Hospital Militar Central

Abstract Background Subdural hematoma (SDH) is a recognized complication following ventriculoperitoneal shunt (VPS) placement, primarily caused by excessive cerebrospinal fluid (CSF) drainage. This overdrainage can result in ventricular collapse and traction of the bridging veins, leading to hemorrhage. Management remains challenging, requiring a balance between evacuating the hematoma, maintaining adequate CSF diversion, and in refractory cases, adjunctive endovascular techniques. Case description A 13-year-old boy with obstructive hydrocephalus underwent VPS placement with initial valve setting of 100 mmH₂O. Three months later, he developed bilateral subdural hematomas (40 mm right, 22 mm left) with 11 mm midline shift. Despite valve adjustment to 160 mmH₂O and two bilateral craniotomies evacuating over 650 mL, collections recurred with radiological progression and chronic neomembrane formation. The course was complicated by pneumocephalus requiring external ventricular drainage and hyperbaric oxygen therapy. Bilateral middle meningeal artery embolization was performed as salvage therapy. At 6-month follow-up, clinical stabilization was achieved without additional interventions, though residual asymptomatic collections persisted (32 mm right, 16 mm left). The patient developed Parinaud syndrome as sequela of acute hydrocephalus but had no other focal deficits. Conclusions Recurrent subdural hematomas following VPS placement due to overdrainage, though uncommon, represent a clinically significant complication in pediatric patients. This case demonstrates that when conventional management fails—including valve pressure adjustment and surgical evacuation—middle meningeal artery embolization may serve as a potential salvage therapy to achieve clinical stabilization in select cases. However, radiological resolution may be incomplete, and neurological sequelae can occur despite optimal management. Prevention through appropriate initial valve selection (150–200 mmH₂O in school-aged patients) is paramount. A stepwise, individualized, multidisciplinary approach combining neurosurgical and endovascular techniques is essential in managing these complex cases.

Catheter-associated bacteremia in hemodialysis is one of the most frequent and serious complications in patients with chronic kidney disease. Its occurrence is directly related to the quality of nursing care, adherence to aseptic protocols, and proper handling of vascular access. Given its high morbidity and mortality, economic impact, and epidemiological variability between units, it is essential to analyze the available evidence on compliance with preventive protocols. A systematic review was conducted following the PRISMA guidelines, including observational, cross-sectional, and cohort studies published in the last ten years, in Spanish and English. Articles were searched for in PubMed, Scielo, Cochrane, and Dialnet, using Boolean operators related to hemodialysis, infections, and nursing care. Two reviewers independently screened the titles, abstracts, and full texts. Seven studies conducted between 2013 and 2022 were included. The reported incidence ranged from 0.25 to 3.7 episodes per 1,000 catheter days, with better results in units with standardized protocols and high adherence by nursing staff. Gram-positive bacteria, especially Staphylococcus aureus and coagulase-negative staphylococci, were the most common microorganisms. The use of non-tunneled catheters and prolonged catheterization time increased the risk of infection. In addition, complications included endocarditis, septic thrombosis, and the need for ICU admission. Evidence confirms that strict adherence to nursing protocols significantly reduces catheter-associated bacteremia. Strengthening surveillance, ongoing training, and standardization of safe practices is essential to improve patient safety and reduce clinical and economic impact.

BACKGROUNDCollision tumors of the thyroid are rare entities, defined by the coexistence of two histologically distinct tumors within the same organ, separated by intervening normal tissue. Graves’ disease (GD) is a well-known risk factor for papillary thyroid cancer but has not been associated with thyroid collision tumor or medullary thyroid cancer (MTC).CASE SUMMARYA 37-year-old female presented with palpitations, weight loss, and tremors. Thyroid function tests showed suppressed thyrotropin and slightly elevated free thyroxine. A thyroid ultrasound was performed with a report of a nodule in the right thyroid lobe. Thyroid scintigraphy revealed a goiter with increased radiotracer uptake. Ultrasound-guided fine needle biopsy suggested an MTC, Bethesda VI. Immunohistochemistry was positive for synaptophysin and negative for thyroglobulin. Calcitonin levels were elevated. Total thyroidectomy with central lymph node dissection was performed. Pathological exam revealed a medullary carcinoma in the right thyroid lobe and a 3-mm papillary microcarcinoma in the left lobe. Lymph nodes showed reactive hyperplasia without evidence of tumor involvement. The final diagnosis was synchronous medullary thyroid carcinoma and papillary thyroid microcarcinoma, staged as T1N0M0. Sequencing of the rearranged during transfection (RET) oncogene revealed no pathogenic variants, and multiple endocrine neoplasia was ruled out.CONCLUSIONCollision tumors are rare entities but thyroid collision tumors in GD are even more infrequent despite the known association between GD and differentiated thyroid cancer. The mechanisms by which this clinical entity occurs are unclear. Because it is a rare pathology, there are currently no guidelines for its treatment. Treatment must be guided separately or based on the more aggressive neoplasm.

In neurosurgery services worldwide, the resection of benign and malignant tumors continues to pose a challenge due to the need to preserve neurological function, especially when these lesions are located in eloquent areas. Among central nervous system oncologic lesions, meningiomas are the most common. Based on the criteria of the World Health Organization, they are classified into three grades according to their malignancy. In this report, we present the case of a 46-year-old female patient with no relevant medical history, who had experienced headaches for a year, which intensified 24 hours prior to her visit to the emergency department, without aggravating or relieving factors. Physical examination revealed no neurological deficits. A contrast-enhanced computed tomography (CT) scan showed a frontoparietal bony prominence measuring 4.41 x 6.2 cm. Due to its size, a wide surgical resection was performed, followed by histopathological analysis, which confirmed the diagnosis of a primary intraosseous meningioma, WHO grade 1. To repair the bone defect, a cranioplasty with a low-profile titanium mesh was performed. At the 12-month follow-up, the patient presented with full recovery and resolution of symptoms, with no evidence of recurrence. This case represents a rare entity with no previous reports in Nicaragua, which may be due to its low incidence and limited awareness among the medical community, often leading to underdiagnosis. Since this is the first case report in this institution, we consider it important to document and share it, aiming to contribute to the development of a diagnostic and therapeutic guideline for low-resource settings and developing countries.

Background: Hypertrophic olivary degeneration (HOD) is a rare trans-synaptic degeneration of the inferior olivary nucleus resulting from disruption of the dentato–rubro–olivary pathway, also known as the Guillain– Mollaret triangle. Unlike most degenerative processes, it produces olivary hypertrophy rather than atrophy. In oncology patients with prior posterior fossa or brainstem involvement, this condition can simulate tumor recurrence or radiation necrosis, leading to unnecessary interventions if unrecognized.Case Description: A 38-year-old woman with a history of human epidermal growth factor receptor 2-positive invasive ductal carcinoma of the breast and previously treated brainstem metastasis presented with progressive right facial paresthesias and gait instability. Neurological examination revealed dysmetria, impaired rapid alternating movements, and gait ataxia without motor or sensory deficits. Magnetic resonance imaging (MRI) demonstrated a nodular enhancing pontine lesion due to the treated metastatic lesion and a new enlargement involving the rostral aspect of the left central tegmental tract with associated hypertrophic change of the inferior olivary nucleus, consistent with unilateral HOD. Magnetic resonance spectroscopy and perfusion imaging excluded neoplastic recurrence. A multidisciplinary neuro-oncology board concluded that the findings were secondary to radiation-induced tract injury. The patient continued maintenance chemotherapy and received symptomatic management and rehabilitative therapy, with serial MRI showing stability.Conclusion: HOD should be considered in patients with prior brainstem surgery or radiotherapy who develop delayed cerebellar signs and characteristic MRI findings. Recognizing its benign and self-limited nature is crucial to prevent misdiagnosis as tumor recurrence and avoid unnecessary oncologic or surgical interventions. Integration of advanced MRI techniques and multidisciplinary evaluation allows precise diagnosis and tailored management, ensuring appropriate treatment and long-term follow-up.

Background:Osteology plays a central role in anatomical, biological, and clinical sciences. However, a comprehensive understanding of its global research landscape, historical development, and emerging trends has been lacking. This study aimed to fill that gap by conducting a scientometrics and visual analysis of bone tissue research over the past 190 years.Methods:A bibliometric study was conducted using Scopus, Web of Science All Collection, and PubMed. Publications were included if they focused on the structure or function of bones and were peer-reviewed articles. Variables included publication volume, journal quartile, citation metrics (h-index, g-index, m-index), collaboration networks, and keyword trends. Countries were classified by income level and geographic region.Results:A total of 8103 publications were included. The field showed modest growth until 1967, followed by a marked increase peaking in 2021. Most articles were original research (91%) and published in Q1 journals (63.9%). Europe and the Americas accounted for over 80% of publications, while low- and lower-middle-income countries contributed <4%. High-income countries dominated Q1 output and collaboration networks. The most common keywords included phylogeny, osteoporosis, and dinosaur. Technological and molecular approaches have become more prominent since the 2000s.Conclusions:This is the first global scientometrics analysis of osteology research. It reveals historical trends, regional inequalities, and thematic evolution, offering valuable insights for researchers, institutions, and policymakers to foster more inclusive and strategically guided research in osteology.

The sternoclavicular joint (SCJ) is a synovial saddle joint and the only articulation between the axial skeleton and the upper limb. Although SCJ pathology is rare, it may include degenerative, autoimmune, infectious, tumoral, or traumatic conditions. Arthroscopic approaches to this region carry a risk of damaging vital mediastinal structures. This study aims to anatomically characterize the SCJ and surrounding neurovascular structures, emphasizing the posterior capsule as a critical safety barrier during arthroscopy. Ten cadaveric specimens were bilaterally dissected. Arthroscopic portals were first marked and used to identify the posterior capsule. Open dissections were performed to measure the distances between the portals and nearby mediastinal structures using digital calipers. Data were recorded in Excel 2024 (Microsoft Corp., Redmond, WA, USA) and REDCap (Vanderbilt University, Nashville, TN, USA) and analyzed with SPSS version 28 (IBM Corp., Armonk, NY, USA). The posterior capsule consistently acted as a protective boundary between the joint and mediastinal structures. The average distances from the superomedial (SM) and inferolateral (IL) portals to the posterior capsule were 26.3 mm and 26.5 mm, respectively. From the posterior capsule, the average distances to key mediastinal structures were: common carotid artery: 42.5 mm (SM), 44.1 mm (IL), brachiocephalic trunk: 40.5 mm (SM), 43.5 mm (IL), innominate vein: 37.8 mm (SM), 39.7 mm (IL), and vagus nerve: 45.4 mm (SM), 46.5 mm (IL). The posterior capsule provides a reliable anatomical safety margin between the SCJ and vital mediastinal structures. During SCJ arthroscopy, referencing the anterior sternoclavicular ligament and maintaining a minimum 5.1 cm safety margin posteriorly can minimize the risk of catastrophic injury. These findings support safer surgical planning and highlight the importance of precise portal placement.

BACKGROUNDAcromegaly, a disease of excess growth hormone, is known to alter bone structure and increase the risk of osteoporosis and fractures. This study aimed to assess the prevalence of vertebral, non-vertebral, and hip fragility fractures, as well as osteoporosis, in a cohort of patients with acromegaly.AIMTo assess the prevalence of vertebral fragility fractures, non-vertebral fragility fractures, hip fragility fractures, and osteoporosis in patients diagnosed with acromegaly.METHODSData were collected on age, sex, body mass index (BMI), time from diagnosis of acromegaly, insulin-like growth factor (IGF-1) levels, disease control, pharmacological management, risk factors for osteoporosis, vertebral fragility fractures, non-vertebral fragility fractures, hip fragility fractures, and osteoporosis.RESULTSA total of 124 patients with acromegaly were included (67 men and 57 women). The mean age at diagnosis was 44 ± 12 years; the mean time from diagnosis was 12 ± 8 years; and the mean BMI was 27 ± 4 kg/m². Fragility fractures were found in 27 patients (21%). There were no significant differences in the presence of osteoporosis or fragility fractures according to age, sex, BMI, duration of acromegaly, or IGF-1 levels at diagnosis. A higher percentage of patients with osteoporosis were treated with somatostatin analogs compared to those without osteoporosis (46% vs 15%; P < 0.05).CONCLUSIONA high prevalence of osteoporosis and fragility fractures was found in patients with acromegaly, regardless of age, sex, BMI, time from diagnosis, IGF-1 levels, and disease control. More patients with osteoporosis were treated with somatostatin analogs compared to those without osteoporosis. Taken together, our results suggest that the severity of the disease and the need for second-line therapies, may be associated with the increased risk of osteoporosis.

BackgroundPulse pressure depends mostly on arterial wall stiffness. Several studies have focused on the fact that many factors, including the metabolic syndrome or its components, interact to impact on great vessels elastic properties, increasing arterial wall stiffness. ObjectiveTo evaluate the influence of the metabolic syndrome and its components on pulse pressure in persons without any apparent disease. Material and MethodsA total of 1.155 subjects without demonstrable disease were randomly selected. The metabolic variables defining metabolic syndrome (ATP III) were recorded: fasting HDL-cholesterol ≤40/50 mg/dl (men/women), fasting triglycerides ≥150 mg/dl, fasting glycemia ≥100 mg/dl, waist circumference ≥102/88 cm (men/women) and systolic/diastolic blood pressure ≥130/85 mm Hg. Patients’ pulse pressure values were compared among different groups according to gender and age. The frequency of the metabolic syndrome components was determined and pulse pressure was adjusted by gender, age and all the components using multiple linear regression analysis. The adjusted value of pulse pressure corresponding to each metabolic syndrome component was determined and compared to that of normal subjects. Finally, adjusted pulse pressure was calculated according to the possible combinations of three factors or greater (diagnostic criteria of metabolic syndrome) and was compared with that of individuals without any component of the metabolic syndrome. ResultsGeneral characteristics of the 1.155 individuals: men 62%, age 38±9 years (range 20-66), waist circumference 89±13 cm, triglycerides 107±74 mg/dl, glycemia 82±16 mg/dl, HDL-cholesterol 48±13 mg/dl, systolic blood pressure 124±14 mm Hg, diastolic blood pressure 78±9 mm Hg, pulse pressure 46±9 mm Hg. Age: 38±9 years in men (n=712) and 37±9 years in women (n=443); p=ns. Pulse pressure was 48±8 mm Hg in men versus 43±9 mm Hg in women; p&lt;0.001. Influence of age on pulse pressure: 45±8 in individuals &lt;35 years versus 47±9 in ≥35 years; p&lt;0.001. Frequency of metabolic syndrome components: waist circumference ≥102/88 cm: 18%, glycemia ≥100 mg/dl: 7%, triglycerides ≥150 mg/dl: 17%, HDL-cholesterol ≤40/50 mg/dl: 45%, systolic blood pressure ≥130 mm Hg: 40%, diastolic blood pressure ≥85 mm Hg: 16%. When pulse pressure adjusted by each component of the metabolic syndrome was compared to that of controls, the following values were obtained: waist circumference ≥102/88 cm: 48±4 versus 46±3, glycemia ≥100 mg/dl: 52±5 versus 46±3, triglycerides ≥150 mg/dl: 48±3 versus 46±4, HDL-cholesterol ≤40/50 mg/dl: 44±3 versus 47±3; systolic blood pressure ≥130 mm Hg: 48±4 versus 45±3; diastolic blood pressure ≥85 mm Hg: 48±5 versus 46±3, all p&lt;0.001. Finally, adjusted pulse pressure according to the possible combinations of three factors or greater was calculated and compared with that of individuals without any component of the metabolic syndrome: 49±5 versus 46±3, p&lt;0,001. ConclusionsThe metabolic syndrome and/or its components induce pulse pressure elevation, except for HDL-cholesterol. This effect seems to be independent of age, gender and the eventual interaction of the variables analyzed.

Introduction: Self-determination in Health (SDH), defined as a patient's inherent ability to make informed and active decisions about their health care, is a modifiable psychological factor that correlates with motivation, proactive behavior, and improved physical health outcomes. In the context of hemodialysis (HD) therapy, SDH promotes functional autonomy and active patient engagement, even in the face of vulnerability; by contrast, its absence is associated with decision delegation and deterioration in health. The study hypothesizes that patients in hemodialysis programs with higher SDH will have a lower perception of symptoms and a longer survival. Methods: This observational, case-control study was carried out in 14 hemodialysis units in Ecuador from May to June 2025. Patients aged 18 years or older who were enrolled in hemodialysis programs were included. Two groups were formed: one with patients without SDH and the other with patients with SDH. The variables studied included age, duration of hemodialysis treatment, self-determination in health, adherence to treatment, labor integration, physical dependence, acceptance of kidney disease, and scores on "The Dialysis Symptom Index." A 1:1 propensity score matching (PSM) was performed between the groups based on age, sex, and presence of type 2 diabetes mellitus. The means were compared using Student's t-test, while proportions were compared using Chi-squared tests. An observational survival analysis was also conducted, examining the length of stay in the hemodialysis unit up to the date of the survey. Results: 180 patients without SDH and 184 with SDH were analyzed. Age was similar in both groups (57.9 ± 13.7 years vs. 58.0 ± 11.8 years, P = 0.938). The proportion of men was similar in both groups (51.1% vs. 51.6%; P=0.921). The prevalence of type 2 diabetes mellitus was comparable between the groups (48.3% vs. 47.3%; P=0.841). The group without SDH had a higher rate of physical dependence (53.3%) compared to the group with SDH (25.5%) (P &lt; 0.001). Adherence was greater in the group with SDH (51.6%) than in the group without SDH (36.7%; P &lt; 0.001). Work activity was more common among the group with SDH (38.0%) compared to 12.2% among the group without SDH (12.2%; P &lt; 0.001). The group with SDH showed lower symptom intensity (–25.82%) than the group without SDH (P&lt;0.001). Increased survival was observed in the SDH group, with 29.5 months versus 36.08 months in the non-SDH group (χ2, Log-Rank 7.71, P&lt;0.005). Conclusions: Patients with SDH exhibited longer survival, significantly higher treatment adherence, and less physical dependence. Additionally, self-determination was associated with a reduction in the severity of perceived symptoms, including pain and psychological symptoms such as worry and sadness, across 18 of the 34 assessed. These findings demonstrate that SDH is not just a psychological concept but also a therapeutic goal that impacts survival. Randomized intervention studies in SDH are necessary.