Federalism, an alternative to overcome the inequalities of sustainable development in the natural regions and macro regions of Peru.

Political doctrines determine the formation of territorial units or geopolitical models more adequate to generate public value in subnational organizations, with positive results in the HDI, productivity indicators and national competitiveness oriented to improve the quality of public service for citizens who participate in democratic electoral processes with identity and that promote a decentralized State that does not generate development obstacles as an effect of geographical limits by departments and regional governments with inequalities in natural resources and comparative advantages, but that projects integration, better economic performance, sustainability, and sustainability for regional and national development and as an alternative to achieve political stability in Peru. The aim of this article is to explore whether the contribution of natural regions and macro-regions to sustainable development is unequal. Information from official web pages. The disparity index, analysis of variance (ANOVA) and Tukey's analysis were used. The GDP per capita of the coastal departments is 64% higher than that of the Andes and 136% higher than those of the Amazon; the HDI of the coast exceeds those regions by 31 and 19%; 44% of the urban population residing in marginal neighborhoods are on the coast, 67% in the Andes and 69% in the Amazon. The percentage of corruption is highest on the coast, followed by the Amazon. At the regional macro level, the primacy in GDP per capita and the HDI moves to the south, although the superiority of the corruption index persists in the center, followed by the south; both significantly higher than the east and north. This fact would reveal the possibility of a regional macro development without Lima and through axes of various development nodes, feasible in the era of globalization.

Real clinical experience after one year of treatment with tolvaptan in patients with autosomal dominant polycystic kidney disease.

Background: Tolvaptan (TV) is the first vasopressin-receptor antagonist approved for the treatment of autosomal dominant polycystic kidney disease (ADPKD). No publications report TV experience in real clinical practice during the first year of treatment. Methods: A prospective study of an initial cohort of 220 rapidly progressing patients treated with TV for 12 months. The tolerability of TV, the evolution of the estimated glomerular filtration rate (eGFR), analytical parameters, and blood pressure were analyzed. Results: A total of 163 patients (78.2%) received TV for 1 year. The main causes of treatment withdrawal were the aquaretic effects (11%), eGFR deterioration (5%), and hepatic toxicity (2.3%). eGFR decreased significantly after 1 month of treatment without further changes. The decrease in eGFR in the first month was higher in patients with an initially higher eGFR. The eGFR drop during the first year of treatment with TV was lower than that reported by patients in the 2 years prior to TV treatment (-1.7 ± 7.6 vs. -4.4 ± 4.8 mL/min, p = 0.003). Serum sodium and uric acid concentrations increased, and morning urinary osmolality decreased in the first month, with no further changes. Blood pressure decreased significantly without changes in antihypertensive medication. Conclusion: TV treatment is well tolerated by most patients. Liver toxicity is very rare and self-limited. TV reduces eGFR in the first month without showing further changes during the first year of treatment. Patients with a higher starting eGFR will suffer a greater initial drop, with a longer recovery. We suggest using the eGFR observed after a month of treatment as the reference for future comparisons and calculating the rate of eGFR decline in patients undergoing TV treatment.

Omega-3 mechanism of action in inflammation and endoplasmic reticulum stress in mononuclear cells from overweight non-alcoholic fatty liver disease participants: study protocol for the "Brazilian Omega Study" (BROS)-a randomized controlled trial.

The low-grade inflammation is pivotal in obesity and its comorbidities; however, the inflammatory proteins are out of target for traditional drug therapy. Omega-3 (ω3) fatty acids can modulate the downstream signaling of Toll-like receptor (TLR) and tumor necrosis factor-α receptor (TNFα) through GPR120, a G-protein-coupled receptor, a mechanism not yet elucidated in humans. This work aims to investigate if the ω3 supplementation, at a feasible level below the previously recommended level in the literature, is enough to disrupt the inflammation and endoplasmic reticulum stress (ER-stress), and also if in acute treatment (3 h) ω3 can activate the GPR120 in peripheral blood mononuclear cells (PBMC) and leukocytes from overweight non-alcoholic fatty liver disease (NAFLD) participants. The R270H variant of the Ffar4 (GPR120 gene) will also be explored about molecular responses and blood lipid profiles. A triple-blind, prospective clinical trial will be conducted in overweight men and women, aged 19-75 years, randomized into placebo or supplemented (2.2 g of ω3 [EPA+DHA]) groups for 28 days. For sample calculation, it was considered the variation of TNFα protein and a 40% dropout rate, obtaining 22 individuals in each group. Volunteers will be recruited among patients with NAFLD diagnosis. Anthropometric parameters, food intake, physical activity, total serum lipids, complete fatty acid blood profile, and glycemia will be evaluated pre- and post-supplementation. In the PBMC and neutrophils, the protein content and gene expression of markers related to inflammation (TNFα, MCP1, IL1ß, IL6, IL10, JNK, and TAK1), ER-stress (ATF1, ATF6, IRE1, XBP1, CHOP, eIF2α, eIF4, HSP), and ω3 pathway (GPR120, ß-arrestin2, Tab1/2, and TAK1) will be evaluated using Western blot and RT-qPCR. Participants will be genotyped for the R270H (rs116454156) variant using the TaqMan assay. It is hypothesized that attenuation of inflammation and ER-stress signaling pathways in overweight and NAFLD participants will be achieved through ω3 supplementation through binding to the GPR120 receptor. TRIAL REGISTRATION: ClinicalTrials.gov #RBR-7x8tbx. Registered on May 10, 2018, with the Brazilian Registry of Clinical Trials.

Socio-economic and cultural factors that influence the labor insertion of University Graduates, Peru.

Access to the labor market by graduates of the National University of Moquegua is limited by a wide range of socioeconomic and cultural factors. The study aimed to develop a multivariate model to identify the socioeconomic and cultural factors that influence labor insertion of graduates of the National University of Moquegua, 2019. The type of research according to its purpose was basic and the non-experimental cross-sectional design, with a stratified random sample with proportional allocation with a significance level of 5% and a sampling error of 7%. The data collection technique was the survey and two validated and reliable instruments were applied. The population consisted of 537 graduates, with a sample of 121 graduates from six Professional Schools. The results of the application of logistic regression models indicate that the employment status (Wald = 21.179 and p-value = 0.000), basic electricity services (Wald = 4.567 and p-value = 0.033), the preference for movies (Wald = 6,136 and p-value = 0.013), and the communications media: TV and radio (Wald = 4.962 and p-value = 0.026) significantly influence the labor insertion of graduates of UNAM. It is concluded that both the working condition, electricity services, the preference for movies and communication media like TV and radio significantly influence the labor insertion of graduates of the National University of Moquegua.

Iatrogenic Colonic Perforations: Changing the Paradigm.

PURPOSE: The purpose of our study was to investigate the clinical outcomes of colonoscopic perforations in patients. MATERIALS AND METHODS: We retrospectively studied patients with perforations secondary to diagnostic/therapeutic colonoscopy between 2009 and 2015 at the Pontevedra Hospital Complex. We analyzed age, closure method, length of hospitalization, and long-term progress. RESULTS: Of the 34 perforations detected, 67.6% occurred in patients aged below 75 years. Most perforations occurred in the descending colon (55%). Perforations occurred in 55.9% of outpatients and 45% of inpatients. Diagnostic and therapeutic colonoscopies caused perforations in 20.6% and 79.4% of patients, respectively. Conservative treatment alone was performed in 5.9%, complete or partial endoscopic closure in 14.7%, and surgery in 79.4% of patients. Patients treated only conservatively or with concomitant endoscopic closure showed no mortality. The mortality rate was 14.8% in those treated surgically, and 55% of these patients required a subsequent ostomy. CONCLUSIONS: Conservative management with antibiotics and parenteral nutrition concomitant with complete/partial endoscopic closure effectively treats perforations, provided intraprocedural diagnosis is possible with immediate administration of antibiotics after the procedure. Nevertheless, studies with larger number of patients and statistical analysis are necessary in the near future.

Rate of adverse events of gastroduodenal snare polypectomy for non-flat polyp is low: A prospective and multicenter study.

AIM: To evaluate the rate of adverse events (AEs) during consecutive gastric and duodenal polypectomies in several Spanish centers. METHODS: Polypectomies of protruded gastric or duodenal polyps ≥ 5 mm using hot snare were prospectively included. Prophylactic measures of hemorrhage were allowed in predefined cases. AEs were defined and graded according to the lexicon recommended by the American Society for Gastrointestinal Endoscopy. Patients were followed for 48 h, one week and 1 mo after the procedure. RESULTS: 308 patients were included and a single polypectomy was performed in 205. Only 36 (11.7%) were on prior anticoagulant therapy. Mean polyp size was 15 ± 8.9 mm (5-60) and in 294 cases (95.4%) were located in the stomach. Hemorrhage prophylaxis was performed in 219 (71.1%) patients. Nine patients presented AEs (2.9%), and 6 of them were bleeding (n = 6, 1.9%) (in 5 out of 6 AE, different types of endoscopic treatment were performed). Other 24 hemorrhagic episodes could be managed without any change in the outcome of the endoscopy and, consequently, were considered incidents. We did not find any independent risk factor of bleeding. CONCLUSION: Gastroduodenal polypectomy using prophylactic measures has a rate of AEs small enough to consider this procedure a safe and effective method for polyp resection independently of the polyp size and location.

Insuficiencia renal aguda secundaria a diarrea severa por enteropatía esprue-like asociada a olmesartán / Acute renal failure secondary to diarrhea due to sprue like-enteropathy associated with olmesartan

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Morbimortalidad de la resección pancreática / Morbidity and mortality in pancreatic resection

Objetivo Evaluar la morbimortalidad postoperatoria de la resección pancreática.Material y métodosEstudio observacional prospectivo que incluye 117 pacientes intervenidos quirúrgicamente de forma consecutiva por presentar tumoración pancreática o periampular. En 61 de ellos se hizo pancreatectomía cefálica; en 15, pancreatectomía total; en uno, enucleación y en 40, resección corporocaudal.ResultadosLa morbilidad global fue de 48,7% (59% para la pancreatectomía cefálica, 35% para la resección corporocaudal y 46,7% para la pancreatectomía total). Las complicaciones más frecuentes fueron las colecciones y abscesos intraabdominales, con un 15,38% y las complicaciones médicas, con un 13,68%. La incidencia de fístula pancreática fue de 9,83%, para la pancreatectomía cefálica y de 10% para la resección corporocaudal. La incidencia de reintervención fue de 14,53%. La mortalidad global fue de 5,12% (6,56% para la pancreatectomía cefálica, 2,5% para la resección corporocaudal y 6,67% para la pancreatectomía total). La presencia de complicaciones postoperatorias, la necesidad de reintervención y la edad superior a 70 años correlacionaron significativamente con la mortalidad.DiscusiónLa resección pancreática tiene una morbilidad alta. La mortalidad es baja y está prácticamente limitada a los pacientes mayores de 70 años (AU)

Aim Assess the postoperative morbidity rates in pancreatic resection.Material and methodProspective observational study which includes 117 patients who underwent surgery consecutively due to pancreatic or periampullary tumours. In 61 of the patients, cephalic pancreatectomy was carried out; 15 underwent total pancreatectomy; one underwent enucleation and 40 underwent distal pancreatectomy.ResultsOverall morbidity was 48.7% (59% for cephalic pancreatectomy, 35% for distal pancreatectomy and 46.7% for total pancreatectomy). The most frequent complications were intra-abdominal abscesses and collections (15.38%) and medical complications (13.68%). The incidence of pancreatic fistula was 9.83% for cephalic pancreatectomy and 10% for distal pancreatectomy. The reintervention incidence was 14.53%. Overall mortality was 5.12% (6.56% for cephalic pancreatectomy, 2.5% for distal pancreatectomy and 6.67% for total pancreatectomy). The presence of postoperative complications, the need for reintervention and the fact of being over 70 years of age correlated significantly with mortality.DiscussionPancreatic resection has high morbidity rates. Mortality is low and is practically limited to patients older than 70 years. (AU)

[Morbidity and mortality in pancreatic resection]. / Morbimortalidad de la resección pancreática.

AIM: Assess the postoperative morbidity rates in pancreatic resection. MATERIAL AND METHOD: Prospective observational study which includes 117 patients who underwent surgery consecutively due to pancreatic or periampullary tumours. In 61 of the patients, cephalic pancreatectomy was carried out; 15 underwent total pancreatectomy; one underwent enucleation and 40 underwent distal pancreatectomy. RESULTS: Overall morbidity was 48.7% (59% for cephalic pancreatectomy, 35% for distal pancreatectomy and 46.7% for total pancreatectomy). The most frequent complications were intra-abdominal abscesses and collections (15.38%) and medical complications (13.68%). The incidence of pancreatic fistula was 9.83% for cephalic pancreatectomy and 10% for distal pancreatectomy. The reintervention incidence was 14.53%. Overall mortality was 5.12% (6.56% for cephalic pancreatectomy, 2.5% for distal pancreatectomy and 6.67% for total pancreatectomy). The presence of postoperative complications, the need for reintervention and the fact of being over 70 years of age correlated significantly with mortality. DISCUSSION: Pancreatic resection has high morbidity rates. Mortality is low and is practically limited to patients older than 70 years.

Prevalence of apical periodontitis and endodontictreatment in Portuguese adult population / Prevalência da periodontite apical e tratamentoendodôntico na população adulta portuguesa

Introduction: Studies on the prevalence of apical periodontitis and endodontic treatment in Portugal are scarce and outdated. However, studies in other countries have shown that the prevalence of apical periodontitis is high, especially in endodontic treated teeth. Objective: To estimate the prevalence of root-filled teeth and apical periodontitis in an adult Portuguese population. Materials and methods: Panoramic radiographs of a random sample of 222 subjects over 18 years old, who had more than seven teeth, and went to the Faculty of Dentistry, University of Porto, for the first time in 2010, were examined. The number of teeth that were root-filled and the periapical status of all teeth were assessed. Results: Apical periodontitis (PAI ≥ 3) was found in 1.7% of all teeth in the population study. Out of 5.552 teeth, 215 (3.9%) had filled roots. The prevalence of apical periodontitis was greater for root-filled teeth, posterior teeth, and men. The prevalence of apical periodontitis is also increased with age. Conclusion: The prevalence of apical periodontitis in Portugal is similar to its prevalence in other European countries and is higher for root-filled teeth than for non-treated teeth. The prevalence of root-filled teeth is different for Portugal than for other countries, which may be due to the differences in healthcare services provided in various countries.

Introdução: Estudos sobre a prevalência da periodontite apical e o tratamento endodôntico em Portugal são raros e desatualizados. Contudo, estudos noutros países revelaram que a prevalência da periodontite apical é alta, especialmente em dentes com tratamento endodôntico. Objetivo: Estimar a prevalência de tratamento endodôntico e periodontite apical em uma população adulta portuguesa. Materiais e métodos: Foram examinadas radiografias panorâmicas de uma amostra aleatória de 222 indivíduos maiores de 18 anos, que tiveram mais de sete dentes, e que atenderam a Faculdade de Odontologia da Universidade do Porto pela primeira vez em 2010. O número de dentes que receberam tratamento endodôntico e o estado periapical de todos os dentes foi avaliado. Resultados: Encontrou-se periodontite apical (PAI ≥ 3) em 1,7% de todos os dentes na população do estudo. De um total de 5.552 dentes, 215 (3,9%) apresentavam tratamento endodôntico. A prevalência de periodontite apical foi maior para dentes com canal tratado, dentes posteriores e homens. A prevalência de periodontite apical também aumentou com a idade. Conclusão: A prevalência de periodontite apical em Portugal é semelhante à sua prevalência em outros países europeus e é maior para dentes com canal tratado do que para os dentes não tratados. A prevalência de dentes com canal tratado é diferente em Portugal, comparado a outros países, em razão de diferenças nos cuidados de saúde prestados nos países.

Seudomixoma peritoneal presentado como ascitis en paciente cirrótico / Peritoneal pseudomyxoma presenting as ascites in a patient with cirrhosis

Presentamos el caso de un paciente cirrótico con ascitis y gradiente de albúmina menor de 1,1g/dl. Tras la realización de pruebas endoscópicas, incluyendo ecoendoscopia alta con PAAF, se decide llevar a cabo una laparoscopia exploradora para esclarecer el diagnóstico, observándose mucina por toda la cavidad peritoneal y nódulos sobre el peritoneo parietal y elvisceral. Tras el estudio anatomopatológico se estableció seudomixoma peritoneal como diagnóstico. Esta infrecuente entidad, de pronóstico infausto en ausencia de tratamiento, suele generarse en tumores mucinosos apendiculares, y en segundo lugar desde tumores ováricos (AU)

We present the case of a cirrhotic patient with ascites and an albumin gradient of less than 1.1g/dl. After endoscopic tests, including upper gastrointestinal endoscopic ultrasound-guided fine-needle aspiration, exploratory laparoscopy was performed to provide the diagnosis, revealing mucin throughout the peritoneal cavity and nodules on the parietal and visceral peritoneum. Histopathological analysis established the diagnosis as peritoneal pseudomyxoma. This uncommon entity, which has a poor prognosis without treatment, is most frequently associated with mucinous tumors of the appendix, and secondly, with tumors of the ovary (AU)

EUS-guided drainage and stent placement for postoperative intra-abdominal and pelvic fluid collections in oncological surgery.

OBJECTIVES: The objective of this study was to evaluate the role and benefits of endoscopic ultrasonography (EUS) in the management of postoperative intra-abdominal fluid collections after attempted curative surgery for abdominal cancer. METHODS: The authors retrospectively analysed the Endobase from 1 July 2007 to 30 January 2011 for patients with a postoperative intra-abdominal fluid collection who had undergone EUS-guided drainage and the placement of a stent. The data analysed included the demographics, type of surgery and clinical indications of each patient as well as their clinical and radiological findings. RESULTS: Six patients (three men and three women; mean age, 61.8 years [range, 38-78 years]) with intra-abdominal and pelvic fluid collections after abdominal surgery for cancer had undergone EUS-guided internal drainage. All procedures had been performed using linear EUS guidance and 8-Fr stent drainage catheters ('one step device', Giovannini, NWOA system Needle-Wire, Cook). The collection types included perigastric abscess (n = 3), perigastric hematoma and rectal hematoma (n = 1), perirectal biloma (n = 1), and perirectal abscess (n = 1). Patients had undergone the following types of surgery: lower-anterior rectal resection (n = 2), Whipple's duodenopancreatectomy type (n = 1), total gastrectomy (n = 1), splenectomy (n = 1), and distal pancreatectomy (n = 1). The number of stents inserted for each collection was one (five patients) and two (one patient). CONCLUSIONS: EUS-guided drainage and stenting provide another option for the management of postoperative collections. It allows access to areas that are difficult to reach with the CT-guided approach and it can be performed accurately, efficiently and safely. In addition to this, the internal nature of the drainage offers patients more comfort.

[Peritoneal pseudomyxoma presenting as ascites in a patient with cirrhosis]. / Seudomixoma peritoneal presentado como ascitis en paciente cirrótico.

We present the case of a cirrhotic patient with ascites and an albumin gradient of less than 1.1 g/dl. After endoscopic tests, including upper gastrointestinal endoscopic ultrasound-guided fine-needle aspiration, exploratory laparoscopy was performed to provide the diagnosis, revealing mucin throughout the peritoneal cavity and nodules on the parietal and visceral peritoneum. Histopathological analysis established the diagnosis as peritoneal pseudomyxoma. This uncommon entity, which has a poor prognosis without treatment, is most frequently associated with mucinous tumors of the appendix, and secondly, with tumors of the ovary.

Extraparietal or lymphatic late relapse of neoplasms: confirmation by means of EUS-FNA key for the treatment.

BACKGROUND: After treatment intended to cure systemic neoplasms, a series of monitoring strategies are followed. OBJECTIVE: To analyse our experience in confirming the cases of lymphatic or extraparietal relapse in areas accessible to endoscopic ultrasonography plus fine-needle aspiration (EUS-FNA) in long-term monitoring (>1 year of treatment for the primary neoplasm) and define what implications have been derived with regards histopathological confirmation in relation to treatment. MATERIALS AND METHODS: Retrospective analysis was made of all EUS-FNA carried out in our Endoscopy Unit during the period from 1/07/2007 to 28/02/2010 by means of searches in the Endobase (Olympus) database. Medical records of patients and drug therapy were reviewed in order to check the chemotherapy used in each case. RESULTS: From a total of 154 EUS-FNA carried out in our service, we have detected histopathological confirmation of malignancy in primary neoplasm treated with initial curative intention at least 1 year before. Locations were: esophageal extraparietal involvement of a squamous cell carcinoma (one patient), perirectal adenopathy of rectal adenocarcinoma (one patient), multiple lymphatic relapse of melanoma (two patients), perigastric adenopathy relapse of gastric adenocarcinoma (one patient), pancreatic head mass secondary to initial breast ductal carcinoma (one patient). In all cases, this fact has involved a directed treatment: surgery (one patient), radiotherapy (one patient), chemotherapy (four patients). CONCLUSIONS: Confirmation by means of EUS-FNA of late relapse in any section of the digestive tract allowed a treatment to be carried out by surgery, radiotherapy, or chemotherapy.

The global impact of endoscopic ultrasound (EUS) regarding the survival of a pancreatic adenocarcinoma in a tertiary hospital.

BACKGROUND: Pancreatic ductal adenocarcinoma is a type of neoplasm with a high mortality rate. There are a number of different procedures that may be followed in the study of the pancreas; one such procedure is endoscopic ultrasonography (EUS). OBJECTIVE: This study aimed to retrospectively evaluate the impact on patient survival of a biliopancreatic EUS performed 2 months prior to the first treatment session of the pancreatic ductal adenocarcinoma. MATERIAL AND METHODS: We carried out a retrospective evaluation of the medical case histories of our patients who had been diagnosed with pancreatic ductal adenocarcinoma over a period of 10 years (1 Jan 1999-31 Dec 2008), combining the computer archives of our Pathological Anatomy (biopsy and cytology) Dept. and those of the Digestive Department's Endoscopic Ultrasonography Unit in order to exclude any pancreatic neoplasms derived from other origins. Information regarding the patients' age, sex, tumor location, and various diagnostic tests (EUS, EUS-fine-needle aspiration (FNA), helical computed tomography (CT), multidetector-row CT (MDCT)) were recorded, along with the different treatments that had been followed in each case. RESULT: When the survival rates of patients diagnosed with and without EUS were compared, evaluating the average survival rate and the survival rate after 1, 3, and 5 years, respectively, the differences in the results proved to be statistically significant (p = 0.014) in favor of the diagnosis with EUS. However, no significant differences were found when using other diagnostic imaging methods, such as EUS-FNA (p = 0.271), helical CT (p = 0.843), or MDCT (p = 0.738). To evaluate other influencing survival factors, a study was undertaken to record data depending on the sex of the patients. Results showed a higher survival rate in the female patients with a median of 6.57 months compared to that of the male patients with a median of 4.7 months (p = 0.014). Variables, which had resulted significant prior to treatment, were included in a multivariate Cox regression model, after which only the sex and EUS remained significant. CONCLUSION: A biliopancreatic EUS carried out during the 2 months prior to the start of the treatment of the pancreatic ductal adenocarcinoma has a statistically significant impact on the patient survival rate. We believe that this is due to the possibility of a very-early-stage diagnosis of the adenocarcinoma permitted by the use of this technique.

Inicio de la enfermedad celíaca tras curación de hepatitis aguda por el virus de la hepatitis B / Onset of celiac disease after acute hepatitis B infection

La enfermedad celíaca se caracteriza por el daño de la mucosa intestinal y la consiguiente malabsorción de nutrientes en individuos genéticamente predispuestos tras la ingesta de gluten. Es una enfermedad compleja, resultado de la interacción de un componente genético poligénico y varios factores ambientales. Se ha propuesto la teoría de que procesos infecciosos transitorios o aumentos en la permeabilidad de la barrera mucosa podrían facilitar el inicio de la enfermedad por los péptidos del gluten de la luz intestinal. Presentamos el caso de 2 pacientes que presentaron el inicio de la enfermedad tras la curación de una hepatitis aguda por virus de la hepatitis B. Se discute la fisiopatología de la enfermedad y se plantean hipótesis que expliquen esta asociación (AU)

Celiac disease is characterized by small intestinal mucosal injury and nutrient malabsorption in genetically susceptible individuals following dietary ingestion of gluten. The pathogenesis of the disease involves interactions between environmental, genetic, and immunologic factors. Transient infections or increased permeability of the mucosa may facilitate disease onset induced by the uptake of gluten peptides into a microenvironmental milieu in the small intestinal mucosa. We present two patients with onset of celiac disease after resolution of acute hepatitis B virus infection. The physiopathology of celiac disease is discussed and possible explanations for this association are proposed (AU)