Prevalence and incidence of chronic obstructive pulmonary disease in Latin America and the Caribbean: a systematic review and meta-analysis.

BACKGROUND: Chronic Obstructive Pulmonary Disease (COPD) remains one of the leading causes of morbidity and mortality worldwide, and its epidemiology in Latin America and the Caribbean is not well described. The aim of this study was to evaluate the prevalence and incidence of COPD in Latin America and the Caribbean. METHODS: We searched systematically in Web of Science (WoS)/Core Collection, WoS/MEDLINE, WoS/Scielo, Scopus, PubMed, and Embase from 2010 to 2021. Studies assessing the prevalence and incidence of COPD according to the GOLD classification were included. The overall prevalence of COPD was calculated as a function of the general population using a random-effects model. RESULTS: 20 studies (19 cross-sectional and 1 cohort) met the inclusion criteria. The prevalence of COPD in the general population older than 35 years was 8.9%. The prevalence in men was 13.7% and in women 6.7%. The prevalence in smokers and ex-smokers was 24.3%. The incidence in the general population of COPD according to one study was 3.4% at 9 years of follow-up. CONCLUSIONS: COPD is prevalent in Latin America, especially in men and in smokers and ex-smokers. Further prevalence and incidence studies in the general population are needed, as well as health policies and strategies to address the disease.

Fecal Microbiota Transplantation for People Living with Human Immunodeficiency Virus: A Scoping Review.

The aim of this scoping review was to determine the characteristics of studies evaluating fecal microbiota transplantation (FMT), as well as its effects and safety as a therapeutic intervention for people living with human immunodeficiency virus (HIV). We conducted a scoping review following the methodology of the Joanna Briggs Institute. We searched the following databases: PubMed, Web of Science, Scopus, Embase, Cochrane Library, and Medline until September 19, 2021. Studies that used FMT in people living with HIV and explored its effects on the health of these people were included. Two randomized and 2 uncontrolled clinical trials with a total of 55 participants were included. Participants were well-controlled HIV-infected people. Regarding microbiota changes, three studies found significant post-FMT increases in Fusobacterium, Prevotella, α-diversity, Chao index, and/or Shannon index, and/or decreases in Bacteroides. Regarding markers of intestinal damage, one study found a decrease in intestinal fatty acid binding protein post-FMT, and another study found an increase in zonulin. Other outcomes evaluated by the studies were as follows: markers of immune and inflammatory activation, markers of immunocompetence (CD4+, and CD8+ T lymphocytes), and HIV viral load; however, none showed significant changes. Clinical outcomes were not evaluated by these studies. Regarding the safety of FMT, only mild adverse events were appreciated. No serious adverse event was reported. The clinical evidence for FMT in people living with HIV is sparse. FMT appears to have good tolerability and, no serious adverse event has been reported so far. Further clinical trials and evaluation of clinically important biomedical outcomes for FMT in people living with HIV are needed.

High mortality among hospitalized adult patients with COVID-19 pneumonia in Peru: A single centre retrospective cohort study.

BACKGROUND: Peru is the country with the world's highest COVID-19 death rate per capita. Characteristics associated with increased mortality among adult patients with COVID-19 pneumonia in this setting are not well described. METHODS: Retrospective, single-center cohort study including 1537 adult patients hospitalized with a diagnosis of SARS-CoV-2 pneumonia between May 2020 and August 2020 at a national hospital in Lima, Peru. The primary outcome measure was in-hospital mortality. RESULTS: In-hospital mortality was 49.71%. The mean age was 60 ± 14.25 years, and 68.38% were males. We found an association between mortality and inflammatory markers, mainly leukocytes, D-dimer, lactate dehydrogenase, C-reactive protein and ferritin. A multivariate model adjusted for age, hypertension, diabetes mellitus, and corticosteroid use demonstrated that in-hospital mortality was associated with greater age (RR: 2.01, 95%CI: 1.59-2.52) and a higher level of oxygen requirement (RR: 2.77, 95%CI: 2.13-3.62). Conclusions: In-hospital mortality among COVID-19 patients in Peru is high and is associated with greater age and higher oxygen requirements.

Guía de práctica clínica para la prevención, diagnóstico y manejo de infecciones asociadas al acceso de hemodiálisis en el Seguro Social de Salud del Perú (EsSalud) / Clinical practice guidelines for the prevention, diagnosis and management of infections related with hemodialysis access of the Peruvian Health Social Security (EsSalud)

Introducción: El presente artículo resume la guía de práctica clínica (GPC) para la prevención, diagnóstico y manejo de infecciones asociadas al acceso de hemodiálisis en el Seguro Social del Perú (EsSalud). Objetivo: Proveer recomendaciones clínicas basadas en evidencia para la prevención, diagnóstico y tratamiento de infecciones asociadas al acceso de hemodiálisis en EsSalud. Material y Métodos: Se conformó un grupo elaborador de la guía (GEG) que incluyó especialistas y metodólogos. El GEG formuló 7 preguntas clínicas. Se realizó búsquedas sistemáticas de revisiones sistemáticas y estudios primarios en PubMed y CENTRAL de Cochrane entre noviembre del 2019 y marzo del 2020. Se seleccionó la evidencia para responder a las preguntas clínicas planteadas. La certeza de la evidencia fue evaluada usando la metodología Grading of Recommendations Assessment, Development, and Evaluation (GRADE). El GEG usó la metodología GRADE para revisar la evidencia y formular recomendaciones, los puntos de buena práctica clínica y el flujograma de tratamiento. Finalmente, la GPC fue aprobada con Resolución N° 116-IETSI-ESSALUD-2020. Resultados: La presente GPC abordó 7 preguntas clínicas, divididas en tres temas: tamizaje, diagnóstico, estadiaje y tratamiento. En base a estas preguntas se formularon 12 recomendaciones (11 fuertes y 1 condicional), 33 puntos de buena práctica clínica y 2 flujogramas de manejo. Conclusión: El presente artículo resume la metodología y las conclusiones basadas en evidencias de la GPC para la prevención, diagnóstico y tratamiento de infecciones asociadas al acceso de hemodiálisis en EsSalud.

Background: This article summarizes the clinical practice guidelines (CPG) for the prevention, diagnosis and management of infections associated with hemodialysis access of the Peruvian Health Social Security (EsSalud). To provide clinical Objective: recommendations based on evidence for the prevention, diagnosis and management of infections associated with hemodialysis access in EsSalud. Aguideline development Material and Methods:group (GDG) was established, including medical specialists and methodologists. The GDG formulated 7 clinical questions to be answered in this CPG. Systematic searches of systematic reviews and primary studies (when pertinent) were conducted in PubMed, and CENTRAL(Cochrane) from November 2019 to March 2020. The evidence was selected to answer each of the clinical questions. The accuracy of the evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation(GRADE) methodology. In periodic work meetings, the GEG used the GRADE methodology to review the evidence and formulate the recommendations, the points of good clinical practice and the treatment flow chart. Finally, the CPG was approved with Resolution No. 116-IETSI-ESSALUD-2020. The present Results:CPG addressed 7 clinical questions of four topics: prevention, diagnosisandtreatment.Basedonthesequestions,12 recommendations (11strongrecommendationsand1weak recommendation), 33 points of good clinical practice, and 2 flowcharts were formulated. This paper summarizes Conclusion:the methodology and evidence-based conclusions from the CPG for the prevention, diagnosis and management of infections associated with hemodialysis access of EsSalud

Guía de práctica clínica para el diagnóstico y manejo inicial de artritis reumatoide en el Seguro Social del Perú (EsSalud) / Clinical Practice Guideline for the diagnosis and initial management of Rheumatoid Arthritis in the Social Security of Peru (EsSalud)

La Artritis Reumatoide (AR) tiene adversas consecuencias en la salud su diagnóstico temprano y manejo óptimo requiere recomendaciones basadas en evidencia de alta calidad adaptadas a cada sistema de salud. Objetivo: Proveer recomendaciones clínicas basadas en evidencia para el diagnóstico y manejo inicial de la AR. Material y Métodos: Se conformó un grupo elaborador de la guía (GEG) que incluyó médicos especialistas y metodólogos. El GEG formuló 10 preguntas clínicas a ser respondidas por la presente GPC. Se realizaron búsquedas sistemáticas de la evidencia publicada en PubMed y CENTRAL entre diciembre 2017 a julio 2019 (revisiones sistemáticas y ­cuando fue considerado pertinente­ estudios primarios). Se seleccionó la evidencia de mayor calidad para responder cada una de las preguntas clínicas planteadas. La certeza de la evidencia fue evaluada usando la metodología Grading of Recommendations Assessment, Development, and Evaluation (GRADE) y en reuniones de trabajo periódicas, el GEG usó dicha metodología para revisar la evidencia y formular las recomendaciones, los puntos de buena práctica clínica y los flujogramas. Finalmente, la GPC fue aprobada con Resolución N° 132 ­ IETSI ­ ESSALUD ­ 2019. Resultados: La presente GPC abordó 10 preguntas clínicas, divididas en dos temas: diagnóstico y manejo. En base a dichas preguntas se formularon 16 recomendaciones (5 fuertes y 11 condicionales), 45 puntos de buena práctica clínica, y 3 flujogramas. Conclusión: El presente artículo resume la metodología y las conclusiones basadas en evidencias de la GPC para el diagnóstico y manejo inicial de la AR en EsSalud.

Rheumatoid arthritis (RA) has adverse health consequences its early diagnosis and optimal management requires high quality evidence-based recommendations tailored to each health system. Objective: To provide evidence-based clinical recommendations for the diagnosis and initial management of RA. Material and Methods: A guideline development group (GDG) was formed that included medical specialists and methodologists. The GEG formulated 10 clinical questions to be answered by this CPG. Systematic searches of the evidence published in PubMed and CENTRAL were performed between December 2017 and July 2019 (systematic reviews and -when considered relevant- primary studies). The highest quality evidence was selected to answer each of the clinical questions posed. The certainty of the evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology, and in periodic working meetings, the GEG used this methodology to review the evidence and formulate the recommendations, good clinical practice points, and flowcharts. Finally, the CPG was approved by Resolution No. 132 - IETSI - ESSALUD - 2019. Results: This CPG addressed 10 clinical questions, divided into two topics: diagnosis and management. Based on these questions, 16 recommendations (5 strong and 11 conditional), 45 points of good clinical practice, and 3 flowcharts were formulated. Conclusion: This article summarizes the methodology and evidence-based conclusions of the CPG for the diagnosis and initial management of RA in EsSalud.

Guía de práctica clínica para el manejo de cáncer de cuello uterino estadios tempranos / Clinical practice guideline for the management of early-stage cervical cancer

Introducción: Este artículo resume la guía de práctica clínica (GPC) para el manejo de cáncer de cuello uterino estadios tempranos (IA1, IA2, IB1, IB2 o IIA1) en el Seguro Social del Perú (EsSalud). Objetivo: Proveer recomendaciones clínicas basadas en evidencia para el manejo de cáncer de cuello uterino estadios tempranos en EsSalud. Material y métodos: Se conformó un grupo elaborador de la guía (GEG) que incluyó médicos especialistas y metodólogos. El GEG formuló 8 preguntas clínicas a ser respondidas por la presente GPC. Se realizó búsquedas sistemáticas de revisiones sistemáticas y ­cuando fue considerado pertinente­ estudios primarios en Pubmed, Embase y CENTRAL durante el 2017 - 2018. Se seleccionó la evidencia para responder cada una de las preguntas clínicas planteadas. La certeza de la evidencia fue evaluada usando la metodología Grading of Recommendations Assessment, Development, and Evaluation (GRADE). En reuniones de trabajo periódicas, el GEG usó la metodología GRADE para revisar la evidencia y formular las recomendaciones, los puntos de buenas prácticas clínicas y los flujogramas de manejo. Finalmente, la GPC fue aprobada con Resolución N° 27-IETSI-ESSALUD-2020. Resultados: La presente GPC abordó 8 preguntas clínicas abordando el manejo del cáncer de cuello uterino en estadios tempranos. En base a dichas preguntas se formularon 10 recomendaciones (2 recomendaciones fuertes y 8 recomendaciones condicionales), 7 puntos de buena práctica clínica, y 4 flujogramas. Conclusión: El presente artículo resume la metodología y las conclusiones basadas en evidencias de la GPC para el manejo del cáncer de cuello uterino en estadios tempranos en EsSalud.

Introduction: This article summarizes the clinical practice guideline (CPG) for the management of early stage cervical cancer (IA1, IA2, IB1, IB2 or IIA1) in the Social Security of Peru (EsSalud). Objective: To provide evidence-based clinical recommendations for the management of early stage cervical cancer in EsSalud. Material and methods: A guideline development group (GEG) was formed that included medical specialists and methodologists. The GEG formulated 8 clinical questions to be answered by this CPG. Systematic searches of systematic reviews and -when considered relevant- primary studies were performed in Pubmed, Embase and CENTRAL during 2017 - 2018. Evidence was selected to answer each of the clinical questions posed. The certainty of the evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. In periodic working meetings, the GEG used the GRADE methodology to review the evidence and formulate recommendations, good clinical practice points, and management flowcharts. Finally, the CPG was approved by Resolution No. 27-IETSI-ESSALUD-2020. Results: This CPG addressed 8 clinical questions on the management of early stage cervical cancer. Based on these questions, 10 recommendations were formulated (2 strong recommendations and 8 conditional recommendations), 7 points of good clinical practice, and 4 flowcharts. Conclusion: This article summarizes the methodology and evidence-based conclusions of the CPG for the management of early stage cervical cancer in EsSalud.

Vasoactive Agents for the Management of Acute Variceal Bleeding: A Systematic Review and Meta-analysis.

BACKGROUND AND AIMS: Vasoactive agents with endoscopic therapy are used to treat acute variceal bleeding (AVB). There are two main groups of vasoactive agents: terlipressin and vasopressin (T-V), and octreotide and somatostatin (O-S). However, the benefit/harm balance is unclear. Our aim was to assess the efficacy and safety of T-V versus O-S for the management of AVB. METHODS: We performed a systematic search for randomized controlled trials (RCTs) in PubMed, Scopus, and CENTRAL. Our main outcomes were mortality and adverse events. Secondary outcomes were bleeding control, rebleeding, blood transfusion, hospital stay. We evaluated the certainty of evidence using GRADE methodology. RESULTS: We included 21 RCTs. The risk of mortality (RR: 1.01; 95%CI: 0.83-1.22), bleeding control (RR: 0.96; 95%CI: 0.91-1.02; I 2 =53%), early rebleeding (RR: 0.91; 95%CI: 0.66-1.24: I 2 =0%), late rebleeding (RR: 0.94; 95 CI: 0.56-1.60; I 2 =0%), blood transfusion (MD: 0.04; 95%CI: -0.31-0.39; I 2 =68%) and hospital stay (MD: -1.06; 95%CI: -2.80-0.69; I 2 =0%) were similar between T-V and O-S groups. Only 15 studies reported adverse events, which were significantly higher in the T-V compared to the O-S group (RR 2.39; 95%CI: 1.58-3.63; I 2 =57%). The certainty of evidence was moderate for the main outcomes, and low or very low for others. CONCLUSIONS: In cirrhotic patients with AVB, those treated with T-V had similar mortality risk compared to O-S. However, the use of T-V showed an increased risk of adverse events compared to O-S.

[Clinical practice guidelines for the diagnosis and management chronic infection of hepatitis viral C of the Peruvian Health Social Security (EsSalud)]. / Guía de práctica clínica para el diagnóstico y tratamiento de la infección crónica por el virus de hepatitis C en el Seguro Social de Salud del Perú (EsSalud).

INTRODUCTION: This article summarizes the clinical practice guidelines (CPG) for the diagnosis and treatment of chronic infection of hepatitis viral C of the Peruvian Health Social Security (EsSalud). OBJECTIVE: To provide clinical recommendations based on evidence for the diagnosis and treatment of chronic infection of hepatitis viral C in EsSalud. METHODS: A guideline development group (GDG) was established, including medical specialists and methodologists. The GDG formulated 4 clinical questions to be answered in this CPG. Systematic searches of systematic reviews and primary studies (when pertinent) were conducted in PubMed, and Central (Cochrane) during 2019. The evidence was selected to answer each of the clinical questions. The accuracy of the evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. In periodic work meetings, the GEG used the GRADE methodology to review the evidence and formulate the recommendations, the points of good clinical practice and the treatment flowchart. Finally, the CPG was approved with Resolution No. 151-IETSIESSALUD-2019. RESULTS: The present CPG addressed 4 clinical questions of four topics: screening, diagnosis, staging and treatment. Based on these questions, 13 recommendations (8 strong recommendations and 5 weak recommendations), 27 points of good clinical practice, and 1 flowchart were formulated. CONCLUSION: This paper summarizes the methodology and evidencebased conclusions from the CPG for for the diagnosis and treatment of chronic infection of hepatitis viral C of the EsSalud.

Colistina en el tratamiento de infecciones por pseudomonas aeruginosa y acinetobacter baumannii extensivamente resistentes (XDR) en un hospital de tercer nivel / Colistin-based treatment for extensively drug resistant (XDR) Pseudomonas aeruginosa and Acinetobacter baumannii infection at a third level hospital

Resumen Objetivo: Describir la respuesta clínica y mortalidad general de Colistina en infecciones por Pseudomonas XDR y Acinetobacter XDR en el Hospital Nacional Arzobispo Loayza in Lima, Peru. Métodos: Estudio observacional, descriptivo y retrospectivo. Se incluyeron los registros de pacientes > 18 años, desde junio del 2014 a junio del 2016, que tuvieron infección por Pseudomonas XDR o Acinetobacter XDR confirmada por cultivo, y que recibieron colistina. Se realizó análisis univariado de las características generales de los pacientes; un análisis bivariado con test de Chi2 , t-student o ANOVA según corresponda, y además se describió los factores asociados a mortalidad. Resultados. Se incluyeron 56 registros de pacientes, la mediana de la edad fue 46,5 [31,5 a 63,5]. El 48,2% tuvo un cultivo positivo para Pseudomonas XDR y el 51,8% para Acinetobacter XDR. La respuesta clínica favorable fue 85,7% a los 15 días y de 78,6% a los 30 días. La mortalidad intrahospitalaria a los 30 días fue 21,4%, la mortalidad en UCI fue de 30,8% y la nefrotoxicidad fue de 5,4%. Conclusiones. Colistina combinada con otro antimicrobiano tuvo una respuesta clínica favorable en infección por Pseudomonas XDR o Acinetobacter XDR.

Abstract Objective: To describe the clinical response and overall mortality of Colistin in infections by Pseudomonas XDR and Acinetobacter XDR at the Hospital Nacional Arzobispo Loayza in Lima, Peru. Methods: Observational, descriptive, retrospective study. Records of all patients > 18 years old, from June 2014 to June 2016, who had infection by Pseudomonas XDR or Acinetobacter XDR confirmed by culture, and who received colistin, were included. A univariate analysis of the general characteristics of the patients was performed; a bivariate analysis with a Chi2, t-student or ANOVA test as appropriate, and the factors associated with mortality were also determined. Results: 56 patient records were included; the median age was 46,5 [31,5 to 63,5]. The Culture was positive for Pseudomonas XDR in 48,2% and for Acinetobacter XDR in 51,8%. The favorable clinical response was 85,7% at 15 days and 78,6% at 30 days. In-hospital mortality at 30 days was 21,4%, ICU mortality was 30,8% and nephrotoxicity was 5,4%. Conclusions: Colistin combined with another antimicrobial had a favorable clinical response in infection with Pseudomonas XDR and Acinetobacter XDR.

Hypertrophic pachymeningitis in a patient with ANCA negative granulomatosis with polyangiitis: A case report / Paquimeningitis hipertrófica en un paciente con granulomatosis con poliangeítis ANCA negativo: reporte de un caso

ABSTRACT Granulomatosis with polyangiitis (GPA) is a vasculitic disease with an infrequent involvement of the central nervous system. This can lead, in rare cases, to hypertrophic pachymeningitis (HP), which is characterized by inflammation and fibrosis that cause a thickening of dura mater. At present, it is crucial to consider GPA in the differential diagnosis of elderly patients with intracranial hypertension. The case is presented of a 60-year-old male with progressive severe headache, vomiting, and wasting syndrome. Physical examination showed pallor, weight loss, and unilateral papilloedema. A gadolinium-enhanced brain MRI scan showed sinusitis, chronic otomastoiditis, and hypertrophic pachymeningitis. Finally, a meningeal biopsy concluded a necrotising granulomatous vasculitis compatible with GPA. However, PR3- and MPO-ANCA were negative. After corticosteroid therapy was initiated, the patient had a favorable outcome during his hospital stay.

RESUMEN La granulomatosis con poliangeítis (GPA) compromete excepcionalmente el sistema nervioso central, conllevando en raras ocasiones a una paquimeningitis hipertrófica (PH), caracterizada por inflamación y fibrosis, que originan un engrosamiento de la duramadre. Actualmente, su consideración es crucial en el diagnóstico diferencial de pacientes ancianos con hipertensión endocraneana. Presentamos el caso de un adulto de 60 anos con cefalea severa progresiva, vómitos, papiledema unilateral y síndrome consuntivo en donde la resonancia magnética cerebral contrastada con gadolinio muestra sinusitis, otomastoiditis y PH. Finalmente, la biopsia de meninges reveló vasculitis granulomatosa necrosante de pequenos y medianos vasos compatible con GPA. Empero, PR3- y MPO-ANCA resultaron negativos. Se inició terapia con corticoides, presentando una evolución clínica favorable durante su hospitalización.

[Panorama of carbapenemases in PeruUm panorama das carbapenemases presentes no Peru]. / Panorama de las carbapenemasas en Perú.

OBJECTIVE: To describe the genotypes of the carbapenemases reported from microbiological isolates of patients in Peru. METHODS: A systematic search of the biomedical literature about carbapenemases with genotypic confirmation was carried out. It included literature published from 1 January 2000 through 15 September 2019 in the PubMed, SCOPUS, Virtual Health Library, CONCYTEC Virtual Library, and Google Scholar databases, and other sources for the publication of abstracts or posters from national or international meetings. Two reviewers carried out the data selection and extraction. RESULTS: Fourteen studies, which carried out the genotypic characterization of 313 carbapenemases, were included. Of the total 313 reports, 103 analyzed enterobacteria: 74 were of Klebsiella pneumoniae, 11 of Proteus mirabilis, 7 of Enterobacter cloacae, and 11 of other enterobacteria; and 61 corresponded to bla NDM , 39 to bla KPC, and 3 to bla IMP . According to their molecular structure, 64 were metallo-ß-lactamases and 39 were serine-ß-lactamases. Of the total reports, 84 analyzed Pseudomonas aeruginosa: 79 corresponded to bla IMP , 4 to bla VIM , and 1 to bla GES. Of the total reports, 126 analyzed Acinetobacter baumannii: 55 corresponded to bla OXA-23 , 66 to bla OXA-24 , 3 to bla NDM, and 2 to bla OXA-143 . CONCLUSIONS: There is a limited number of publications about carbapenemases among patients in Peru. The genotype reports come primarily from hospitals in the country's capital. This is the first review that aims to identify the types of carbapenemases reported in enterobacteria, P. aeruginosa, and A. baummani.

OBJETIVO: Descrever os genótipos das carbapenemases relatadas a partir de isolados microbiológicos de pacientes no Peru. MÉTODOS: Fizemos uma pesquisa sistemática da literatura biomédica publicada de 1º de janeiro de 2000 a 15 de setembro de 2019 nas bases de dados PubMed, SCOPUS, Biblioteca Virtual de Saúde, Biblioteca Virtual CONCYTEC, Google Scholar e outras fontes de publicações de resumos ou pôsteres em conferências nacionais ou internacionais sobre carbapenemases com confirmação genotípica; a seleção e extração de dados foi feita por pares. RESULTADOS: Incluímos 14 estudos nos quais foi feita a caracterização genotípica de 313 carbapenemases. Ao todo, 103 destes relatos vieram de testes efetuados em enterobactérias; destes, 74 foram em Klebsiella pneumoniae, 11 em Proteus mirabilis, 7 em Enterobacter cloacae e 11 em outros organismos. Destes 103 relatos, 61 correspondem a bla NDM, 39 a bla KPC e 3 a bla IMP. Segundo a estrutura molecular, 64 foram metalo-betalactamases e 39 foram serino-betalactamases. Foram incluídos 84 relatos sobre Pseudomonas aeruginosa, dos quais 79 corresponderam a bla IMP, 4 a bla VIM e 1 a bla GES. Também houve 126 relatos sobre Acinetobacter baumannii, dos quais 55 corresponderam a bla OXA-23, 66 a bla OXA-24, 3 a bla NDM e 2 a bla OXA-143. CONCLUSÕES: Existem poucas publicações sobre carbapenemases em pacientes no Peru; os relatos genotípicos provêm, em sua maioria, de hospitais da capital do país. Esta é a primeira revisão que procura estabelecer os tipos de carbapenemases relatadas em enterobactérias, P. aeruginosa e A. baumannii.

Panorama de las carbapenemasas en Perú

[RESUMEN]. Objetivo. Describir los genotipos de las carbapenemasas reportadas de aislamientos microbiológicos de pacientes en Perú. Métodos. Se realizó una búsqueda sistemática de la literatura biomédica publicada desde el 1 enero de 2000 hasta el 15 de setiembre de 2019 en las bases de datos PubMed, SCOPUS, Biblioteca Virtual de Salud, Biblioteca Virtual de CONCYTEC, Google Scholar y otras fuentes de publicaciones de resúmenes o póster en congresos nacionales o internacionales sobre carbapenemasas con confirmación genotípica; la selección y extracción de datos fue por pares. Resultados. Se incluyeron 14 estudios en los que se realizó la caracterización genotípica de 313 carbapenemasas. Ciento tres de estos reportes pertenecían a estudios efectuados en enterobacterias; de estos, 74 fueron en Klebsiella pneumoniae, 11 en Proteus mirabilis, 7 en Enterobacter cloacae y 11 en otras. Sesenta y una de estas 103 corresponden a blaNDM, 39 a blaKPC y 3 a blaIMP. Según su estructura molecular, 64 son metalobetalactamasas y 39 son serinbetalactamasas. En Pseudomonas aeruginosa se incluyeron 84 reportes, 79 corresponden a blaIMP, 4 a blaVIM, y 1 a blaGES. En Acinetobacter baumannii 126 reportes, 55 corresponden a blaOXA-23, 66 a blaOXA24, 3 a blaNDM y 2 a blaOXA-143. Conclusiones. Existe un número escaso de publicaciones respecto a carbapenemasas de pacientes en Perú; los reportes genotípicos provienen en su mayoría de hospitales de la capital del país. Esta es la primera revisión que intenta conocer los tipos de carbapenemasas reportadas en enterobacterias, P. aeruginosa y A. baumannii.

[ABSTRACT]. Objective. To describe the genotypes of the carbapenemases reported from microbiological isolates of patients in Peru. Methods. A systematic search of the biomedical literature about carbapenemases with genotypic confirmation was carried out. It included literature published from 1 January 2000 through 15 September 2019 in the PubMed, SCOPUS, Virtual Health Library, CONCYTEC Virtual Library, and Google Scholar databases, and other sources for the publication of abstracts or posters from national or international meetings. Two reviewers carried out the data selection and extraction. Results. Fourteen studies, which carried out the genotypic characterization of 313 carbapenemases, were included. Of the total 313 reports, 103 analyzed enterobacteria: 74 were of Klebsiella pneumoniae, 11 of Proteus mirabilis, 7 of Enterobacter cloacae, and 11 of other enterobacteria; and 61 corresponded to blaNDM, 39 to blaKPC, and 3 to blaIMP. According to their molecular structure, 64 were metallo-ß-lactamases and 39 were serine-ß-lactamases. Of the total reports, 84 analyzed Pseudomonas aeruginosa: 79 corresponded to blaIMP, 4 to blaVIM, and 1 to blaGES. Of the total reports, 126 analyzed Acinetobacter baumannii: 55 corresponded to blaOXA-23, 66 to blaOXA-24, 3 to blaNDM, and 2 to blaOXA-143. Conclusions. There is a limited number of publications about carbapenemases among patients in Peru. The genotype reports come primarily from hospitals in the country’s capital. This is the first review that aims to identify the types of carbapenemases reported in enterobacteria, P. aeruginosa, and A. baummani.

[RESUMO]. Objetivo. Descrever os genótipos das carbapenemases relatadas a partir de isolados microbiológicos de pacientes no Peru. Métodos. Fizemos uma pesquisa sistemática da literatura biomédica publicada de 1º de janeiro de 2000 a 15 de setembro de 2019 nas bases de dados PubMed, SCOPUS, Biblioteca Virtual de Saúde, Biblioteca Virtual CONCYTEC, Google Scholar e outras fontes de publicações de resumos ou pôsteres em conferências nacionais ou internacionais sobre carbapenemases com confirmação genotípica; a seleção e extração de dados foi feita por pares. Resultados. Incluímos 14 estudos nos quais foi feita a caracterização genotípica de 313 carbapenemases. Ao todo, 103 destes relatos vieram de testes efetuados em enterobactérias; destes, 74 foram em Klebsiella pneumoniae, 11 em Proteus mirabilis, 7 em Enterobacter cloacae e 11 em outros organismos. Destes 103 relatos, 61 correspondem a blaNDM, 39 a blaKPC e 3 a blaIMP. Segundo a estrutura molecular, 64 foram metalobetalactamases e 39 foram serino-betalactamases. Foram incluídos 84 relatos sobre Pseudomonas aeruginosa, dos quais 79 corresponderam a blaIMP, 4 a blaVIM e 1 a blaGES. Também houve 126 relatos sobre Acinetobacter baumannii, dos quais 55 corresponderam a blaOXA-23, 66 a blaOXA-24, 3 a blaNDM e 2 a blaOXA-143. Conclusões. Existem poucas publicações sobre carbapenemases em pacientes no Peru; os relatos genotípicos provêm, em sua maioria, de hospitais da capital do país. Esta é a primeira revisão que procura estabelecer os tipos de carbapenemases relatadas em enterobactérias, P. aeruginosa e A. baumannii.

Diagnóstico y tratamiento de la etapa aguda del accidente cerebrovascular isquémico: Guía de práctica clínica del Seguro Social del Perú (EsSalud) / Diagnosis and therapy for the acute stage of ischemic cerebrovascular accident: A clinical practice guideline from Peruvian Social Security (EsSalud)

RESUMEN Objetivo: proveer recomendaciones clínicas basadas en evidencia para el diagnóstico y tratamiento de la etapa aguda del ataque cerebrovascular isquémico en EsSalud. Materiales y métodos: se conformó un grupo elaborador de la guía (GEG) que incluyó médicos especialistas y metodólogos. El GEG formuló 8 preguntas clínicas a ser respondidas por la presente GPC. Se realizó búsquedas sistemáticas de revisiones sistemáticas y -cuando fue considerado pertinente- estudios primarios en Medline y Cochrane Controlled Register of Trials durante el 2018. Se seleccionó la evidencia para responder cada una de las preguntas clínicas planteadas. La certeza de la evidencia fue evaluada usando la metodología Grading of Recommendations Assessment, Development, and Evaluation (GRADE). En reuniones de trabajo periódicas, el GEG usó la metodología GRADE para revisar la evidencia y formular las recomendaciones, los puntos de buenas prácticas clínicas y el flujograma de diagnóstico y tratamiento. Finalmente, la GPC fue aprobada con Resolución N° 128-IETSI-ESSALUD-2019. Resultados: la presente GPC abordó 8 preguntas clínicas, divididas en cuatro temas: tamizaje, diagnóstico, tratamiento, soporte y rehabilitación. En base a estas preguntas se formularon 28 recomendaciones (8 fuertes y 20 condicionales), 38 puntos de buena práctica clínica, 1 nota de implementación y 2 flujogramas. Conclusión: el presente artículo resume la metodología y las conclusiones basadas en evidencias de la GPC para el diagnóstico y tratamiento de la etapa aguda del ataque cerebrovascular isquémico en EsSalud.

ABSTRACT Objective: to provide evidence based clinical recommendations for the diagnosis and therapy of the acute stage of ischemic cerebrovascular accident in EsSalud. Materials and methods : a group for producing the guideline was conveyed, including specialized physicians and methodologists. The group prepared 8 clinical questions to be answered by the guideline. Systematic searches of previous reviews were performed, and - when it was deemed necessary - primary studies in Medline and the Cochrane Controlled Registry of Trials for 2018 were reviewed. Evidence was selected aiming to respond each one of the proposed clinical questions. Certainty of the evidence was determined using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. In periodic work sessions, the group used GRADE methodology for reviewing the evidence and generated recommendations, good clinical practice items, and designed flow charts for both diagnosis and therapy. Finally, the guide was approved with the decree N° 128-IETSI-ESSALUD-2019. Results : this clinical practice guideline focused in 8 clinical questions, which were divided into four topics: screening, diagnosis, therapy, support and rehabilitation. On the basis of these questions, 28 recommendations were formulated (8 strong and 20 conditional), 38 items for good clinical practice, 1 implementation note, and 2 flow charts. Conclusion : this paper summarizes both evidence based methodology and conclusions from a new clinical practice guide for diagnosis and therapy of the acute stage of a cerebrovascular accident in EsSalud.

Clinical practice guideline for the evaluation and management of patients with severe aortic stenosis for the Peruvian Social Security.

Introduction: This article summarizes the clinical practice guide (CPG) for the evaluation and management of patients with severe aortic stenosis in the Social Security of Peru (EsSalud). Objective: To provide clinical evidence-based recommendations for the evaluation and management of patients with severe aortic stenosis in the EsSalud. Methods: A local guideline development group (local GDG) was established, including medical specialists and methodologists. The local GDG formulated 7 clinical questions to be answered by this CPG. Systematic searches of systematic reviews and, when it was considered pertinent, primary studies, were conducted in PubMed during 2018. The evidence to answer each of the posed clinical questions was selected. The quality of the evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. In periodic work meetings, the local GDG used the GRADE methodology to review the evidence and formulate the recommendations, points of good clinical practice, and the flowchart of evaluation and management. Finally, the CPG was approved with Resolution N.° 47 - IETSI - ESSALUD - 2018. Results: This CPG addressed 7 clinical questions regarding two issues: the initial evaluation and the management of severe aortic stenosis. Based on these questions, 9 recommendations (1 strong recommendation and 8 weak recommendations), 16 points of good clinical practice, and 1 flowchart were formulated. Conclusion: This article summarizes the methodology and evidence-based conclusions from the CPG for the evaluation and management of patients with severe aortic stenosis in the EsSalud.

Introducción: El presente artículo resume la guía de práctica clínica (GPC) para la evaluación y el tratamiento de pacientes con estenosis aórtica severa en el Seguro Social del Perú (EsSalud). Objetivo: Proveer recomendaciones para la evaluación y el tratamiento de pacientes con estenosis aórtica severa en el EsSalud basadas en evidencia científica. Métodos: Se conformó un grupo elaborador local (GEG-Local) que incluyó médicos especialistas y metodólogos. El GEG-Local formuló siete preguntas clínicas que ser respondidas en la presente GPC. Se realizaron búsquedas sistemáticas de revisiones sistemáticas y, cuando fue considerado pertinente, estudios primarios en PubMed durante el 2018. Se seleccionó la evidencia para responder cada una de las preguntas clínicas planteadas. La calidad de la evidencia fue evaluada usando la metodología Grading of Recommendations Assessment, Development, and Evaluation (GRADE). En reuniones de trabajo periódicas, el GEG-Local usó la metodología GRADE para revisar la evidencia y formular las recomendaciones, los puntos de buenas prácticas clínicas y el flujograma de evaluación y tratamiento. Finalmente, la GPC fue aprobada con Resolución N.° 47 ­ IETSI ­ ESSALUD ­ 2018. Resultados: La presente GPC abordó siete preguntas clínicas, respecto a dos temas: la evaluación inicial y el tratamiento de la estenosis aórtica severa. Con base en dichas preguntas se formularon nueve recomendaciones (una recomendación fuerte y ocho recomendaciones débiles), 16 puntos de buena práctica clínica y un flujograma. Conclusión: El presente artículo resume la metodología y las conclusiones de la GPC para la evaluación y el tratamiento de pacientes con estenosis aórtica severa en el EsSalud.

Clinical practice guideline for the evaluation and management of patients with severe aortic stenosis for the Peruvian Social Security.

Introduction: This article summarizes the clinical practice guide (CPG) for the evaluation and management of patients with severe aortic stenosis in the Social Security of Peru (EsSalud). Objective: To provide clinical evidence-based recommendations for the evaluation and management of patients with severe aortic stenosis in the EsSalud. Methods: A local guideline development group (local GDG) was established, including medical specialists and methodologists. The local GDG formulated 7 clinical questions to be answered by this CPG. Systematic searches of systematic reviews and, when it was considered pertinent, primary studies, were conducted in PubMed during 2018. The evidence to answer each of the posed clinical questions was selected. The quality of the evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. In periodic work meetings, the local GDG used the GRADE methodology to review the evidence and formulate the recommendations, points of good clinical practice, and the flowchart of evaluation and management. Finally, the CPG was approved with Resolution N.° 47 - IETSI - ESSALUD - 2018. Results: This CPG addressed 7 clinical questions regarding two issues: the initial evaluation and the management of severe aortic stenosis. Based on these questions, 9 recommendations (1 strong recommendation and 8 weak recommendations), 16 points of good clinical practice, and 1 flowchart were formulated. Conclusion: This article summarizes the methodology and evidence-based conclusions from the CPG for the evaluation and management of patients with severe aortic stenosis in the EsSalud.

Introducción: El presente artículo resume la guía de práctica clínica (GPC) para la evaluación y el tratamiento de pacientes con estenosis aórtica severa en el Seguro Social del Perú (EsSalud). Objetivo: Proveer recomendaciones para la evaluación y el tratamiento de pacientes con estenosis aórtica severa en el EsSalud basadas en evidencia científica. Métodos: Se conformó un grupo elaborador local (GEG-Local) que incluyó médicos especialistas y metodólogos. El GEG-Local formuló siete preguntas clínicas que ser respondidas en la presente GPC. Se realizaron búsquedas sistemáticas de revisiones sistemáticas y, cuando fue considerado pertinente, estudios primarios en PubMed durante el 2018. Se seleccionó la evidencia para responder cada una de las preguntas clínicas planteadas. La calidad de la evidencia fue evaluada usando la metodología Grading of Recommendations Assessment, Development, and Evaluation (GRADE). En reuniones de trabajo periódicas, el GEG-Local usó la metodología GRADE para revisar la evidencia y formular las recomendaciones, los puntos de buenas prácticas clínicas y el flujograma de evaluación y tratamiento. Finalmente, la GPC fue aprobada con Resolución N.° 47 ­ IETSI ­ ESSALUD ­ 2018. Resultados: La presente GPC abordó siete preguntas clínicas, respecto a dos temas: la evaluación inicial y el tratamiento de la estenosis aórtica severa. Con base en dichas preguntas se formularon nueve recomendaciones (una recomendación fuerte y ocho recomendaciones débiles), 16 puntos de buena práctica clínica y un flujograma. Conclusión: El presente artículo resume la metodología y las conclusiones de la GPC para la evaluación y el tratamiento de pacientes con estenosis aórtica severa en el EsSalud.

Guía de práctica clínica para la evaluación y el tratamiento de pacientes con estenosis aórtica severa en el Seguro Social del Perú / Clinical practice guideline for the evaluation and management of patients with severe aortic stenosis for the Peruvian Social Security

Resumen Introducción: El presente artículo resume la guía de práctica clínica (GPC) para la evaluación y el tratamiento de pacientes con estenosis aórtica severa en el Seguro Social del Perú (EsSalud). Objetivo: Proveer recomendaciones para la evaluación y el tratamiento de pacientes con estenosis aórtica severa en el EsSalud basadas en evidencia científica. Métodos: Se conformó un grupo elaborador local (GEG-Local) que incluyó médicos especialistas y metodólogos. El GEG-Local formuló siete preguntas clínicas que ser respondidas en la presente GPC. Se realizaron búsquedas sistemáticas de revisiones sistemáticas y, cuando fue considerado pertinente, estudios primarios en PubMed durante el 2018. Se seleccionó la evidencia para responder cada una de las preguntas clínicas planteadas. La calidad de la evidencia fue evaluada usando la metodología Grading of Recommendations Assessment, Development, and Evaluation (GRADE). En reuniones de trabajo periódicas, el GEG-Local usó la metodología GRADE para revisar la evidencia y formular las recomendaciones, los puntos de buenas prácticas clínicas y el flujograma de evaluación y tratamiento. Finalmente, la GPC fue aprobada con Resolución N.° 47 — IETSI — ESSALUD — 2018. Resultados: La presente GPC abordó siete preguntas clínicas, respecto a dos temas: la evaluación inicial y el tratamiento de la estenosis aórtica severa. Con base en dichas preguntas se formularon nueve recomendaciones (una recomendación fuerte y ocho recomendaciones débiles), 16 puntos de buena práctica clínica y un flujograma. Conclusión: El presente artículo resume la metodología y las conclusiones de la GPC para la evaluación y el tratamiento de pacientes con estenosis aórtica severa en el EsSalud.

Abstract Introduction: This article summarizes the clinical practice guide (CPG) for the evaluation and management of patients with severe aortic stenosis in the Social Security of Peru (EsSalud). Objective: To provide clinical evidence-based recommendations for the evaluation and management of patients with severe aortic stenosis in the EsSalud. Methods: A local guideline development group (local GDG) was established, including medical specialists and methodologists. The local GDG formulated 7 clinical questions to be answered by this CPG. Systematic searches of systematic reviews and, when it was considered pertinent, primary studies, were conducted in PubMed during 2018. The evidence to answer each of the posed clinical questions was selected. The quality of the evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. In periodic work meetings, the local GDG used the GRADE methodology to review the evidence and formulate the recommendations, points of good clinical practice, and the flowchart of evaluation and management. Finally, the CPG was approved with Resolution N.° 47 — IETSI — ESSALUD — 2018. Results: This CPG addressed 7 clinical questions regarding two issues: the initial evaluation and the management of severe aortic stenosis. Based on these questions, 9 recommendations (1 strong recommendation and 8 weak recommendations), 16 points of good clinical practice, and 1 flowchart were formulated. Conclusion: This article summarizes the methodology and evidence-based conclusions from the CPG for the evaluation and management of patients with severe aortic stenosis in the EsSalud.

Laryngeal Tuberculosis in Pregnant Women: A Case Report and Review of the Literature.

Tuberculosis is the most frequent granulomatous disease but the involvement of the larynx is rare. Immunosuppressed patients have a higher risk of developing this clinical form due to primoinfection or reactivation of latent tuberculosis. It is common to confuse the diagnosis of laryngeal tuberculosis with laryngeal cancer because they have similar macroscopic lesions and both produce dysphonia of chronic evolution. We present the case of a pregnant woman with chronic dysphonia, dysphagia, and odynophagia, diagnosed initially with laryngeal cancer after the first laryngoscopy. However, the patient also presented with fever, productive cough, weight loss, and dyspnea. The sputum sample showed a positive result for acid-fast bacilli (AFB) test; chest X-ray was showed bibasal nodular lesions with a predominance of right hemithorax and reticular opacities in left apex. A new laryngoscopy revealed a mamelonated tumor in the arytenoid cartilage, which led to the initiation of the antituberculous treatment without confirming the diagnosis by biopsy, with clinical improvement and no serious sequelae at the end of treatment. The reason for presenting this case is to consider the possibility of tuberculosis in areas of high endemicity, in patients who have a laryngeal tumor of probable neoplastic etiology, and that a biopsy is not necessary for the diagnosis of laryngeal tuberculosis in cases associated with pulmonary symptomatology.

Tetralogy of Fallot and pheochromocytoma in a situs inversus totalis: An unusual association.

Introduction: Situs inversus totalis is an uncommon anomaly which exist a complete transposition of organs and it's occasionally associated with congenital heart diseases, such as tetralogy of fallot. Pheochromocytoma is a rare neuroendocrine tumor with an annual incidence of 2-8 cases per million people and for years has been studied its relationship with the hypoxic pathway. Case Report: A 29 year old male with a history of tetralogy of fallot corrected at 10 years and situs inversus totalis. He was admitted to hospital with a progressive story of four months of constipation, palpitations, headache, dyspnea and sweating. Physical examination revealed a thinned man with peripheral cyanosis, clubbing and signs of decompensated congestive heart failure as hepatomegaly, legs edema, multifocal systodiastolic murmurs, abdominal distension and jugular venous distention. The echocardiogram shows severe right ventricular dysfunction and severe pulmonary hypertension. Furthermore, abdominal computed tomography shows right adrenal mass. Elevated metanephrines and catecholamines confirmed the diagnosis of pheochromocytoma. Surgical removal is decided and preoperative management begins with alpha-adrenergic blockade, however the patient had a hemodynamic decompensation with an unfavorable evolution. Discussion: In conclusion, there are few reports of cyanotic congenital heart disease with pheochromocytoma. Several studies show a significant association between both of them due to chronic hypoxia leads sustained hyperresponsiveness in adrenal medulla and it would cause the tumor. Special preoperative management of pheochromocytoma is recommended when there underlying heart disease and congestive heart failure. We present the first international report of tetralogy of fallot and pheochromocytoma in a patient with situs inversus totalis.

Claves diagnósticas clínicas y laboratoriales en fiebre de origen desconocido en el Hospital Nacional Arzobispo Loayza 2011 - 2014 / Clinical and laboratory diagnostic features in fever of unknown origin at the National Hospital Arzobispo Loayza 2011 - 2014

Introducción: La Fiebre de Origen Desconocido (FOD) es aún un reto diagnóstico en la práctica clínica. La evaluación de las características clínicas y laboratoriales de los pacientes con FOD podría ayudar a determinar la etiología de la FOD. Objetivo: Determinar las características clínicas y laboratoriales que nos permitan determinar el subgrupo etiológico de los pacientes con FOD, asimismo encontrar la causa más frecuente de FOD y determinar las características epidemiológicas, clínicas y laboratoriales. Metodología: Se logró reunir 60 pacientes, de los cuales en 52 se logró determinar la etiología. De acuerdo a la etiología se les agrupó en FOD infeccioso, inmunológico o neoplásico. Se evaluaron las características clínicas y laboratoriales de los pacientes con FOD clásica que acudieron al Hospital Nacional Arzobispo Loayza durante el periodo 2011 al 2014. Resultados: La etiología infecciosa fue la causa más frecuente de FOD y dentro de este grupo la tuberculosis extrapulmonar, seguida por el FOD inmunológico y por último el FOD neoplásico. En grupo de FOD infeccioso se asoció a un menor nivel de ferritina 275 (SD+/-102) (p<0.0006); en el grupo de FOD inmunológico se asoció a artralgias 78,6 por ciento (p<0.01), artritis 35,7 por ciento (p<0.003), prurito 35,7 por ciento (p<0.014) y a un menor nivel de TGP 56 (SD+/-25) (p<0.049), fosfatasa alcalina 224 (SD+/-102) (p<0.02) y GGTP 73 (SD+/-55) (p<0.049). El subgrupo neoplásico se asoció a un menor nivel de leucocitos 5911 (SD+/-3241) (p<0.001), neutrófilos 4170 (SD+/-2927) (p<0.006), plaquetas 141700 (SD+/-96048) (p<0.001), PCR 6,15 (SD+/-2,97) (p<0.003)y albumina 2,86 (SD+/-0,37) (p<0.008); además se asoció a un mayor nivel de bilirrubina 1,32 (SD+/-0,63) (p<0.008), DHL 1529 (SD+/-2667) (p<0.025) y B2 microglobulina 4,23 (SD+/-2,13) (p<0.01) Conclusiones: La etiología infecciosa fue la causa más frecuente de FOD. Existen datos clínicos y laboratoriales asociados con determinados subgrupos etiológicos de FOD...

Introduction: Fever of unknown origin (FUO) is still a diagnostic challenge in c1inical practice. Evaluation of the clinical and laboratory features of the patients with FUO could help determine the etiology of the FUO. Objective: To determine the c1inical features and laboratory that will allow us to determine the etiologic subgroup of patients with FUO, also found the most common cause of FUO and determine the epidemiological, c1inical and laboratory characteristics. Methodology: I matched 60 patients, of which 52 the etiology was determinate. According to the etiology were grouped in infectious, immunological or neoplastic FUO. We assessed the clinical and laboratory features of patients with c1assical FUO, who were attended in the National Hospital Arzobispo Loayza during the period 2011 to 2014. Results: The infectious etiology was the most frequent cause of FOD and within this group extrapulmonary tuberculosis was the most common, followed by immune FUO and finally the neoplastic FUO. The infectious FUO group was associated with a lower level of ferritin 275 (SD +/-102) (p<0.0006); immune FOD group was associated with arthralgias 78.6 per cent (p<0.01), arthritis 35.7 per cent (p<0.003), pruritus 35.7 per cent (p<0.014) and a lower level of TGP 56 (SD+/-25) (p<0.049), alkaline phosphatase 224 (SD+/-102) (p<0.02) and GGTP 73 (SD+/-55) (p<0.049). Neoplastic subgroup was associated with a lower level of leukocytes 5911 (SD+/-3241) (p<0.001), neutrophils 4170 (SD+/-2927) (p<0.006), platelets 141700 (SD+/-96048) (p<0.001), PCR 6.15 (SD+/-2.97) (p<0.003) and albumin 2.86 (SD+/-0.37) (p<0.008); also associated with a higher level of bilirubin 1.32 (SD+/-0.63) (p<0.008), DHL 1529 (SD+/-2667) (p<0.025) and 82 microglobulin 4.23 (SD+/-2.13) (p<0.01). Conclusions: The infectious etiology was the most frequent cause of FUO. There are c1inical and laboratory data associated with certain etiological subgroups of FOD, which could help a faster diagnosis.

Melanoma maligno cutáneo / Malignant cutaneous melanoma

Se presenta el caso de una mujer que fue sometida a amputación parcial del primer dedo del pie derecho y que 21 meses más tarde notó la aparición de lesiones tumorales en el miembro inferior derecho, en el párpado superior derecho, en la axila derecha y en las mamas. El estudio histológico confirmó que se trataba de metástasis de un melanoma maligno.

This is the case of a female patient that underwent a partial amputation of the first right toe and 21 months later she noted the appearance of tumors in the right lower limb, the right upper eyelid, the right armpit and both breasts. The histological study of the lumps confirmed that they were metastasis of a cutaneous malignant melanoma.