Effect of cannula insertion site during fetal endoscopic tracheal occlusion for congenital diaphragmatic hernia on preterm prelabor rupture of membranes.

OBJECTIVE: To assess whether the cannula insertion site on the maternal abdomen during fetal endoscopic tracheal occlusion (FETO) for congenital diaphragmatic hernia (CDH) was associated with preterm prelabor rupture of membranes (PPROM) before balloon removal. METHODS: This was a multicenter retrospective study of consecutive pregnancies with isolated left- or right-sided CDH that underwent FETO in four centers between January 2009 and January 2021. The site for balloon insertion was categorized as above or below the umbilicus. One propensity score was analyzed in both groups to calculate an average treatment effect (ATE) by inverse probability of treatment weighting. Logistic regression and Cox proportional hazard regression including the ATE weights were performed to examine the effect size of entry point on the frequency and timing of PPROM before balloon removal. RESULTS: A total of 294 patients were included. The mean ± SD gestational age at PPROM was 33.45 ± 2.01 weeks and the mean rate of PPROM before balloon removal was 25.9% (76/294). Gestational age at FETO was later in the below-umbilicus group (mean ± SD, 29.47 ± 1.29 weeks vs 29.00 ± 1.25 weeks; P = 0.002) and the duration of FETO was longer in the above-umbilicus group (median, 14.49 min (interquartile range (IQR), 8.00-21.00 min) vs 11.00 min (IQR, 7.00-14.49 min); P = 0.002). After balancing for possible confounding factors, trocar entry point below the umbilicus did not increase the risk of PPROM before balloon removal (adjusted odds ratio, 1.56 (95% CI, 0.89-2.74); P = 0.120) and had no effect on the timing of PPROM before balloon removal (adjusted hazard ratio, 1.56 (95% CI, 0.95-2.55); P = 0.080). CONCLUSION: There was no evidence that uterine entry site for FETO was correlated with the risk of PPROM before balloon removal. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.

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.

Traqueostomía quirúrgica en un paciente con súper-súper obesidad. Caso clínico y revisión de la literatura / Surgical tracheostomy in a super-super obese patient. Case report and literature review

La obesidad es un problema de salud que ha presentado un aumento preocupante en Chile y el mundo, en las últimas décadas. Esta condición se asocia a múltiples comorbi-lidades, entre ellas, afecciones respiratorias. La traqueostomía es un procedimiento quirúrgico que puede resultar desafiante en este tipo de pacientes, debido a las alteraciones que la obesidad genera en la anatomía cervical, asociándose a mayor morbimortalidad. Requiere una buena planificación preoperatoria. Se presenta el caso de un paciente con antecedente de súper-súper obesidad, con un índice de masa corporal de 78 kg m2, que requirió la realización de una traqueostomía quirúrgica. Se describe el manejo realizado, junto a las consideraciones especiales aplicadas al caso: se realizó lipectomía cervical, se utilizó instrumental quirúrgico de mayor longitud, suturas al plano subcutáneo para facilitar visualización intraoperatoria, suturas de la piel a la tráquea previo a la apertura de la vía aérea, uso de cánula de traqueostomía extra larga. El paciente presentó como complicación postoperatoria un granuloma periostomal que fue tratado y, finalmente, fue decanulado previo su alta hospitalaria. Se presenta una revisión en la literatura pertinente al caso.

Obesity is a health problem that has shown a worrisome increase in Chile and the world in recent decades. This condition is associated to multiple comorbidities, including respiratory disorders. A tracheostomy is a surgical procedure that can be challenging in this type of patient due to the variations that obesity generates in the cervical anatomy, which is associated to greater morbidity and mortality. Due to this, it requires good preoperative planning. We present the case of a male patient with a history of super-super obesity, with a body mass index (BMI) of 78 kg m2, who required surgical tracheostomy; the management is described with the special considerations applied to the case: cervical lipectomy was performed, longer surgical instruments were used, sutures to the subcutaneous plane were placed to facilitate intraoperative visualization, skin sutures to the trachea were placed prior to opening the airway, use of extra-large tracheostomy cannula (XL). The patient presented a peristomal granuloma as a postoperative complication which was treated, and he was decannulated prior to hospital discharge. A review of the literature relevant to the case is presented.

Post-Traumatic Stress Disorder after the 6.1 Magnitude Earthquake in Piura, Peru: A Cross-Sectional Study.

In Peru, major disasters like the 2007 Pisco earthquake have produced high rates of post-traumatic stress. However, evidence is still needed to strengthen interventions. In 2021, a major earthquake struck Piura, in northern Peru. In this context, we aimed to assess the prevalence of PTSD and its associated factors. A cross-sectional study was conducted during August-September 2021 in people who experienced the 6.1 Piura earthquake on 30 July 2021. The questionnaire included the PCL-C, CD-RISC, ISI, HFIAS, and additional demographic data. Generalized linear models were used. The prevalence of PTSD was 20.3%. Household income was between PEN 2001 and 3000 (PR = 4.26, 95% CI: 1.08-16.75), smoking (PR = 2.49, 95% CI: 1.03-6.01), experience of a nervous breakdown (PR = 1.83, 95% CI: 1.09-3.09), moderate food insecurity (PR = 2.91, 95% CI: 1.10-7.73), and severe insomnia (PR = 8.25, 95% CI: 2.22-30.71) increased the prevalence of PTSD. One out of five individuals experienced post-traumatic stress symptoms after the 2021 earthquake in Piura, which varies depending on socioeconomic, psychosocial, and individual factors. Further research should strengthen these findings to ensure a fair and early mental health intervention against new seismic events in this and other Peruvian regions.

Smartphone overuse, depression & anxiety in medical students during the COVID-19 pandemic.

INTRODUCTION: Medical students have made particular use of smartphones during the COVID-19 pandemic. Although higher smartphone overuse has been observed, its effect on mental disorders is unclear. This study aimed to assess the association between smartphone overuse and mental disorders in Peruvian medical students during the COVID-19 pandemic. METHODS: A cross-sectional study was conducted in 370 students aged between 16 and 41 years (median age: 20) in three universities from July to October 2020. A survey including Smartphone Dependence and Addiction Scale, PHQ-9, and GAD-7 was applied. Prevalence ratios were estimated using generalized linear models. RESULTS: Smartphone overuse was a common feature among students (n = 291, 79%). Depressive symptoms were present in 290 (78%) students and anxiety symptoms in 255 (69%). Adjusted for confounders, addictive/dependent smartphone use was significantly associated with presence of depressive symptoms (PR = 1.29, 95% CI: 1.20-1.38 for dependent use; PR = 1.30, 95% CI: 1.12-1.50 for addictive use). Also, addictive/dependent smartphone use was significantly associated with presence of anxiety symptoms (PR = 1.59, 95% CI: 1.14-2.23 for dependent use; PR = 1.61, 95% CI: 1.07-2.41 for addictive use). CONCLUSIONS: Our findings suggest that medical students exposed to smartphone overuse are vulnerable to mental disorders. Overuse may reflect an inappropriate way of finding emotional relief, which may significantly affect quality of life and academic performance. Findings would assist faculties to establish effective measures for prevention of smartphone overuse.

Toxoplasma gondii Infection and Threatened Abortion in Women from Northern Peru.

Introduction: Toxoplasma gondii infection can cause important complications during pregnancy. Threatened abortion may be a late indicator for infection in settings with high prevalence of toxoplasmosis. We aimed to determine the association between T. gondii infection and threatened abortion in women from northern Peru. Methods: We conducted a secondary analysis of a cross-sectional study in pregnant women from a hospital and a rural community in Lambayeque, Peru. Exposure variable was serological diagnosis of toxoplasmosis, defined as the demonstration of either IgM or IgG antibodies against T. gondii. Outcome variable was threatened abortion, defined as the diagnosis of bloody vaginal discharge or bleeding during the first half of pregnancy. Prevalence ratios were estimated in simple and multiple regression analyses. Results: Of 218 pregnant women, 35.8% presented positive serology for T. gondii and 14.7% had threatened abortion in their current pregnancy. Pregnant women with positive T. gondii infection had 2.45-fold higher frequency of threatened abortion (PR: 2.45, 95% CI: 1.15-5.21). In addition, the frequency of threatened abortion decreased by 9% for each additional year of age (PR: 0.91, 95% CI: 0.86-0.97). A previous history of threatened abortion also showed a higher frequency of threatened abortion (PR: 5.22, 95% CI: 2.45-11.12). Conclusions: T. gondii infection is associated with threatened abortion. An early age of pregnancy and a previous history of abortion are also associated with this condition.

Mental Health Disturbance after a Major Earthquake in Northern Peru: A Preliminary, Cross-Sectional Study.

Little has been studied in Peru on the mental health repercussions after a major earthquake. We aimed to explore the factors associated with depressive and anxiety symptoms in people who experienced a 6.1 magnitude earthquake in Piura, Peru, on 30 July 2021. A preliminary cross-sectional study was conducted in the general population between August-September 2021. An online questionnaire was provided using PHQ-9, GAD-7, and other relevant measures. Generalized linear models were applied. Of the 177 participants, the median age was 22 years, the majority were female (56%), and many experienced depressive (52%) or anxiety symptoms (52%). Presence of depressive symptoms was associated with a personal history of mental disorder, moderate housing damage, social/material support from politicians, moderate food insecurity, and insomnia. Presence of anxiety symptoms was associated with physical injury caused by the earthquake, mild food insecurity, and insomnia. The development of depressive and anxiety symptoms following the 2021 earthquake experienced in Piura depended on multiple individual and socioeconomic factors. Additional studies should reinforce the factors identified here given the methodological limitations, such as the study design, sampling method, and sample size. This would lead to effective intervention measures to mitigate the impact of earthquakes on mental health.

COVID-19 Vaccine Effectiveness at a Referral Hospital in Northern Peru: A Retrospective Cohort Study.

COVID-19 vaccines have achieved a significant reduction in mortality, yet objective estimates are needed in specific settings. We aimed to determine the effectiveness of COVID-19 vaccination at a referral hospital in Lambayeque, Peru. We conducted a retrospective cohort study from February to September 2021. We included hospitalized patients with COVID-19, whose data were stored in NotiWeb, a patient data system of the Peruvian Ministry of Health. We applied a propensity score-weighting method according to baseline characteristics of patients, and estimated hazard ratios (HR) using Cox regression models. Of 1553 participants, the average age was 55 years (SD: 16.8), 907 (58%) were male, and 592 (38%) deceased at 28-day follow-up. Before hospital admission, 74 (4.8%) had been immunized with at least one vaccine dose. Effectiveness against death in vaccinated patients was 50% at 90-day follow-up (weighted HR 0.50, 95% CI 0.28-0.89). Our results support the effectiveness of COVID-19 vaccination against death and provide information after early immunization in Peru.

Quality of life of medical students with migration background: a cross-sectional study from a Peruvian university.

The study aimed to describe the association between internal migration status and QoL in medical students from a Peruvian university. A cross-sectional survey was conducted in medical students from a public university in Lima, Peru. We used the brief version of the World Health Organization Quality of Life instrument (WHOQOL-BREF) and obtained data on demographic and migration-related student's characteristics. Linear mixed models were used to assess how migration status affected each of the WHOQOL-BREF domains (physical health, psychological status, social relationships, and environment). Of 410 participants, 110 (27%) and 46 (11%) were 'late' and 'recent' migrants, respectively. Compared with non-migrants, most recent migrants were older (87.0%, p = 0.000), lived alone (32.6%, p = 0.000), had at least one highly educated parent (87.0%, p = 0.002) and reported no chronic conditions (73,9%, p = 0.019). The environment domain scored the lowest and the psychological domain, the highest. Adjusting by all study confounders, migration status was not associated with QoL in any domain. However, adjusting by variables showing a favorable proportion in migrants (parental education and chronic conditions), recent migrants had lower QoL than did non-migrants in the environment domain (b - 4.8, 95% CI -9.2 to -0.5). The results suggest that the parents' higher education level and the absence of chronic conditions could protect migrants' QoL against environmental stressors.

Factores asociados a seropositividad para SARS-CoV-2 en pacientes atendidos en un hospital de zona altoandina peruana / Factors associated with seropositivity for SARS-CoV-2 in patients treated at a hospital in the Peruvian highlands

Introducción:El COVID 19 es una enfermedad infecciosa causada por el SARS-CoV-2 que ha afectado en gran escala al Perú. No están documentados los potenciales factores clínicos y/o epidemiológicos que están relacionados a la positividad de SARS-CoV-2 en población altoandina. Determinar los factores asociados a positividad de SARS-Cov-2 en Objetivo:personas que viven en Ancash. Estudio transversal analítico. Se Material y métodos:utilizaron los registros de pacientes atendidos por sospecha de COVID-19 en un hospital público de Huaraz en marzo-mayo 2020. Se estimaron razones de prevalencia (RP) con intervalos de confianza. En el análisis de regresión simple, se estimaron razones de prevalencia e intervalos de confianza al 95%, utilizando familia de distribución Poisson, función de enlace log y varianza robusta De 903 pacientes, 13,7% pacientes Resultados:resultaron positivos a SARS-CoV-2. En la regresión simple, resultó que el sexo masculino (RP=2,98), presentar tos (RP=2,27), dificultad respiratoria (RP=2,97), diarrea (RP=2,69), malestar general (RP=1,82), odinofagia (RP=1,69) se asociaron positivamente a tener prueba SARS-CoV-2 positiva. En la regresión múltiple se mantuvo la asociación en cuatro características: ser varón (RP=2,7), presentar tos (RP=1,45), dificultad respiratoria (RP=2,15) y diarrea (RP=1,89). :En zona altoandina, los casos positivos en su Conclusiónmayoría presentan síntomas típicos. Los factores asociados a la positividad fueron el sexo masculino y la presencia de dificultad tos, respiratoria y diarrea

Background:COVID 19 is an infectious disease caused by SARS-CoV-2 that has affected Peru on a large scale. Potential clinical and/or epidemiological factors that are related to the positivity of SARS-CoV-2 in the high Andean population are not documented. Objective: To determine factors associated with positivity of SARS-CoV-2 in people living in Ancash. Material and methods: Analytical transversal study. We used the records of patients treated for suspected COVID-19 in a public hospital in Huaraz in March-May 2020. Prevalence ratios (PR) with confidence intervals were estimated. In simple regression analysis, prevalence ratios and 95% confidence intervals were estimated, using Poisson distribution family, log-link function and robust variance. Out of 903 patients, Results: 13.7% tested positive for SARS-CoV-2. In simple regression, male (RP=2.98), cough (RP=2.27), respiratory distress (RP=2.97), diarrhea (RP=2.69), general malaise (RP=1.82), odynophagia (RP=1.69) were positively associated with having a positive SARS-CoV-2 test. In the multiple regressions, the association was maintained in four characteristics: being male (RP=2.7), having a cough (RP=1.45), respiratory distress (RP=2.15), and diarrhea (RP=1.89). Conclusion: In high Andean areas, most positive cases present typical symptoms. The factors associated with positivity were male sex and the presence of cough, respiratory difficulty and diarrhea.

Factores asociados al afrontamiento psicológico frente a la COVID-19 durante el periodo de cuarentena / Factors associated with psychological coping with COVID-19 during quarantine period

Introducción: Aunque se está generando múltiple evidencia clínica sobre la COVID-19, también es crítico abordar sobre las estrategias y acciones que han adoptado las personas para enfrentar situaciones estresantes durante la cuarentena obligatoria debido a la pandemia. Objetivo: Determinar los factores asociados al afrontamiento psicológico frente a la COVID-19 en la población general. Métodos: Estudio transversal analítico. Se reclutaron los participantes a través de una encuesta en línea, durante el periodo de pandemia por la COVID-19. Se evaluó el nivel de afrontamiento pasivo y activo, utilizando la escala de afrontamiento frente a riesgos extremos. Adicionalmente, se utilizó la media de los puntajes de afrontamiento pasivo y activo, se evaluó la asociación con variables sociodemográficas, pertenencia a grupos, cumplimiento de aislamiento social y reporte de conocer alguien diagnosticado con la COVID-19. Se estimaron razones de prevalencia (RP) con el uso de modelos lineales generalizados. Resultados: De 463 participantes, la mayoría era peruano (67,4 por ciento), cumplía totalmente las medidas de aislamiento social (78,4 por ciento). La media de puntuación de afrontamiento activo y pasivo fue de 54,1 y 30,3, respectivamente. El 57,2 por ciento y 54 por ciento de los participantes presentó nivel de afrontamiento activo y pasivo superior a la media, respectivamente. Los factores asociados a alto nivel de afrontamiento activo fueron alto nivel educativo (RP = 1,23) y cumplir completamente las medidas de aislamiento social (RP = 1,35). Conclusión: Tener alto nivel educativo y el cumplimiento del aislamiento social estuvieron asociados positivamente a alto nivel de afrontamiento activo(AU)

Introduction: Although multiple clinical evidence is being generated about COVID-19, it is also critical to address the strategies and actions that people have adopted to face stressful situations during the mandatory quarantine due to the pandemic. Objective: To determine the factors associated with psychological coping to COVID-19 in the general population. Method: Analytical cross-sectional study. Participants were recruited through an online survey during the COVID-19 pandemic period. The level of passive and active coping was evaluated, using the coping scale against extreme risks. Additionally, using the mean of the passive and active coping scores, the association with sociodemographic variables, group membership, compliance with social isolation and the report of knowing someone diagnosed with COVID-19 was evaluated. Prevalence ratios (PR) were estimated using generalized linear models. Results: Of 463 participants, the majority was Peruvian (67,4 percent), fully complying with social isolation measures (78,4 percent). The mean active and passive coping scores were 54,1 and 30,3, respectively. 57,2 percent and 54 percent of the participants presented a level of active and passive coping above the mean, respectively. The factors associated with a high level of active coping were a high educational level (RP = 1,23) and complete compliance with social isolation measures (RP = 1,35). Conclusion: Having a high educational level and compliance with social isolation were positively associated with a high level of active coping(AU)

Recomendaciones para realización de traqueostomías en paciente adulto con COVID-19 (+) o sospechoso / Recommendations for performing tracheostomies in adult patients with COVID-19 (+) or suspicious

Resumen La traqueostomía es un procedimiento generador de aerosoles, lo que cobra particular importancia en la pandemia por SARS-CoV-2, causante de COVID-19, al tener un importante riesgo de contagio asociado si no implementamos adecuadamente las modificaciones necesarias para disminuir los aerosoles formados. A medida que el número de pacientes infectados aumente, también lo hará la necesidad de realizar traqueostomías, por lo que es fundamental estar preparados. Todos los ámbitos del procedimiento, desde la selección del paciente hasta el cuidado postoperatorio tienen modificaciones importantes para permitir realizar una cirugía y seguimiento seguro, tanto para el paciente como para los trabajadores de salud involucrados. En este artículo se realiza una revisión narrativa de la literatura disponible hasta mediados de abril de 2020 y se describen los principales cambios a considerar, tanto previo, durante y después de la cirugía de traqueostomía. Con respecto a la técnica quirúrgica, la decisión puede ser controversial entre una traqueostomía abierta y percutánea según las fuentes citadas, pero con las actuales modificaciones a ambas, se deberían considerar equivalentes en la cantidad de aerosoles generados, por lo que la elección debería estar basada en la experiencia local. Está desaconsejado innovar en una técnica con la que el cirujano esté poco familiarizado por el potencial riesgo de infección que significa para todas las personas involucradas en el procedimiento en este tipo de pacientes.

Abstract Tracheostomy is an aerosol-generating procedure, which is particularly important during the COVID-19 pandemic caused by SARS-CoV-2, since it presents a significant risk of infection if we do not properly implement the necessary modifications to decrease aerosolization. As the number of infected patients increases, so will the demand for performing tracheostomies, therefore being prepared is fundamental. Every aspect of the procedure, from patient selection to postoperative care have significant modifications to allow for a safe surgery and follow-up, both for the patient and the health workers involved. In this article, a literature review of the available information until mid-april is performed and the main changes to consider before, during and after the surgery are described. Regarding the surgical technique, there is no clear consensus between open and percutaneous tracheostomy depending on the sources cited, but with the current modifications to both, they should be considered equivalent in the aerosolization generated, therefore the decision should be based on the local experience. Innovating in a technique in which the physician is unfamiliar is discouraged due to the potential risk of infection for everyone involved in the procedure in this type of patients.

Perception of medical students about courses based on peer-assisted learning in five Peruvian universities.

OBJECTIVES: Peer-assisted learning (PAL) is a supportive strategy in medical education. In Peru, this method has been implemented by few universities. However, there are no consistent studies evaluating their acceptability by medical students. The objective of this study was to evaluate the perception of medical students about PAL in five Peruvian universities. RESULTS: A total of 79 medical students were included in the study. The mean age was 20.1 ± 1.9 years, 54% were female, and 87% were in the first 4 years of study. Most of the students were satisfied with classes and peer teachers. Similarly, most of the students agreed with the interest in developing teaching skills. It was also observed that 97% of students approved to implement PAL in medical education programs.

Real-world evidence of secukinumab in psoriasis treatment - a meta-analysis of 43 studies.

Real-world evidence (RWE) meta-analyses provide valuable insights from patients in routine clinical practice. Secukinumab, the first fully human monoclonal antibody that neutralizes IL-17A, has shown long-lasting effectiveness and safety in plaque psoriasis (PsO). Since its licence approval in 2015, many RWE studies have been published. The objective of this study was to review all available literature on RWE studies with secukinumab and the secukinumab arm of comparator studies in patients with moderate-to-severe PsO to evaluate its effectiveness, drug survival and safety. https://www.embase.com and https://clinicaltrials.gov databases were searched using prespecified inclusion criteria between 1 January 2015 and 31 May 2019. Using a meta-package and R statistical software to analyse data, key outcomes were measured at 3, 6 and 12 months. PASI and DLQI score data were recorded for patients who remained on secukinumab treatment. Overall, 43 studies were included. Drug survival was 90% at 3 and 6 months, and 80% at 12 months. At 12 months, 8% of patients had discontinued treatment due to lack of effectiveness. At 3, 6 and 12 months, Psoriasis Area and Severity Index (PASI) 90 scores were as follows: 50%, 53% and 60%, and PASI 100 scores were 36%, 46% and 51%, respectively. At 3, 6 and 12 months, 57%, 55% and 65% of patients achieved a Dermatology Life Quality Index (DLQI) score of 0 or 1, respectively. Adverse events were consistent with rates observed in clinical trials with no new safety signals. This meta-analysis strengthens existing evidence on the clinical effectiveness of secukinumab in patients with moderate-to-severe PsO, demonstrating high drug survival rates, high levels of patient-reported outcomes, and good tolerance.

Learning curves of open and endoscopic fetal spina bifida closure: systematic review and meta-analysis.

OBJECTIVE: The Management of Myelomeningocele Study (MOMS) trial demonstrated the safety and efficacy of open fetal surgery for spina bifida aperta (SBA). Recently developed alternative techniques may reduce maternal risks without compromising the fetal neuroprotective effects. The aim of this systematic review was to assess the learning curve (LC) of different fetal SBA closure techniques. METHODS: MEDLINE, Web of Science, EMBASE, Scopus and Cochrane databases and the gray literature were searched to identify relevant articles on fetal surgery for SBA, without language restriction, published between January 1980 and October 2018. Identified studies were reviewed systematically and those reporting all consecutive procedures and with postnatal follow-up ≥ 12 months were selected. Studies were included only if they reported outcome variables necessary to measure the LC, as defined by fetal safety and efficacy. Two authors independently retrieved data, assessed the quality of the studies and categorized observations into blocks of 30 patients. For meta-analysis, data were pooled using a random-effects model when heterogeneous. To measure the LC, we used two complementary methods. In the group-splitting method, competency was defined when the procedure provided results comparable to those in the MOMS trial for 12 outcome variables representing the immediate surgical outcome, short-term neonatal neuroprotection and long-term neuroprotection at ≥ 12 months of age. Then, when raw patient data were available, we performed cumulative sum analysis based on a composite binary outcome defining successful surgery. The composite outcome combined four clinically relevant variables for safety (absence of extreme preterm delivery < 30 weeks, absence of fetal death ≤ 7 days after surgery) and efficacy (reversal of hindbrain herniation and absence of any neonatal treatment of dehiscence or cerebrospinal fluid leakage at the closure site). RESULTS: Of 6024 search results, 17 (0.3%) studies were included, all of which had low, moderate or unclear risk of bias. Fetal SBA closure was performed using standard hysterotomy (11 studies), mini-hysterotomy (one study) or fetoscopy by either exteriorized-uterus single-layer closure (one study), percutaneous single-layer closure (three studies) or percutaneous two-layer closure (one study). Only outcomes for standard hysterotomy could be meta-analyzed. Overall, outcomes improved significantly with experience. Competency was reached after 35 consecutive cases for standard hysterotomy and was predicted to be achieved after ≥ 57 cases for mini-hysterotomy and ≥ 56 for percutaneous two-layer fetoscopy. For percutaneous and exteriorized-uterus single-layer fetoscopy, competency was not reached in the 81 and 28 cases available for analysis, respectively, and LC prediction analysis could not be performed. CONCLUSIONS: The number of cases operated is correlated with the outcome of fetal SBA closure, and the number of operated cases required to reach competency ranges from 35 for standard hysterotomy to ≥ 56-57 for minimally invasive modifications. Our observations provide important information for institutions looking to establish a new fetal center, develop a new fetal surgery technique or train their team, and inform referring clinicians, potential patients and third parties. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Curvas de aprendizaje del cierre de la espina bífida fetal mediante cirugía abierta y endoscópica: revisión sistemática y metaanálisis OBJETIVO: El ensayo del Estudio sobre la Gestión del Mielomeningocele (MOMS, por sus siglas en inglés) demostró la seguridad y eficacia de la cirugía fetal abierta para la espina bífida aperta (EBA). Las técnicas alternativas recientemente desarrolladas pueden reducir los riesgos de la madre sin comprometer los efectos neuroprotectores del feto. El objetivo de esta revisión sistemática fue evaluar la curva de aprendizaje (CA) de diferentes técnicas de cierre de la EBA fetal. MÉTODOS: Se realizaron búsquedas en las bases de datos de MEDLINE, Web of Science, EMBASE, Scopus y Cochrane, así como en la literatura gris, para identificar artículos relevantes sobre cirugía fetal para la EBA, sin restricción de idioma, publicados entre enero de 1980 y octubre de 2018. Se examinaron sistemáticamente los estudios identificados y se seleccionaron los que informaban de todos los procedimientos consecutivos y con seguimiento postnatal ≥12 meses. Los estudios se incluyeron sólo si informaban sobre las variables de resultado necesarias para medir la CA, definidas por la seguridad y la eficacia para el feto. Dos autores recuperaron los datos de forma independiente, evaluaron la calidad de los estudios y clasificaron las observaciones en bloques de 30 pacientes. Para el metaanálisis, los datos se agruparon mediante un modelo de efectos aleatorios cuando fueron heterogéneos. Para medir la CA, se usaron dos métodos complementarios. En el método de división de grupos, la competencia se definió cuando el procedimiento proporcionó resultados comparables a los del ensayo MOMS para 12 variables de resultados que representaban el resultado quirúrgico inmediato, la neuroprotección neonatal a corto plazo y la neuroprotección a largo plazo a ≥12 meses de edad. Luego, cuando se dispuso de los datos brutos de los pacientes, se realizó un análisis de suma acumulada basado en un resultado binario compuesto que definió el éxito de la cirugía. El resultado compuesto combinó cuatro variables clínicamente relevantes en cuanto a la seguridad (ausencia de parto pretérmino extremo <30 semanas; ausencia de muerte fetal a ≤7 días después de la cirugía) y eficacia (reducción de la hernia del rombencéfalo y ausencia de cualquier tratamiento neonatal de dehiscencia o derrame de líquido cefalorraquídeo en el lugar del cierre). RESULTADOS: De los 6024 resultados de la búsqueda, se incluyeron 17 (0,3%) estudios, todos ellos con un riesgo de sesgo bajo, moderado o incierto. El cierre de la EBA fetal se realizó mediante histerotomía estándar (11 estudios), mini histerotomía (un estudio) o fetoscopia, ya fuera mediante el cierre exteriorizado del útero de una sola capa (un estudio), el cierre percutáneo de una sola capa (tres estudios) o el cierre percutáneo de dos capas (un estudio). Sólo se pudieron metaanalizar los resultados de la histerotomía estándar. En general, los resultados mejoraron significativamente con la experiencia. Se alcanzó la competencia después de 35 casos consecutivos para la histerotomía estándar y se predijo que se alcanzaría después de ≥57 casos para la mini histerotomía y ≥56 para la fetoscopia percutánea de dos capas. En el caso de las fetoscopias percutánea y exteriorizada del útero de una sola capa, no se alcanzó la competencia en los 81 y 28 casos disponibles para el análisis, respectivamente, y no se pudo realizar el análisis de predicción de la CA. CONCLUSIONES: El número de casos operados está correlacionado con el resultado del cierre de la EBA fetal, y el número de casos operados necesarios para alcanzar la competencia estuvo entre 35 para la histerotomía estándar y ≥56-57 para las operaciones con mínima agresividad. Las observaciones realizadas proporcionan información importante para las instituciones que buscan establecer un nuevo centro fetal, desarrollar una nueva técnica de cirugía fetal o entrenar a su equipo, e informar a los médicos que remiten a especialistas a los posibles pacientes y a terceros. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Orbital metastasis diagnosed by ultrasound-guided fine-needle aspiration biopsy: Case report of unknown primary site. / Metástasis de la órbita diagnosticada por biopsia por aspiración con aguja fina guiada por ultrasonido: reporte de caso de sitio primario desconocido.

Twenty five percent of orbital metastasis is usually of unknown primary origin and it requires histopathological and immunohistochemical confirmation. The fine-needle aspiration biopsy of the orbit is an alternative procedure to conventional orbitotomy. The case is presented of a 60 year-old woman with a right orbit tumour mass and neoplastic lesions in her brain and cranium. As an incidental finding, she had a thrombus in her left atrium, and so an orbitotomy procedure was ruled out. An ultrasound-guided fine-needle aspiration biopsy was performed instead with rapid on-site evaluation of biopsy samples. These showed malignant cells of a lung adenocarcinoma, which was confirmed with immunohistochemistry and chest diagnostic images. In conclusion, biopsy samples obtained by fine-needle aspiration biopsy, together with cytopathological and immunohistological analysis, enabled orbital metastasis to be identified in the case described, and showed that fine-needle aspiration biopsy is a safe, effective, and minimally invasive alternative.

Fetal cardiac interventions

In the last 15­20 years, fetal cardiac interventions have become an accepted therapeutic modality for some complex congenital heart diseases (CHD) in utero, including aortic stenosis (AS) and evolving hypoplastic left heart syndrome (HLHS), HLHS with intact or highly restrictive interatrial septum (IAS), and pulmonary atresia (PA) or critical pulmonary stenosis (CPS) with intact ventricular septum (IVS) and evolving hypoplastic right heart syndrome (HRHS). The purpose of a fetal cardiac intervention is to remodel cardiac morphology and function and improve pre- and postnatal outcomes. Increased survival rates, reduced morbidity, and increased likelihood of achieving a biventricular (BV) circulation may all result from a successful fetal cardiac intervention in some scenarios. The objective of this chapter is to give an overview of these procedures with emphasis on pictures to illustrate how they are performed in a step-to-step fashion. (AU)

Tendencias en el número de médicos titulados anualmente en el Perú, 2007-2016 / Trends in the number of physicians annually graduating in Peru, 2007-2016

Objetivo: Describir la tendencia en el número de médicos que se titularon durante el periodo 2007-2016 en Perú, en forma general y en subgrupos de acuerdo a las características ligadas a la universidad en la que cursaron los estudios de pregrado. Materiales y métodos: Estudio descriptivo. Se obtuvo el listado de todos los médicos colegiados entre 2007-2016 por medio de la página web del Colegio Médico del Perú; mientras que la fecha de titulación y universidad de procedencia provino de la página web de la Superintendencia Nacional de Educación Superior Universitaria (SUNEDU). Para evaluar las tendencias, se utilizó la prueba de correlación de Spearman. Resultados: En el periodo de estudio se colegiaron 27 611 médicos a nivel nacional, con una tendencia anual creciente en la cantidad de médicos titulados (p<0,001). Entre los egresados de universidades peruanas, se encontró un incremento del número de médicos que estudiaron en universidades de Lima (p<0,001) y de la región costa (p<0,001). Adicionalmente, se evidenció un incremento en la cantidad de titulados provenientes de universidades privadas de Lima (p<0,001) y de provincias (p<0,001). Conclusiones: El número de médicos titulados aumenta anualmente, con predominio de aquellos provenientes de universidades de Lima, la costa y universidades privadas. Se evidencia la necesidad urgente de políticas que regulen este crecimiento, con la finalidad de evitar problemas de calidad educativa y empleabilidad.

Objective. To describe the trends in the number of physicians who graduated from 2007 to 2016 in Peru, both in a general manner as well as in subgroups based on the school they studied. Materials and Methods. This is a descriptive and retrospective study. A list of all physicians who graduated during the 2007-2016 period was obtained from the Peruvian College of Physicians website. Their graduating dates and the schools where they studied were obtained from the National University Education Superintendence (SUNEDU, according to its Spanish initials). Trends were assessed using the Spearman correlation test. Results: During the study period, 27,611 physicians graduated in Peru. There was an annual increase in the total number of graduates (p<0.001). Amongst graduates from Peruvian medical schools, there was an increase in the number of physicians who studied in Lima (p<0.001) and in the Peruvian coast (p<0.001). Also, there were a greater number of graduated physicians from Lima (p<0.001) and other provinces medical schools (p<0.001). Conclusions. The number of graduated physicians annually increases, particularly those who studied in Lima, the coast, and private medical schools. We evidence an urgent need for policies for regulating this growth, aiming to avoid employability and educational quality problems.