Hospital Posadas

Retroperitoneal ectopic pregnancy is a rare form of ectopic pregnancy, accounting for less than 1% of all cases. This location carries a high risk of massive hemorrhage due to its proximity to major retroperitoneal vessels. A 24-year-old female patient, G1P1, presented with a 2-week history of abdominal pain, which had exacerbated in the last 24 hours, accompanied by fever. Laboratory tests revealed elevated serum β-hCG levels (89,331 IU/L), anemia (Hb 8.1 g/dL), and leukocytosis. Abdominal ultrasonography and computed tomography (CT) identified a heterogeneous retroperitoneal mass anterior to the left psoas muscle, consistent with an ectopic pregnancy. An exploratory laparotomy was performed, with the successful removal of the gestational sac and embryo. A retrospective review of the medical records of a patient diagnosed with a retroperitoneal ectopic pregnancy was performed. Demographic data, clinical findings, imaging studies (ultrasonography and CT), intraoperative findings, and postoperative follow-up were analyzed. A literature search was conducted across databases (PubMed, SciELO) to compare the case with current literature. Retroperitoneal ectopic pregnancy is a rare but potentially life-threatening entity that requires early diagnosis via serum β-hCG and imaging studies (ultrasound, CT), as well as immediate surgical treatment to prevent catastrophic complications.

Laparoscopic cholecystectomy is widely performed and safe, but may present rare complications such as retained gallstones ("dropped gallstones"), which can act as a nidus for infection and cause late intra-abdominal or retroperitoneal abscesses. A 40-year-old male with prior laparoscopic cholecystectomy presented with fever and right lumbar pain. Examination showed an inflammatory lumbar mass with leukocytosis and elevated C-reactive protein. Imaging revealed a right paravertebral collection with a fistulous tract to the abdominal cavity. Despite antibiotics and percutaneous drainage, recurrence occurred. Surgical lumbotomy revealed multiple gallstones, confirming the etiology, with subsequent clinical improvement. Retained gallstones may migrate, act as foreign bodies, and cause recurrent infection. Magnetic resonance imaging was key to identifying the abdominal origin, and surgical stone removal was required for definitive treatment. Lumbar abscesses in patients with previous cholecystectomy should raise suspicion of retained gallstones. Definitive management requires drainage and complete stone removal to prevent recurrence.

To evaluate the response to transcutaneous sacral neurostimulation (tSNS) treatment in children with refractory functional constipation (RFC), myelomeningocele (MMC), and anorectal malformations (ARM) with fecal incontinence (FI). To compare manometric data before and after treatment. A prospective, analytical, quasi-experimental cohort study was conducted in the three populations over a period of 2 years. Twelve 30-min electrostimulation sessions were performed once weekly, using two posterior cutaneous electrodes placed between S2 and S4, with anorectal manometry performed before and after treatment. Forty-two patients with FI were included: 20 with MMC, 14 with ARM, and 8 with RFC. Mean age: 10 years; 71.4% were male. After treatment, complete continence was achieved in 57%, partial continence in 26%, and without improvement in 17% of patients. In manometry, a significant increase in median resting pressure and squeezing pressure was observed as well as an improvement of sensory function, with first sensation occurring at a median pretreatment volume of 100 cc and a median posttreatment volume of 20 cc (p < 0.001). Urge sensation required less volume in 66.7% of patients, and maximum tolerance decreased in 61.9%. Laxatives were discontinued after treatment in 31.4%, and urinary incontinence resolved in 32%. tSNS was shown to be effective in improving symptoms of constipation and FI, especially in patients with organic pathology. Urinary incontinence also improved. Favorable changes were observed at the second manometry in patients with total or partial continence, especially for sensory function.

<title>Abstract</title> Background Invasive intracranial pressure (ICP) monitoring is not universally available in low-resource settings, mainly due to high costs. In this scenario, non-invasive ICP (nICP) estimation could be integrated in therapeutic protocols. The objective of this international survey was to describe the utilization of nICP monitoring in this setting. Methods The survey was composed by 23 items. Target respondents were doctors treating severe traumatic brain injury (TBI) patients in low-resource settings without the availability of invasive ICP monitoring. Results One hundred and twenty-six physicians from 114 centers among 21 countries worldwide responded. The main findings of this study were: a) a predominant use of optic nerve sheath diameter (ONSD) as nICP assessment tool; b) the utilization of at least two methods for nICP estimation in approximately half of the cases; and c) the absence of specific protocol for nICP monitoring. We also reported a certain degree of variability regarding the parameters suggestive of intracranial hypertension for each of the methods used. Conclusions Brain ultrasounds, particularly ONSD assessment, are the most frequently utilized tools for nICP estimation in TBI patients managed in low-resource settings worldwide. Educational efforts linked with protocols development could be a step forward to improve the care of TBI in resource-limited settings.

Introducción: La enfermedad de Parkinson (EP) es el segundo trastorno neurodegenerativo más frecuente, con alta prevalencia mundial y marcado impacto en la calidad de vida debido a síntomas motores como no motores. El tratamiento farmacológico inicial ofrece beneficios, aunque su eficacia disminuye con los años, debido principalmente a disquinesias y fluctuaciones motoras. En este contexto, la cirugía funcional (ablativa o de estimulación cerebral profunda) se plantea como alternativa. El objetivo de nuestro estudio es determinar el impacto de los procedimientos quirúrgicos en la calidad de vida de los pacientes con enfermedad de Parkinson mediante la valoración del cuestionario PDQ39.Método: Se diseñó un estudio observacional retrospectivo que incluyó pacientes con EP intervenidos quirurgicamente entre 2019 y 2022 en el Hospital Nacional Prof. Alejandro Posadas. Se establecieron los siguientes criterios de inclusión: Paciente con diagnóstico de enfermedad de Parkinson, que posea evaluación con cuestionario PDQ 39 pre y postquirúrgico y, haya sido intervenido quirúrgicamente dentro de los límites de tiempo preestablecido. La evaluación postquirúrgica no fue sistematizada previamente por lo que el tiempo de evaluación difiere en un periodo de 2 a 5 años.Resultado: De los 108 pacientes evaluados, 39 cumplieron criterios de inclusión. La edad promedio fue de 56 años y el tiempo medio de evolución de la enfermedad de 10,3 años. Se realizaron 22 cirugías ablativas y 17 DBS. El mayor beneficio se observó en el ítem estigma social (mejoría del 56%), seguido de actividades de la vida diaria y movilidad (20–26%). La DBS mostró mejor impacto en movilidad frente a la cirugía ablativa. Por el contrario, cognición y comunicación presentaron deterioro, especialmente tras DBS bilateral. La psicoprofilaxis prequirúrgica se asoció con mejores resultados en dominios emocionales y sociales. Discusión: El cuestionario PDQ-39 contiene 39 ítems agrupados en 8 dominios: movilidad, actividades de la vida diaria, bienestar emocional, estigma, apoyo social, estado cognitivo, comunicación, malestar corporal. Los hallazgos de nuestro estudio difieren parcialmente de la literatura, donde el estigma social suele mostrar baja mejoría siendo en nuestro estudio el dominio que presentó mayor mejoría global. Se concuerda que tanto el ítem de apoyo social como de comunicación y cognición presentan detrimento, pero con la salvedad de que aquellos pacientes que realizaron psicoprofilaxis prequirúrgica, el impacto positivo en los ítems mencionados fue mayor que en aquellos pacientes que no realizaron la misma. Los procedimientos bilaterales, en especial DBS, mejoraron movilidad y malestar corporal, aunque a expensas de mayor deterioro cognitivo y de comunicación. En nuestra serie se pudo observar que los pacientes que fueron intervenidos a los 7 años de evolución presentaron mayor impacto positivo sobre la calidad de vida que aquellos en los que se realizó previo y posterior a este tiempo.Conclusiones: La cirugía funcional representa una mejoría en la calidad de vida global de los pacientes con enfermedad de Parkinson. Mejorando significativamente el estigma social y las actividades de la vida diaria. La psicoprofilaxis prequirúrgica representa un pilar fundamental para el éxito quirúrgico. No obstante, creemos que la realización de un estudio doble ciego reforzaría los resultados obtenidos.

Langerhans cell histiocytosis (LCH) is a rare disease that predominantly affects children, characterized by the abnormal clonal proliferation of Langerhans cells with a broad clinical spectrum and prognosis. Refractory LCH to standard treatment usually presents multisystem and risk organs involvement, and mainly affects children under 2 years of age. In these cases, more than half present the BRAF-V600E mutation; detection of this mutation is essential for targeted treatment, such as vemurafenib, a BRAF inhibitor. We present the case of a 6-month-old patient diagnosed with multisystemic LCH without involvement of risk organs, who responded poorly to first- and second-line therapy. A molecular biology study was performed, which reported a BRAF-V600E mutation. Treatment with vemurafenib was indicated, and a good clinical response was obtained after 2 weeks.

Objective To assess the effect of an iatrogenic gastroschisis on fetal pulmonary growth in an animal model of congenital left-sided diaphragmatic hernia (CDH). Methods Eighteen time-dated ewes were studied: Group I: healthy controls (H); Group II: CDH controls (untreated) (CDH); Group III: CDH and iatrogenic gastroschisis (CDH+GS). CDH was created in Groups II and III at a mean gestational age of 85 days as previously described. In Group III, a gastroschisis was created concomitantly with the creation of the CDH. A silo was placed around the intestines during the creation of the gastroschisis. Outcome variables included the lung-to-body weight ratio (LBWR) in unfixed and fixed lungs, as well as histological right and left radial alveolar counts (RAC), as previously described. Results One animal miscarried, leaving 17 for analysis. One ewe had a twin gestation of which one fetus died in the womb after CDH creation, and the co-twin was used as a healthy control, leaving 17 fetuses for analysis. In six of the 8 ewes with CDH+GS, the silo prevented the intestines from protruding outside the abdomen. However, the CDH was confirmed in all 8 fetuses. Therefore, 6 fetuses with a failed gastroschisis but with a persistent CDH were crossed over to Group II (CDH), while the other two were kept in Group III. In three subsequent ewes, the silo was not placed during the creation of the gastroschisis (CDH+GS without silo). This resulted in 4 fetuses in Group I (H), 8 fetuses in Group II (CDH), and 5 fetuses in Group III (CDH+GS). The LBWR was significantly smaller in Group II, compared to the other two groups. There was no difference in the LBWR between groups I and III. In Group III, the LBWR in the fixed lungs was significantly higher than in Group II, and had a tendency to be significantly different in the unfixed lung (p = 0.057). The right and left RAC were significantly smaller in Group II compared to groups I and III, whereas they were not different between groups I and III. The RAC in Group III was significantly higher in Group III compared to Group II. The intestine of two CDH+GS fetuses was analyzed and showed fibrous tissue with chronic inflammation. Conclusion Gastroschisis prevents the development of pulmonary hypoplasia in an ovine model of CDH. Further studies are warranted to confirm these findings.