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Introducción: el reto de líquidos es una prueba que consiste en administrarlos y medir la respuesta hemodinámica mediante el cambio del gasto cardíaco (GC), aunque solo medir el GC resulta insuficiente. El acople ventrículo-arterial (AVA) (elastancia arterial efectiva/ elastancia telesistólica: Eae/Ets) aparece como una variable que evalúa el estado cardiocirculatorio en forma integral. Objetivo: evaluar el AVA en un biomodelo de choque endotóxico y durante retos de líquidos. Materiales y métodos: biomodelo de choque endotóxico (9 porcinos). Se midieron variables hemodinámicas cada hora desde un tiempo 0 (T0) hasta T6. Se realizaron 5 retos de líquidos entre T0 y T4. El tiempo de hipotensión se denominó TH0. Se calcularon diferencias de medianas de variables entre T0-T4. Se clasificaron los retos en dos grupos según el delta del AVA (AVA posreto-AVA prerreto), en ΔAVA≤0 o >0, se midieron variables antes y después de cada reto. Se determinó la relación lactato/piruvato (L/P) en T0, T3 y T6, se establecieron correlaciones entre la diferencia LP T6-T0 y de variables hemodinámicas. Resultados: el AVA aumentó (1.58 a 2,02, p=0.042) por incremento en la Eae (1.74 a 2,55; p=0.017). El grupo ΔAVA≤0 elevó el GC (4.32 a 5,46, p=0.032) y el poder cardíaco (PC) (0.61 a 0,77, p=0,028). El Δ L/P se correlacionó con el Δ del índice de choque sistólico y diastólico (r=0.73), pero no con el del AVA. Conclusión: durante el choque endotóxico el AVA aumentó de manera significativa. Durante el reto de líquidos el grupo Δ AVA≤0, elevó el GC y PC. El Δ L/P no se correlacionó con variables del AVA.

Introduction: fluid challenges (FCs) consist of measuring hemodynamic response through changes in cardiac output (CO) after fluid administration, although only measuring CO proves insufficient. Ventriculo-arterial coupling (V-A) (effective arterial elastance / tele-systolic elastance: E(a)/Ets) are variables used for a comprehensive cardiac and circulatory status appraisal. Objective: to evaluate V-A in an endotoxic shock bio-model by FCs. Materials and methods: an endotoxic shock bio-model (9 pigs). Hemodynamic variables were measured every hour from time 0 (T0) to T6. Five FCs were performed between T0 and T4. Hypotension time was referred to as HT. The median differences in variables between T0-T4 were calculated. Challenges were classified into two groups according to V-A delta (post-challenge V-A - pre-challenge V-A). In ΔV-A≤0 o>0, variables were measured before and after each FC. The lactate to pyruvate (L/P) ratio was determined at T0, T3 and T6. Correlations between the LP T6-T0 difference and hemodynamic variables, were established. Results: V-A increased (1.58 to 2,02, p=0.042) as Eae increased (1.74 to 2.55; p=0.017). CO (4.32 to 5.46, p=0.032) and cardiac power (CP) (0.61 to 0.77, p=0,028) increased, in the ΔV-AC≤0 group. The ΔLP correlated with the systolic and diastolic shock index (r=0.73), but not with V-A. Conclusion: V-A increased significantly during endotoxic shock. The ΔAVA≤0 group, showed elevated CO and CP during FC. ΔLP did not correlate with any of the V-A variables.

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Resumen OBJETIVO: Describir y comparar las características obstétricas de pacientes puérperas, con anemia, con finalización del embarazo por parto o cesárea. MATERIALES Y METODOS: Estudio retrospectivo, observacional, descriptivo y comparativo de pacientes con anemia en el puerperio de parto y de cesárea atendidas en el Hospital de Lircay de Huancavelica en el año 2020. Se aplicó la técnica del análisis documental y el instrumento fue una ficha de recolección de datos. RESULTADOS: Se analizaron 162 partos y 46 cesáreas. En las características patológicas se encontró una diferencia significativa: anemia en el embarazo (112 de 162; 69.1% posparto y 23 de 46 [50% de poscesárea]), trastornos hipertensivos (4 de 162; 2.5% postparto y 8 de 46 [7.4% de poscesárea]), hemorragias de la segunda mitad del embarazo (2 de 162 [1.2% de postparto] y 4 de 46 [8.7% poscesárea]). En cuanto al grado de anemia se encontró diferencia significativa en ambos grupos en relación con el grado moderado (89 de 162 [54.9%] postparto y 33 de 46 [71.7%] en poscesárea). CONCLUSIONES: En la frecuencia de anemia puerperal se encontró una diferencia conforme al tipo de finalización del embarazo. La edad, grado de escolaridad, anemia gestacional, trastorno hipertensivo, hemorragia de la segunda mitad de embarazo y la placenta previa se identificaron como factores con diferencias significativas en la anemia, según el tipo de finalización del embarazo.

Abstract OBJECTIVE: To describe and compare the obstetric characteristics of postpartum patients with anemia, with termination of pregnancy by delivery or cesarean section. MATERIALS AND METHODS: Retrospective, observational, descriptive and comparative study of patients with anemia in the postpartum period after childbirth and cesarean section attended at the Lircay Hospital in Huancavelica in 2020. The documentary analysis technique was applied and the instrument was a data collection form. RESULTS: A total of 162 deliveries and 46 cesarean sections were analyzed. In the pathological characteristics a significant difference was found: anemia in pregnancy (112 of 162; 69.1% postpartum and 23 of 46 [50% post cesarean]), hypertensive disorders (4 of 162; 2.5% postpartum and 8 of 46 [7.4% post cesarean]), hemorrhages in the second half of pregnancy (2 of 162 [1.2% postpartum] and 4 of 46 [8.7% post cesarean]). Regarding the degree of anemia, a significant difference was found in both groups in relation to moderate degree (89 of 162 [54.9%] postpartum and 33 of 46 [71.7%] postcesarean section). CONCLUSIONS: In the frequency of puerperal anemia, a difference was found according to the type of termination of pregnancy. Age, level of education, gestational anemia, hypertensive disorder, hemorrhage in the second half of pregnancy and placenta previa were identified as factors with significant differences in anemia, according to the type of termination of pregnancy.

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Introduction: Mixed histology tumours are rarely found in the stomach. Of these, collision tumours are mainly composed of adenocarcinomas and sarcomas or lymphomas. This is the seventh case reported in the literature of an acinar cell carcinoma arising from an ectopic pancreas located in the stomach and the first described within a collision tumour. Clinical case: We present the case of a 58-year-old female patient diagnosed with gastric cancer who, after undergoing a total gastrectomy, presented with a pathology report describing findings compatible with gastric collision tumour with components of tubular adenocarcinoma and acinar cell carcinoma of probable pancreatic ectopic aetiology. Discussion: At the beginning of the 20th century, collision tumours were rarely described. Those located in the stomach are an infrequent pathology and are rarely diagnosed preoperatively. A collision tumour is composed of two independent neoplastic tissue with tumour areas separated in two different histological patterns and, in case of metastasis, this separation must also be clearly identified. There are different theories about its carcinogenesis and the debate regarding the ideal treatment is still ongoing. Conclusion: This is the first report of a malignant gastric tumour with probable heterotopic pancreatic origin that collides with gastric adenocarcinoma.

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Merkel cell carcinoma (MCC) is a rare neoplasm of unknown multifactorial origin first described in 1972. It occurs most often in older Caucasian males and is typically associated with sun-exposed areas of skin. However, cases have also been reported in other areas, such as the trunk and the gluteal region. Metastatic disease will occur in up to one-third of cases at onset or during the course of the disease, including metastases to the abdominal organs. We present the case of a 53-year-old male with a history of primary MCC of the right buttock and local resection surgery. Eighteen months later, he presented with a small bowel obstruction and had an emergency segmental bowel resection. Pathology examination with immunohistochemistry concluded that findings were consistent with metastatic MCC.

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Objetivos: determinar y comparar la percepción del ambiente educacional de los internos de medicina de hospitales públicos y clínicas privadas del Perú. Métodos: se llevó a cabo un estudio Observacional de corte transversal, mediante el cuestionario PHEEM el cual fue respondido por 101 estudiantes que realizaban su internado en clínicas y hospitales del Perú; el muestreo fue no probabilístico y por conveniencia debido a la facilidad de acceso a dichas sedes. Los datos fueron analizados en el programa SPSS versión 23, se realizó un análisis descriptivo y otro comparativo a través de la prueba de T student tanto en los puntajes globales cómo en cada una de las dimensiones del cuestionario. Resultados: la media global de las puntuaciones del ambiente educacional medico fue de 83,16 (DS 25,4) indicando un ambiente más positivo que negativo. Al comparar las medias entre los internos de los hospitales y los de las clínicas, el ambiente fue mejor percibido por los estudiantes que realizaban su internado en las clínicas privadas tanto en puntaje global, como en todas las dimensiones p valor <0,05 indicando diferencia estadísticamente significativa. La dimensión más preocupante fue la enseñanza donde se observó la mayor diferencia entre estos dos sectores. Conclusiones: existe una percepción negativa en los internos de hospitales comparados a los internos de clínicas. Se deberían realizar estrategias de intervención de mejoría en los internos de hospitales para cada una de las dimensiones del ambiente educacional, en especial en la enseñanza.

Objectives: to determine and compare the perception of the educational environment of medical interns in public hospitals and private clinics in Peru. Methods: a cross-sectional observational study was carried out using the PHEEM questionnaire, which was answered by 101 students who were doing their internship in clinics and hospitals in Peru. The sampling was non-probabilistic and convenient due to the ease of access to these sites. The data were analyzed in the SPSS version 23 program, a descriptive analysis and a comparative one were carried out using the t-student t test both in the overall scores and in each of the dimensions of the questionnaire. Results: the overall mean score of the medical educational environment was 83.16 (SD 25.4), indicating a more positive than negative environment. When comparing the means between interns in hospitals and those in clinics, the environment was better perceived by students doing their internship in private clinics in both the overall score and in all dimensions, p value <0.05 indicating a statistically significant difference. The most concerning dimension was teaching, where the greatest difference between these two sectors was observed. Conclusions: there is a negative perception among interns in hospitals compared to interns in clinics. Intervention strategies to improve the educational environment in interns in hospitals should be implemented in all dimensions, especially in teaching.

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RESUMEN Objetivo : Describir y analizar la seguridad de la aplicación del programa de "Recuperación Mejorada Después de Cirugía" (ERAS) para cirugía electiva por cáncer colorrectal. Materiales y Métodos : Estudio observacional retrospectivo de 272 pacientes con cáncer colorrectal operados con cirugía electiva entre enero 2019 y setiembre 2020 en el Instituto Nacional de Enfermedades Neoplásicas, Perú. Se utilizó la Prueba U de Mann-Whitney, Chi-cuadrado de Pearson, y odds ratios (OR) para el análisis estadístico. Resultados : 90 pacientes ingresaron al programa ERAS con una mediana de estancia hospitalaria postoperatoria de 3 días (rango 3-19). La cirugía laparoscópica se realizó en el 53 % de los casos, con una estancia hospitalaria significativamente menor que los pacientes con cirugía convencional (p=0,035). El inicio de la tolerancia oral < 24 horas se realizó en el 91 % de casos y la deambulación temprana en 89 %. La incidencia de complicaciones postoperatorias fue de 29 %, mayor en los pacientes con resección de recto/ano que en el grupo con resección de colon (40 % vs 20 %, p=0,043) (OR=2,67, IC del 95 %: 1,02 - 7,01). Ocho pacientes presentaron complicación mayor, 4 con dehiscencia de anastomosis y 4 requirieron readmisión hospitalaria. Conclusiones : El manejo según ERAS para cirugía electiva por cáncer colorrectal es seguro y factible con un riesgo de morbimortalidad perioperatoria aceptable.

ABSTRACT Aim : Describe and analyze the safety of the "Enhanced Recovery After Surgery" (ERAS) protocol in elective procedures for colorectal cancer. Materials and Methods : Observational study of 272 patients with colorectal cancer who underwent elective surgery from January 2019 to September 2020 at the "Instituto Nacional de Enfermedades Neoplásicas", Peru, were retrospectively collected. U Mann-Whitney test, Pearson chi-square test and odds ratios (OR) were used for statistical analysis. Results : 90 patients were included in the ERAS program with a median postoperative hospital stay of 3 days (range 3-19). Laparoscopic surgery was performed in 53% of the patients with significantly shorter postoperative hospital stay in comparison with the patients who had open surgery (p=0,035). Oral food intake less than 24 hours postoperatively was 91%, and early mobilization in 89% of the cases. The postoperative complication rate was 29%, higher in rectal/anus resection than in colonic resections (40% vs 20%, p=0,043) (OR=2,67, CI 95%: 1,02 - 7,01). Eight patients had a major postoperative complication, four with anastomotic leakage and four required hospital readmission. Conclusions : The perioperative management of ERAS program for colorectal cancer in elective surgery is safe and feasible with acceptable morbimortality risk.

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Introducción: Según el estado de la nación 2018, Costa Rica es el tercer país latinoamericano con mayor densidad vehicular; es solo superado por Argentina y México. Objetivo: Identificar los factores asociados al nivel de estrés por el congestionamiento en el traslado a la universidad en los estudiantes y los factores asociados a la presencia o ausencia de estrés por el congestionamiento en el traslado a la universidad. Métodos: Estudio observacional, analítico de corte transversal, donde participaron 420 estudiantes, quienes completaron las encuestas correspondientes, para evaluar el nivel de estrés que genera el congestionamiento vial en dicha población. Las variables asociadas a la presencia o ausencia de estrés fueron edad, rendimiento, traslado de casa a la universidad por la mañana, de casa a la universidad por la tarde, de casa a la universidad por la noche, carro, taxi, tren, bus y moto. Las asociadas al nivel fueron: sexo, cantón de residencia, la forma de traslado en carro, moto y tiempo de traslado. Resultados: Los estudiantes utilizaban como principal medio de transporte el bus. El rendimiento académico reportado por el 83 por ciento de la muestra estaba en el valor de 7. El 90 por ciento de los encuestados dijo presentar estrés asociado al congestionamiento vial. La presencia de estrés no estaba asociada al tiempo de traslado, el nivel de estrés sí lo estaba. Conclusión: El rendimiento académico está asociado a la presencia de estrés, no al nivel, o sea, que su existencia podría estar afectando la situación académica del estudiante(AU)

Introduction: According to the state of the nation 2018, Costa Rica is the third Latin American country with the highest traffic density; it is only surpassed by Argentina and Mexico. Objective: To identify the factors associated with level of stress in students due to congestion during their transit to the university and the factors associated with the presence or absence of stress due to the congestion in the transit to the university. Methods: An observational, analytical and cross-sectional study was carried put, with the participation of 420 students, who completed the corresponding surveys, which allowed assessing the level of stress generated by road congestion in the study population. The variables associated with the presence or absence of stress were age, academic performance, travel from home to university in the morning, from home to university in the afternoon, from home to university at night, car, taxi, train, bus and motorcycle. The variables associated with the level of stress were sex, canton of residence, the way of transportation by car, motorcycle, and travel time. Results: The students used the bus as their main means of transportation. The academic performance reported by 83 percent of the sample was in the value of 7. 90 percent of the respondents expressed that they present stress associated with road congestion. The presence of stress was not associated with travel time; the stress level was. Conclusion: Academic performance is associated with the presence of stress, not with the level of stress; that is, its existence could be affecting the student's academic situation(AU)

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RESUMEN Objetivo: Desarrollar un modelo de predicción de riesgo para infección posoperatoria mayor (IPM) a cirugía cardiaca pediátrica y validar el de la Society of Thoracic Surgeons (STS). Materiales y métodos: Se analizó una cohorte retrospectiva de 1025 niños sometidos a cirugía cardiaca con circulación extracorpórea (CEC) del 2000 al 2010. Se empleó un modelo de regresión logística y se validó el modelo. Resultados: De los 1025 pacientes, 59 (5,8%) tuvieron al menos un episodio de IPM (4,8% sepsis, 1% mediastinitis, 0% endocarditis). La mortalidad hospitalaria (63% vs. 13%; p<0,001), al igual que la duración de la ventilación posoperatoria (301,6 vs. 34,3 horas; p<0,001) y la estancia en la unidad de cuidados intensivos (20,9 vs. 5,1 días; p <0,001) fueron mayores en los pacientes con IPM. Los factores predictores fueron: edad, sexo, peso, cardiopatía cianótica, RACHS-1 3-4, clase funcional IV modificada por Ross, estancia hospitalaria previa y antecedente de ventilación mecánica. El modelo tuvo un c-estadístico de 0,80 (intervalo de confianza [IC] al 95%: 0,74-0,86) y es clínicamente útil. El modelo de la STS mostró un c-estadístico de 0,78 (IC 95%: 0,71-0,84) y Hosmer-Lemeshow de 18,2 (p = 0,020). Se realizó una comparación entre ambos modelos empleando una prueba exacta de Fisher. Conclusión: Se desarrolló un modelo para identificar preoperatoriamente a niños con alto riesgo de infección grave después de una cirugía cardiaca con CEC con buen desempeño y calibración. Asimismo, se validó el modelo de la STS con moderada discriminación.

ABSTRACT Objective: The aim of this study was to develop a risk prediction model for major postoperative infection (MPI) after pediatric heart surgery and to validate the model of the Society of Thoracic Surgeons (STS). Materials and methods: We analyzed a retrospective cohort of 1,025 children who underwent heart surgery with cardiopulmonary bypass (CPB) from 2000 to 2010. We used a logistic regression model, which was validated. Results: Of the 1,025 patients, 59 (5.8%) had at least one episode of MPI (4.8% had sepsis, 1% had mediastinitis, 0% had endocarditis). Hospital mortality (63% vs. 13%; p < 0.001), as well as duration of postoperative ventilation (301.6 vs. 34.3 hours; p < 0.001) and intensive care unit stay (20.9 vs. 5.1 days; p < 0.001) were higher in patients with MPI. The predictive factors found were age, sex, weight, cyanotic heart disease, RACHS-1 3-4, Ross-modified functional class IV, previous hospital stay, and previous history of mechanical ventilation. The proposed model had a c-statistic of 0.80 (95% CI: 0.74-0.86) and was considered as clinically useful. The STS model showed a c-statistic of 0.78 (95% CI: 0.71-0.84) and a Hosmer-Lemeshow of 18.2 (P = 0.020). A comparison between the two models was made using an accurate Fisher test. Conclusion: A model with good performance and calibration was developed to preoperatively identify children at high risk for severe infection after cardiac surgery with CPB. The STS model was also validated and was found to have a moderate discrimination performance.

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OBJECTIVE: The aim of this study was to develop a risk prediction model for major postoperative infection (MPI) after pediatric heart surgery and to validate the model of the Society of Thoracic Surgeons (STS). MATERIALS AND METHODS: We analyzed a retrospective cohort of 1,025 children who underwent heart surgery with cardiopulmonary bypass (CPB) from 2000 to 2010. We used a logistic regression model, which was validated. RESULTS: Of the 1,025 patients, 59 (5.8%) had at least one episode of MPI (4.8% had sepsis, 1% had mediastinitis, 0% had endocarditis). Hospital mortality (63% vs. 13%; p < 0.001), as well as duration of postoperative ventilation (301.6 vs. 34.3 hours; p < 0.001) and intensive care unit stay (20.9 vs. 5.1 days; p < 0.001) were higher in patients with MPI. The predictive factors found were age, sex, weight, cyanotic heart disease, RACHS-1 3-4, Ross-modified functional class IV, previous hospital stay, and previous history of mechanical ventilation. The proposed model had a c-statistic of 0.80 (95% CI: 0.74-0.86) and was considered as clinically useful. The STS model showed a c-statistic of 0.78 (95% CI: 0.71-0.84) and a Hosmer-Lemeshow of 18.2 (P = 0.020). A comparison between the two models was made using an accurate Fisher test. CONCLUSION: A model with good performance and calibration was developed to preoperatively identify children at high risk for severe infection after cardiac surgery with CPB. The STS model was also validated and was found to have a moderate discrimination performance.

OBJETIVO: Desarrollar un modelo de predicción de riesgo para infección posoperatoria mayor (IPM) a cirugía cardiaca pediátrica y validar el de la Society of Thoracic Surgeons (STS). MATERIALES Y MÉTODOS: Se analizó una cohorte retrospectiva de 1025 niños sometidos a cirugía cardiaca con circulación extracorpórea (CEC) del 2000 al 2010. Se empleó un modelo de regresión logística y se validó el modelo. RESULTADOS: De los 1025 pacientes, 59 (5,8%) tuvieron al menos un episodio de IPM (4,8% sepsis, 1% mediastinitis, 0% endocarditis). La mortalidad hospitalaria (63% vs. 13%; p < 0,001), al igual que la duración de la ventilación posoperatoria (301,6 vs. 34,3 horas; p < 0,001) y la estancia en la unidad de cuidados intensivos (20,9 vs. 5,1 días; p < 0,001) fueron mayores en los pacientes con IPM. Los factores predictores fueron: edad, sexo, peso, cardiopatía cianótica, RACHS-1 3-4, clase funcional IV modificada por Ross, estancia hospitalaria previa y antecedente de ventilación mecánica. El modelo tuvo un c-estadístico de 0,80 (intervalo de confianza [IC] al 95%: 0,74-0,86) y es clínicamente útil. El modelo de la STS mostró un c-estadístico de 0,78 (IC 95%: 0,71-0,84) y Hosmer-Lemeshow de 18,2 (p = 0,020). Se realizó una comparación entre ambos modelos empleando una prueba exacta de Fisher. CONCLUSIÓN: Se desarrolló un modelo para identificar preoperatoriamente a niños con alto riesgo de infección grave después de una cirugía cardiaca con CEC con buen desempeño y calibración. Asimismo, se validó el modelo de la STS con moderada discriminación.

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OBJECTIVE: The aim of this study was to make an indirect comparison of the results from meta-analyses that evaluated the severity of hot flushes in postmenopausal women exposed to hormone therapy (HT) or soy extracts. METHODS: A systematic review and meta-analysis of HT and soy extracts related to the reduction of hot flushes in postmenopausal women versus the same control (placebo) were conducted. In addition, the combination of the overall results obtained from these two meta-analyses (indirect comparison) was adjusted to the common control (placebo). RESULTS: The indirect standardized mean difference (SMD) obtained from the combination of both individual meta-analyses was calculated by using the following equation: SMD(indirect SOY vs HT) = SMD(soy) - SMD(HT), with a total indirect variance (var) equivalent to the following equation: var(total) = var(soy) + var(HT). These calculations yielded a point estimate of -0.84 (95% CI, -1.33 to -0.35) for the indirect SMD favorable to HT. CONCLUSIONS: HT and soy interventions showed a significant difference in efficacy for the reduction of hot flushes in postmenopausal women when each treatment was compared with placebo. However, using indirect comparison, there is a statistically significant difference between HT and soy extracts in their effects on hot flushes.

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