partial cystectomy was an appropriate option for the location of this tumor, with optimal surgical results. Still, a long-term follow-up is necessary. More specific management guidelines are required for the treatment of AC.

Case Report: Penile necrosis associated to paraphimosis with calciphylaxis due to terminal chronic kidney disease.

Background: Penile necrosis is a rare condition that may present in patients with diabetes mellitus or chronic kidney disease (CKD). The recommended treatment is controversial. We report a case of penile necrosis in a diabetic patient caused by episode of paraphimosis associated with uremic arteriopathy treated with partial amputation. Clinical Case: A 53-year-old male with a background of arterial hypertension, diabetes mellitus and CKD in hemodialysis. The patient presented with paraphimosis and glans necrosis. An emergency circumcision was carried out. A doppler ultrasound found fluid collection in the left corpus cavernosum, parietal vascular calcifications and vascular insufficiency in the corpus cavernosum that suggested necrosis. A partial amputation of the penis was carried out. After three years of follow-up, the outcome has remained favorable. Conclusions: Penile necrosis is a rare but serious complication of terminal CKD. In these patients, systemic calciphylaxis is usually observed. The main take-away lesson is that a multidisciplinary approach is necessary.

[Ceftriaxone-resistant Streptococcus pneumoniae meningitis: case report]. / Meningitis por Streptococcus pneumoniae resistente a ceftriaxona: reporte de un caso.

Infectious meningitis is a medical emergency. Within the spectrum of infectious agents, the most important is Streptococcus pneumoniae, the most frequent etiological agent of bacterial meningitis. The initiation of empirical antimicrobial treatment bears great importance and considers third-generation cephalosporins as the first alternative. However, cases of ceftriaxone resistance have been reported in several regions of the world. This has become an emerging problem in need of reconsideration of the current empirical antibiotic treatment schemes. We present the case of a 56-year old man with acute infectious meningitis caused by ceftriaxone-resistant Streptococcus pneumoniae, who responded favorably to combined empirical treatment with ceftriaxone and vancomycin and to whom, during his hospital stay, the presence of hypothyroidism and mega cisterna magna was diagnosed.

La meningitis infecciosa es una emergencia médica. Dentro del espectro de agentes infecciosos, el más importante es el Streptococcus pneumoniae, agente etiológico más frecuente de la meningitis bacteriana. El inicio de tratamiento antimicrobiano empírico es de gran importancia y considera a las cefalosporinas de tercera generación como la primera alternativa. Sin embargo, casos de resistencia a ceftriaxona han sido reportados en diversas partes del mundo, siendo un problema emergente, por lo que necesita una reconsideración de los esquemas antibióticos empíricos actuales. Presentamos el caso de un varón de 56 años que presenta meningitis aguda infecciosa por Streptococcus pneumoniae resistente a ceftriaxona, que respondió favorablemente al tratamiento empírico combinado con ceftriaxona y vancomicina y que durante su estadía hospitalaria se detectó la presencia de hipotiroidismo y megacisterna magna.

Eosinophilic cystitis treated with hydrodistention and complementary methods: Case report. / Cistitis eosinofílica tratada con hidrodistensión y métodos complementarios: comunicación de un caso.

OBJECTIVE: Even though there is no established standard therapy for Eosinophilic cystitis (EC), the series of cases guide us in the treatment of patients. We report our therapeutic experience with hydrodistention and complementary methods. In order to establish a standard treatment in patients with EC. METHODS: Retrospective review of the clinical history of a patient diagnosed with eosinophilic cystitis. RESULTS: A 66-year-old woman presented female urethral syndrome 1 year before and was initially treated as a chronic cystitis. After further investigations including cystoscopy and bladder biopsy, she was diagnosed with EC.Urothelial mucosa bleeding was evidenced and cauterization and hydrodistention were performed. After the surgical treatment, corticosteroids and antibiotics were initiated.The maintenance treatment was continued with Vitamin C, Maurita flexuosa and Peumus boldus. The patient's condition has been improving and she is still asymptomatic one year later. CONCLUSION: The efficacy of treatment with hydrodistention, corticosteroids and antibiotics showed positive results in short and long term in this patient. Vitamin C, Maurita flexuosa and Peumus boldus showed favorable results in EC maintenance treatment.

OBJETIVO: A pesar de que no existe una terapia estándar establecida para la cistitis eosinofílica (CE), la serie de casos nos guía en el tratamiento de los pacientes. Presentamos nuestra experiencia terapéutica con hidrodistensión y métodos complementarios. Con el fin de establecer un tratamiento estándar en pacientes con CE.MÉTODOS: Revisión retrospectiva de la historia clínica de un paciente con diagnóstico de cistitis eosinofílica. RESULTADOS: Una mujer de 66 años presentó síndrome uretral femenino hace un año y fue tratada inicialmente como una cistitis crónica. Después de más investigaciones incluyendo una cistoscopia y una biopsia de la vejiga, se le diagnosticó CE. Se evidenció sangrado de la mucosa urotelial y se realizaron cauterización e hidrodistensión. Después del tratamiento quirúrgico, se iniciaron corticosteroides y antibióticos. El tratamiento de mantenimiento se continuó con Vitamina C, Maurita flexuosa y Peumus boldus. La condición del paciente ha mejorado y sigue estando asintomática un año después.CONCLUSIÓN: La eficacia del tratamiento con hidrodistención, corticosteroides y antibióticos mostró resultados positivos a corto y largo plazo en este paciente. La vitamina C, Maurita flexuosa y Peumus boldus mostraron resultados favorables en el tratamiento de mantenimiento de CE.

Case Report: Double penile fracture.

Penile fracture is an underreported surgical emergency. It usually occurs as a single rupture of the tunica albuginea in one of two corpora cavernosa; a rupture of both masses is an uncommon finding. We report a case of a young male who presented to the emergency department two hours after sustaining penile trauma. Prompt surgical exploration was performed four hours post-injury. He was found to have one fracture on each corpora cavernosa, without urethral injury, which were repaired successfully. The patient had a favorable recovery and was discharged on the third postoperative day without complications. The aim of this report is to highlight the importance of complete degloving of the penile shaft for a meticulous search during surgery to avoid missed injuries. This approach will ensure a successful outcome avoiding physical and psychological disabilities.

Factores asociados al conocimiento sobre la COVID-19 y salud mental en médicos residentes / Factors associated with the perception of knowledge of COVID-19 and mental health in resident doctors

RESUMEN Introducción: El personal sanitario representa la primera respuesta del sistema de salud en la pandemia de la COVID-19, por ello, es importante valorar su conocimiento sobre la identificación y atención de pacientes con la COVID-19. Objetivo: Identificar los factores asociados a la percepción del conocimiento de médicos residentes ante la atención de pacientes con la COVID-19 y describir la percepción de la salud mental durante la pandemia de la COVID-19. Métodos: Estudio transversal, realizado en 2020 en hospitales del Perú. Se empleó la escala "Perception of Knowledge in Health Workers" (alpha de Cronbach: 0,77). También, se empleó la escala "Mental Health COVID-19" (alpha de Cronbach: 0,88). Se realizó estadística bivariada y multivariada. Resultados: De los 200 encuestados, el 12 % y 5 % manifestaron que eran capaces de reconocer a un caso sospechoso y atender un paciente diagnosticado, respectivamente. El 41 % y 35 % estuvo muy de acuerdo con el miedo/preocupación de contagiar a su familia y sentir el maltrato por los pocos equipos de protección personal, respectivamente. En el análisis multivariado, la percepción del conocimiento se asoció a trabajar en emergencias (p= 0,007), a la cantidad de amistades positivos a la COVID-19 (p= 0,012) y a realizar recientemente una intubación (p= 0,035); estas fueron ajustadas por el puntaje de la percepción de salud mental. Conclusiones: Trabajar en emergencias, haber tenido contacto con pacientes contagiados y haber realizado procedimientos médico-quirúrgicos influyen en la percepción de conocimientos de los médicos sobre la atención de pacientes con la COVID-19.

ABSTRACT Introduction: Health personnel represent the first response of the health system in the COVID-19 pandemic. Therefore, it is important to assess their knowledge about the identification and care of patients with COVID-19. Objective: To identify the factors associated with the perception of knowledge of Peruvian resident physicians regarding the care of patients with COVID-19 and to describe the perception of mental health during the COVID-19 pandemic. Methods: Cross-sectional study, carried out in 2020 in hospitals in Peru. The "Perception of Knowledge in Health Workers" scale was used (Cronbach's Alpha: 0.77). And also, the "Mental Health COVID-19" scale was used (Cronbach's Alpha: 0.88). Bivariate and multivariate statistics were performed. Results: Of the 200 respondents, 12% and 5% stated that they were able to recognize a suspected case and care for a diagnosed patient, respectively; 41% and 35% strongly agreed with the fear/concern of infecting their family and feeling mistreatment due to the lack of personal protective equipment, respectively. In the multivariate analysis, the perception of knowledge was associated with working in emergencies (p= 0.007), with the number of positive friends for COVID-19 (p= 0.012) and with having recently undergone intubation (p= 0.035); these were adjusted by the mental health perception score. Conclusions: Working in emergencies, having had contact with infected patients and having performed medical-surgical procedures influence the perception of knowledge of doctors about the care of patients with COVID-19.

Frecuencia de depresión e incontinencia urinaria en pacientes de una institución de alta complejidad en Callao, Perú / Frequency of depression and urinary incontinence in patients of a highly complex institution in Callao, Peru

Introducción: El objetivo fue explorar la frecuencia y asociación entre la presencia de síntomas depresivos con la existencia de síntomas sugestivos de incontinencia urinaria en un grupo de mujeres atendidas en un hospital público del Perú. Material y Métodos: Estudio transversal realizado en mujeres con Seguro Integral de Salud que acudieron al consultorio de ginecología del hospital público de alta complejidad Hospital Nacional Daniel Alcides Carrión durante noviembre y diciembre del 2018. Se calculó una muestra con Epidat versión 3.1 y se seleccionó a las participantes por conveniencia. Las principales variables de interés fueron incontinencia urinaria y depresión, ambas medidas mediante instrumentos de medición validados: ICIQ-SFy escala de autoevaluación para la depresión de Zung, respectivamente. Para explorar la asociación se usó exacta de Fisher y Kruskall-Wallis. Resultados: Se estudió a 186 mujeres con edades entre 40 y 60 años. Un total de 176 mujeres (94,6 %) se definieron como incontinentes y 183 con depresión (98,4 %). No se encontró asociación entre los síntomas depresivos con los síntomas sugestivos de incontinencia urinaria (p>0,05), pero sí en el grado de síntomas depresivos con el puntaje de incontinencia (p=0,0001). Conclusiones: Una proporción considerable de mujeres padece de síntomas depresivos y de incontinencia urinaria. Por otra para, parece existir una posible asociación entre los puntajes de incontinencia urinaria y la severidad de los síntomas depresivos. Se requieren más estudios que exploren esta posible asociación para dilucidar el impacto potencial que la incontinencia urinaria posee sobre el estado anímico de las mujeres en Perú.

Introduction: The objective of this research was to explore the association between the presence of depressive symptoms and the existence of symptoms suggestive of urinary incontinence in a group of women treated in a public hospital in Peru. Material and Methods: Cross-sectiona lstudy was conducted in women with "Seguro Integral de Salud" who attended the gynecology consultation room of Hospital Nacional Daniel Alcides Carrión during November and December of 2018. Asample was calculated with Epidat version 3.1 and the participants were selected by convenience. Themainvariablesofinterestwereurinary incontinence and depression, both measured by validated measurement instruments: ICIQ-SF and self-assessment scale for Zung depression, respectively. Fisher's exact and Kruskall-Wallis were used to explore the association. Results: Atotal of 186 women aged between 40 and 60 years were studied. Atotal of 176 women (94,6%) defined themselves as incontinent and 183 as depression (98,4%). No association was found between the symptoms suggestive of depression with symptoms suggestive of urinary incontinence (p>0,05), but there was an association between the degree of depressive symptoms and the incontinence score (p = 0,0001). Conclusions: Aconsiderable proportion of women suffer from depressive symptoms and urinary incontinence. On the other hand, there seems to be a possible association between urinary incontinence score and the severity of depressive symptoms. More studies are needed to explore this possible association to elucidate the impact that urinary incontinence has on the mood of women in Peru.

Meningitis por Streptococcus pneumoniae resistente a ceftriaxona: reporte de un caso / Ceftriaxone-resistant Streptococcus pneumoniae meningitis: case report

RESUMEN La meningitis infecciosa es una emergencia médica. Dentro del espectro de agentes infecciosos, el más importante es el Streptococcus pneumoniae, agente etiológico más frecuente de la meningitis bacteriana. El inicio de tratamiento antimicrobiano empírico es de gran importancia y considera a las cefalosporinas de tercera generación como la primera alternativa. Sin embargo, casos de resistencia a ceftriaxona han sido reportados en diversas partes del mundo, siendo un problema emergente, por lo que necesita una reconsideración de los esquemas antibióticos empíricos actuales. Presentamos el caso de un varón de 56 años que presenta meningitis aguda infecciosa por Streptococcus pneumoniae resistente a ceftriaxona, que respondió favorablemente al tratamiento empírico combinado con ceftriaxona y vancomicina y que durante su estadía hospitalaria se detectó la presencia de hipotiroidismo y megacisterna magna.

ABSTRACT Infectious meningitis is a medical emergency. Within the spectrum of infectious agents, the most important is Streptococcus pneumoniae, the most frequent etiological agent of bacterial meningitis. The initiation of empirical antimicrobial treatment bears great importance and considers third-generation cephalosporins as the first alternative. However, cases of ceftriaxone resistance have been reported in several regions of the world. This has become an emerging problem in need of reconsideration of the current empirical antibiotic treatment schemes. We present the case of a 56-year old man with acute infectious meningitis caused by ceftriaxone-resistant Streptococcus pneumoniae, who responded favorably to combined empirical treatment with ceftriaxone and vancomycin and to whom, during his hospital stay, the presence of hypothyroidism and mega cisterna magna was diagnosed.

Ictericia obstructiva por neuroma de amputación de vía biliar: Reporte de caso / Obstructive ictericia by neuroma of amputation of via biliar: Case report

Los neuromas del conducto biliar se desarrollan a partir de las fibras nerviosas simpáticas y parasimpáticas que envuelven la pared de la vía biliar. Mujer de 44 años de edad con antecedente de colecistectomía convencional seis meses previos al ingreso acude a emergencia por ictericia obstructiva de 15 días de evolución. En los estudios de imagen impresiona la presencia de una masa a nivel de las vías biliares considerándose el diagnostico de una neoplasia maligna. Por los antecedentes, ausencia de marcadores tumorales se decide realizar una biopsia percutánea sin resultados concluyente, realizándose posteriormente una intervención quirúrgica con estudio anatomo-patológico compatible con neuroma de amputación de vía biliar. El neuroma de amputación a nivel de la vía biliar es un tumor infrecuente. Puede manifestarse clínicamente como una ictericia obstructiva y suele simular a un tumor maligno de las vías biliares. El manejo quirúrgico es el tratamiento definitivo.

Neuromas of the bile duct develop from the sympathetic and parasympathetic nerve fibers that surround the wall of the bile duct. A 44-year-old woman with a history of conventional cholecystectomy six months prior to hospital admission attended emergency due to obstructive jaundice that lasted 15 days. In the imaging studies, the presence of a mass at the level of the bile ducts is considered, considering the diagnosis of a malignant neoplasm. Due to the antecedents, the absence of tumor markers, it was decided to perform a percutaneous biopsy without conclusive results, performing later a surgical intervention with anatomopathological study compatible with neuroma of biliary tract amputation. The amputation neuroma at the level of the bile duct is an infrequent tumor. It can manifest clinically as obstructive jaundice and usually simulates a malignant tumor of the bile ducts. Surgical management is the definitive treatment.

Loxoscelismo escrotal / Scrotal loxoscelism

Loxoscelismo es el cuadro clínico originado por la mordedura de araña del género Loxosceles. Es considerado un accidente que ocurre con mayor frecuencia en las noches, debido al hábito nocturno de la araña y buena adaptación a los ambientes domésticos, preferentemente en espacios oscuros y secos. Clínicamente presenta dos escenarios, cutáneo (83,3 %) y visceral o sistémico (16 %), con una variación del cuadro cutáneo denominado loxoscelismo predominantemente edematoso. El objetivo es informar un caso inusual de loxoscelismo escrotal. El diagnóstico se realizó mediante las características clínicas y epidemiológicas del accidente. En conclusión, el loxoscelismo escrotal es una entidad muy infrecuente, el manejo del paciente influye mucho en su evolución y progresión; el tratamiento exhaustivo con sulfadiazina 2 veces al día y antibióticos intravenosos, muestra resultados muy favorables.

Loxoscelism is a condition produced by the bite of spiders from the genus Loxosceles. It is considered to be an accident that occurs mostly in the night, due to the spider's nocturnal habits and good adaptation to domestic environments, preferably dark, dry spaces. It presents in two clinical scenarios: cutaneous (83.3 %) and visceral or systemic (16 %), with a variation in the cutaneous manifestation known as predominantly edematous loxoscelism. The objective of the study was to report an unusual case of scrotal loxoscelism. Diagnosis was based on the clinical and epidemiological characteristics of the accident. It is concluded that scrotal loxoscelism is a very infrequent condition. Management of the patient greatly influences its evolution and progress. Exhaustive treatment with sulfadiazine twice daily and intravenous antibiotics yields very favorable results.