ACTA MEDICA PERUANA Acta Médica Peruana es la revista científica oficial del Colegio Médico del Perú; tiene como finalidad difundir el conocimiento médico a la comunidad médica y científica a nivel nacional e internacional. Colegio Médico del Perú en-US ACTA MEDICA PERUANA 1018-8800 The covid-19 pandemic and its impact on public health in Peru Manuel Castro Baca Arturo Villena Pacheco Copyright (c) 2021 ACTA MEDICA PERUANA 2021-10-24 2021-10-24 38 3 10.35663/amp.2021.383.2227 Mortality with hydroxichloroquine and azythromycin use in COVID-19 patients undergoing mechanical ventilation in an intensive care unit in Lima <p><strong><em>Objective:</em></strong> To estimate mortality rates associated with hydroxichloroquine and azithromycin use in Covid-19 patients undergoing mechanical ventilation in an intensive care unit in Lima. <strong><em>Material and methods: </em></strong>This is a retrospective analytical cohort. One hundred and five patients with Covid-19 undergoing invasive mechanical ventilation who were admitted with a diagnosis of acute respiratory insufficiency to the intensive care unit of Cayetano Heredia Hospital in Lima during 2020. <strong><em>Results: </em></strong>The overall mortality rate was 38%. Most patients (79%) were male, their mean age was 50 ± 13 years, two thirds (65%) did not have comorbidities; APACHE II and SOFA scores were 12 ± 6 points and 5 ± 3 points, respectively. Thirty percent of all patients received hydroxichloroquine, 32% received azithromycin, and 32% received both drugs. Mortality was significantly higher in those patients who received hydroxichloroquine (p= 0.001), azithromycin (p= 0.03), and the <br>combination of hydroxichloroquine and azithromycin (p= 0.001). However, when a Cox regression analysis was performed, it was evidenced that deceased patients were more likely to have been exposed to hydroxichloroquine (p= 0.001) (HR: 21, CI: 3.4-131.3), but this was not the case with azithromycin (p= 0.22) (HR: 0.43, CI: 0.11-1.6). <strong><em>Conclusion:</em></strong> Mortality in Covid-19 patients undergoing invasive mechanical ventilation was higher in those who received hydroxichloroquine.</p> Diana Fernández Merjildo Lady Lévano Díaz Jaime Zegarra Piérola Copyright (c) 2021 ACTA MEDICA PERUANA 2021-10-24 2021-10-24 38 3 10.35663/amp.2021.383.2165 National Medicine Exam: an Analysis of the last decade of theoretical exams in peruvian last year medical students <p><strong>Objectives:</strong> To assess grades from the National Medical Exam (ENAM, according to its Spanish initials) that serve to last year medical students as a prerequisite to apply for places in Peruvian Medical Rural Service (SERUMS, according to its Spanish initials) between 2009 and 2019.</p> <p><strong>Materials and Methods:</strong> This is an analytical retrospective study where a secondary analysis of registries for applying to the Peruvian Medical Rural Service (SERUMS) between years 2009 and 2019. Number of applicants to SERUMS places were determined, together with median values of ENAM results. Each of these pieces of information were presented according to different characteristics. Bivariate and multivariate models were used for obtaining prevalence rates.</p> <p><strong>Results</strong>: More than thirty thousand students were assessed (30750), and 9087, 17607, and 4056 were <br>from public, private, and foreign medical schools, respectively. Forty-three percent of those who registered tor applying the SERUMS failed the exam. Percentages of those who failed were 31%, 34%, and 79% of those coming from public, private, and foreign medical schools, respectively. Multivariate analyses showed that those who most frequently failed came from private medical schools (odds ratio [OR]: 1.42; 95% CI: 1.37–1.47, p&lt;0.001), those who studied medicine in a Lima City medical school (OR: 1.18; 95% CI: 1.14 – 1.22, p&lt;0.001), and those who studied outside Peru.&nbsp;</p> <p><strong>Conclusions</strong>: There is a greater number of physicians doing rural service (SERUMS), but many of them fail the examination (ENAM), particularly those coming from private medical schools in Lima City and those who come from foreign medical schools. These results suggest that a great proportion of physicians applying for the rural service are not adequately qualified, at least in the theoretical areas which are measured by the ENAM.</p> Giuston Mendoza Chuctaya Milagros Calla Torres Kevin Ramos Chuctaya Christian Mejía Álvarez Copyright (c) 2021 ACTA MEDICA PERUANA 2021-10-24 2021-10-24 38 3 10.35663/amp.2021.383.2164 Association between mental health and attitudes towards confinement during the COVID-19 pandemic in hospitals in Lima and Callao <p><strong>Objective:</strong> Identify the association between depression, anxiety and stress with attitudes towards confinement during the COVID-19 pandemic in health staff from the Daniel Alcides Carrion National Hospital and Central Military Hospital by using the DASS-21 scale. <strong>Materials and methods:</strong> Cross-sectional, observational and analytical study, health staff participated who worked in COVID areas during the Covid-19 pandemic. The Dass-21 scale was used to measure the existence of emotional states of depression, anxiety and stress, and the scale of attitudes adapted to confinement for Covid-19. Results: 124 participants were included, 54% female (n=67), with a median age of 34.5 years [Ri]= 16.5, who reported a median year of experience of 6 (Ri = 17). The median Dass-21 score for anxiety was 2 (Ri = 5), the median Dass-21 score for depression was 1 (Ri = 4.5), and the median Dass-21 scale score for stress was 4 (Ri = 5). The bivariate analysis between the values of the Dass-21 Scale domains and the other covariates identified that the level of education had a highly significant relationship with the depression subscale, anxiety and stress. <strong>Conclusion:</strong> An association was found between the affective parameters of the scale on attitudes towards confinement and the three subscales of DASS-21.</p> Iris Campos-De La Cruz María C. Burneo-Ramírez Fernando M. Runzer-Colmenares Copyright (c) 2021 ACTA MEDICA PERUANA 2021-10-24 2021-10-24 38 3 10.35663/amp.2021.383.2025 Clinical and demographic characteristics of an adult population with neuroendocrine tumors <p><strong>Introduction: </strong>Neuroendocrine tumors represent a group of low-incidence neoplasms derived from neuroendocrine cells distributed throughout the body, especially the respiratory and gastrointestinal systems.</p> <p><strong>Objective:</strong> To determine the clinical and sociodemographic characteristics of an adult population with neuroendocrine tumors.</p> <p><strong>Materials and methods:</strong> In a descriptive cross-sectional study, 91 medical records with a diagnosis of neuroendocrine tumors confirmed by pathology were evaluated between the years 2013 and 2020. Analysis carried out in Microsoft Excel 2013 and Epi Info 7.2.</p> <p><strong>Results:</strong> The mean age was 61 years, with a predominance in men (57%). The main antecedents were smoking (35%), arterial hypertension (22%), and COPD (9%). The main symptoms were abdominal pain (43%), weight loss (31%), and cough (26%).</p> <p>According to the origin, those of the foregut were more frequent (75%), predominantly those of the respiratory tract (39.5%). In 21.9%, the origin was unknown.</p> <p>Taking into account 2019 WHO classification, neuroendocrine carcinomas predominated (56%), of which the most frequent was small cell carcinoma. Among the well-differentiated (44%), low-grade (58%) followed by intermediate grade (24%) and low-grade (17%).</p> <p>Metastases were registered in 37% of the cases with mainly liver involvement (49%), lymph nodes (21%), and central nervous system (9%).</p> <p>Death occurred in 24% of cases.</p> <p><strong>Conclusions:</strong> The results of the present study coincide with those reported worldwide, highlighting the predominance of tumors of pulmonary origin, as well as similar clinical symptoms according to the affected organs</p> Carlos Mauricio Martínez Montalvo Deiner Yivelson Muñoz Delgado Yeison Rodolfo Gómez Ledesma Manuel Antonio Pérez Hetting María Daniela Vargas Calderón Silvia Gabriela Ordoñez Muñoz Alejandro Pinzón Tovar Héctor Conrado Jiménez Sánchez Copyright (c) 2021 ACTA MEDICA PERUANA 2021-10-24 2021-10-24 38 3 10.35663/amp.2021.383.2058 Oxygen saturation in patients during hemodialysis at different altitudes <p><strong>Introduction</strong></p> <p>Patients undergoing hemodialysis may develop hypoxemia during the procedure, and hypoxemia may become more intense if hemodialysis is performed in a high altitude environment.</p> <p><strong>Objectives</strong></p> <p>To assess variations in oxygen saturation in patients undergoing hemodialysis at different altitude levels.</p> <p><strong>Material and methods</strong></p> <p>This is a prospective case series, where patients from hemodialysis programs in three cities were assessed. These places were at 101-, 2335-, and 3825- meters above sea level. Patients had their oxygen saturation measured in a semi-sitting position with a pulse oxymeter device. Measurements were taken before, during, and at the end of hemodialysis sessions.</p> <p><strong>Results</strong></p> <p>Sixty-five patients undergoing hemodialysis were included. They were from three cities at different altitude above sea level. Oxygen saturation significantly decreased as long as altitude increased (97,32 ± 1,10 vs. 94,75 ± 2,17 vs. 84,85 ± 5,86 p= 0,00). Oxygen saturation showed changes before, during, and at the end of hemodialysis procedures at different altitude. Ferritin levels were lower in high altitude patients compared with those at sea level and at moderate altitude (131,75 [106,04 – 157,45] vs. 493,38 [273,19 – 713,56] vs. 550,66 [329,75-771,57] p=0,01). Hemoglobin values were lower in patients from middle altitude levels (10,8 [10,12-11,47] vs 11,32 [10,79-11,85] vs 11,84 [11,54-12,14] p=0,03)</p> <p><strong>Conclusions</strong></p> <p>In patients undergoing chronic hemodialysis oxygen saturation is reduced as long as altitude increases, and significant variations were found during hemodialysis procedures.</p> Karina Janet Rosales Mendoza Jose Gonzalez-Polar Romina Sumen Christian Vizcarra Vizcarra Abdias Hurtado-Aréstegui Copyright (c) 2021 ACTA MEDICA PERUANA 2021-10-24 2021-10-24 38 3 10.35663/amp.2021.383.2146 Decompressive craniectomy as primary therapy for cranial hypertension due to head trauma: Observational experience in 24 patients <p><strong>Introduction:</strong> Head trauma is one of the main causes of death in Peru. Medical and surgical therapy during the initial stages of severe head trauma focus in preventing the elevation of intracranial pressure. <strong>Objective:</strong> To describe the associated characteristics and main complications in patients undergoing decompressive craniectomy. <strong>Methods:</strong> This is a retrospective observational study performed between February 2018 and July 2020 in patients who had been admitted because of head trauma and who had undergone unilateral decompressive craniectomy. <strong>Results:</strong> Two-thirds (66.7%) of patients were persons less than 40 years of age; 87.5% were males; 16.7% were admitted with Glasgow Coma Score (GCS) scores between 13 and 15; 37.5% were admitted with GCS between 9 and 12; 42.9% had asymmetric pupils; 33.3% were admitted because of traffic accidents; 21.7% were Marshall II, 65.2% were Marshall III, and 13.0% were Marshall IV. <strong>Conclusions:</strong> Our results suggest that characteristics associated to decompressive craniectomy because of head trauma contribute for its proper management.</p> José Luis León Palacios Abel Paul Carranza-Vásquez Wesley Alaba-García Rolando Lovatón Copyright (c) 2021 ACTA MEDICA PERUANA 2021-10-24 2021-10-24 38 3 10.35663/amp.2021.383.2085 Head injury because of free fall in neonates <p><strong>Objective</strong>: To describe clinical characteristics of head trauma in neonates. <strong>Material and methods:</strong> This is a case series of neonate patients with head trauma. All of them had a clinical diagnosis and computed tomography scans performed. They were taken care of in both Neuropediatrics and Neonatology services in Cayetano Heredia National Hospital in Lima, Peru from 2014 to 2019. <strong>Results: </strong>Twelve neonates were included, 67% (8/12) were male, 33% (4/12) were less than four days old, and 25% (3/12) were born to mature mothers. Free fall was the mechanism of lesion for all cases, and three of them fell down from baby trolleys. Places where these accidents occurred were at the hospital. Three neonates were in joint housing, two were in the waiting room of the outpatient clinic, and one fall occurred in the hospitalization ward. Eightythree per cent (10/12) of all cases fell from ≥0.5- m height, and 33% (4/12) fell from 1- m height. Fifty-eight per cent (7/12) developed symptoms after the fall, four had lethargy and one had irritability. Also, vomits and respiratory distress were reported. Four neonates developed epidural hematoma and three had cranial fracture, two of these latter cases were severe because of decompensated cranial hypertension that required emergency surgical decompression.&nbsp;<strong>Conclusion:</strong> Head trauma in neonates is a potentially severe condition. Epidural hematoma was the most frequent intracranial lesion. Lethargy and irritability were most frequent symptoms in neonates who fell from ≥0.5- m height.</p> <p>&nbsp;</p> Carol Giselle Munayco Cortez Daniel Guillén-Pinto Copyright (c) 2021 ACTA MEDICA PERUANA 2021-10-24 2021-10-24 38 3 10.35663/amp.2021.383.2078 Acute abdomen by chylous ascites secundary to acute pancreatitis: a case report <p>Chylous ascites (CA) is a rare condition, and it can present as a peritoneal reaction named acute chylous peritonitis (ACP). We report the case of a 26-year old male who developed acute abdomen. He underwent surgery and turbid milky fluid was found in his abdominal cavity. A prophylactic appendectomy was performed, as well as aspiration and lavage of the abdominal cavity. Drainage tubes were placed. Studies of the fluid revealed increased triglyceride and amylase contents. Gram-staining and cultures were negative. A computed tomography scan revealed acute pancreatitis (Balthazar C), so a diagnosis of chylous ascites secondary to pancreatitis was confirmed. The patient did well, he received hydration, analgesics, and oral diet according to tolerance. Very few cases of ACP have been reported in the literature, and its association with acute pancreatitis is very unusual. This condition may resemble surgical acute abdomen, and its management includes surgical exploration with peritoneal drainage. Nutritional support may also be needed.</p> Angel F. Vera-Portilla Raul Arenas Ramirez Pedro Quispe Ala Walter Alberto Vera Portilla Jose Luis Galdos Macedo Darling Dudley Cornejo Valencia Copyright (c) 2021 ACTA MEDICA PERUANA 2021-10-24 2021-10-24 38 3 10.35663/amp.2021.383.2074 Hepatic abscess by xanthogranulomatous cholecystitis and vesicular adenomyomatosis: a case report. <p>Xanthogranulomatous cholecystitis (CXG) and Adenomyomatosis (VA) are rare, with few reports in our setting. The preoperative and intraoperative differentiation is difficult because it presents radiological and macroscopic characteristics, similar to cancer. It often presents as acute cholecystitis. And the diagnosis is established by the presence of fibrosis, foamy histiocytes, and Rokitansky-Aschoff sinuses, respectively. We present the case of a woman who came in for abdominal pain, nausea and vomiting. The tomography revealed a subcapsular liver collection. Surgery was performed and a hepatic abscess blocked by the omentum was evidenced, with multiple adhesions; and thickened-walled vesicle perforated in bacinete. Patient receives antibiotic therapy, progresses well, and histopathology concludes CXG and VA. CXG and VA are rare diseases associated with cholelithiasis. In our case, its association, and its complication with liver abscess, make it particularly exceptional. Requiring both surgery and histopathology to confirm them.</p> Angel F. Vera-Portilla Malory Jamille Minaya Ruiz Walter Alberto Vera Portilla Jose Luis Galdos Macedo Copyright (c) 2021 ACTA MEDICA PERUANA 2021-10-24 2021-10-24 38 3 10.35663/amp.2021.383.2075 Cranial base chondrosarcoma: Clinicopathological analysis of a case <p><strong>Introduction:</strong>Chondrosarcoma is an unusual malignant neoplasm; cranial location is rare. Sometimes its complete resection is not possible because of vicinity of the mass to important vascular and neural structures.</p> <p><strong>Clinical case: </strong>This is a 56-year old female subject who developed headache in the right side, paresthesia in the right side of her upper lip, short term memory loss, and ageusia. A magnetic resonance imaging study showed an enhanced extra-axial mass. This patient underwent complete surgical resection. The anatomopathological study showed a well differentiated chondrosarcoma of the cranial base.</p> <p><strong>Conclusion: </strong> Chondrosarcoma is a malignancy with pure differentiation of the hyaline cartilage. It represents 0.15% of all intracranial tumors, and this is the second case with a cranial base location reported in Peru. Both histological characteristics and immunohistochemistry markers revealed the classic characteristics of this tumor. Therapy is given on an individualized basis.</p> Jose Romero Yauri Alejandro Esteban Castillo Gutierrez Ana Lucia Castillo Soto Copyright (c) 2021 ACTA MEDICA PERUANA 2021-10-24 2021-10-24 38 3 10.35663/amp.2021.383.2145 The regulating role of the peruvian government in authorizations for performing clinical trials. A qualitative study <p><strong>Objectives:</strong> To explain the role of the Peruvian Government related to participation of different stakeholders influencing regulations for authorizing clinical trials (CT). <strong>Methodology:</strong> We present part of a case study corresponding to a PhD thesis performed between 2015 and 2017. We used document information and 14 semi-structured interviews with key informants were performed. We also systematized experiences related to clinical trial authorization and inspection, as well as verification of investigation sites. We also had access to publicly available information from the Peruvian National Institute of Health. The analysis was performed within epistemological and hermeneutical frameworks, and it was approved by the Ethics Committee from San Fernando Public Medicine School. <strong>Results:</strong> Issues identified were as follows: Delay in regulatory times authorized for CTs; suspension of authorizations for performing CTs in children, which led to progressive reduction in requests and consequently to a reduction in CTs from 2009 on. <strong>Conclusions:</strong> According to this study, regulations by Peruvian authorities have weakened, since participants and some stakeholders are not able to exert their rights, particularly with respect to competence generation for researchers when trying to develop CTs.</p> Hernán A. Sanabria Rojas Copyright (c) 2021 ACTA MEDICA PERUANA 2021-10-24 2021-10-24 38 3 10.35663/amp.2021.383.2094 Duration of untreated psychosis: first steps towards the adoption of early intervention programs of psychosis in Peru Ruben Valle Copyright (c) 2021 ACTA MEDICA PERUANA 2021-10-24 2021-10-24 38 3 10.35663/amp.2021.383.2168