Inversión uterina no puerperal en paciente con leiomioma uterino: caso clínico

La inversión uterina es una patología de presentación rara e infrecuente. Se presenta el caso de una paciente con inversión uterina no puerperal con requerimiento de histerectomía abdominal total. Sin antecedentes de importancia asistió al servicio de urgencias por un cuadro clínico de dolor abdominal de 10 días de evolución asociado a sangrado vaginal abundante con inestabilidad hemodinámica y sensación de masa vaginal. Al examen físico se evidenció una masa sobresaliente del canal vaginal de aspecto necrótico, por lo que se sospechó mioma nascens. Durante la estancia hospitalaria presentó inestabilidad hemodinámica, por lo que fue llevada a histerectomía abdominal de urgencia con hallazgo de inversión uterina. La inversión uterina no puerperal es infrecuente. Es importante realizar un buen diagnóstico clínico apoyado de las imágenes si se encuentran disponibles, la intervención quirúrgica es necesaria y proporciona un buen pronóstico. La histerectomía vaginal no es sencilla en estos casos, por lo que se recomienda la histerectomía abdominal total.

Uterine inversion is a rare and infrequent disease. The case of a patient with a non-puerperal uterine inversion that had to be treated with a total abdominal hysterectomy is presented in this study. With no important history of disease, she attended the emergency department presenting abdominal pain in the last 10 days associated with vaginal bleeding and mass sensation. The physical examination revealed a protruding necrotic-like mass through the vagina, hence the suspicion of a myoma nascens. During her hospital ward stay, she presented hemodynamic instability, urgent abdominal hysterectomy had to be done which revealed uterine inversion. Non-puerperal uterine inversion is infrequent. Precise clinical diagnosis is important supported by diagnostic imaging if available. The surgical intervention is necessary, giving a good prognosis. Vaginal hysterectomy is not easy in this type of cases, therefore total abdominal hysterectomy is recommended.

[Depression and anxiety among medical students in virtual education during COVID-19 pandemic]. / Depresión y ansiedad en estudiantes de medicina en la educación virtual durante la pandemia por COVID-19.

Background: The lockdown derived from the declaration of a pandemic due to SARS-CoV-2 in March 2020 by the World Health Organization altered daily activities, including the academic ones, which were adapted to virtuality. In Ecuador, the new modality of study had an increase in the use of electronic devices that triggered new problems. Objective: To stablish the prevalence of depression and anxiety among medical students from the Universidad Central del Ecuador (Central University of Ecuador) in virtual education during the COVID-19 pandemic. Material and methods: Cross-sectional analytic study conducted between June and July of 2021 in students from first to tenth semester during virtual education. All studied subjects were evaluated using an electronic survey, depression and anxiety variables were assessed with the BDI-II and GAD-7 scales, respectively. In addition, sociodemographic data were collected, including the family APGAR. A response rate of 63.3% (1528 students) was obtained. Results: Overall prevalence of depression was 37.8% and the prevalence of anxiety 30.3%. Lower-years students were the most affected by these pathologies. The protective factors found were physical activity and psychological support in religion, whereas the main risk factors found were a dysfunctional family, lack of an exclusive study space and low academic performance. Furthermore, the frequency of depression and anxiety was significantly higher in women. Conclusion: The virtual modality showed a high prevalence of depression and anxiety in medical students.

Introducción: el confinamiento derivado de la declaración de pandemia por SARS-CoV-2 en marzo de 2020 por la Organización Mundial de la Salud alteró las actividades diarias, incluidas las académicas, que se adaptaron a la virtualidad. En Ecuador, la nueva modalidad de estudio tuvo un aumento del uso de dispositivos electrónicos que desencadenó nuevos problemas. Objetivo: determinar la prevalencia de depresión y ansiedad en estudiantes de medicina de la Universidad Central del Ecuador en el ciclo de educación virtual durante la pandemia por COVID-19. Material y métodos: estudio analítico transversal realizado entre junio y julio de 2021 en estudiantes de medicina de primero a décimo semestre durante la educación virtual. Por medio de una encuesta electrónica enviada a todos los sujetos de estudio, se evaluaron las variables depresión y ansiedad mediante las escalas BDI-II y GAD-7 respectivamente. Además, se recopilaron datos sociodemográficos, incluido el APGAR familiar. Se obtuvo una tasa de respuesta del 63.3% (1528 estudiantes). Resultados: la prevalencia de depresión fue de 37.8% y la de ansiedad 30.3%. Los estudiantes de años inferiores fueron los más afectados. Los factores protectores fueron la actividad física y el apoyo psicológico en la religión, mientras que los factores de riesgo fueron tener una familia disfuncional, la ausencia de un espacio exclusivo de estudio y un bajo rendimiento académico. Asimismo, la frecuencia de depresión y ansiedad fue significativamente superior en mujeres. Conclusión: durante la modalidad virtual se observó una alta prevalencia de sintomatología de depresión y ansiedad en estudiantes de medicina.

Substance use, injection risk behaviors, and fentanyl-related overdose risk among a sample of PWID post-Hurricane Maria.

BACKGROUND: While natural disasters like hurricanes are increasingly common, their long-term effects on people who inject drugs are not well understood. Although brief in duration, natural disasters can radically transform risk environments, increasing substance use and drug-related harms. METHODS: Based on a study of people who inject drugs (PWID) and injection risk behaviors in rural Puerto Rico, the present study uses data from two different phases of the parent study. Data for 110 participants were collected from December 2015 to January 2017, soon before Hurricane Maria landed in September 2017; the 2019 phase, in the aftermath of the hurricane, included a total of 103 participants. The present study's main analyses used data from 66 PWID who participated in both the pre-Maria and post-Maria interviews (66 individuals measured at two time points, for a total of 132 observations), using mixed-effects binomial logistic regression to examine recent overdose experiences pre- and post-Maria. A separate descriptive analysis included all 103 participants from the 2019 interview. RESULTS: After Hurricane Maria, some declines in injection frequency were observed (the percentage of people reporting injecting monthly or less increased from 3.0% before Hurricane Maria to 22.7% after Hurricane Maria). However, fewer PWID reported using a new needle for most or all injections. In the pre-Maria interview, 10.6% of participants indicated they had experienced an overdose during the year of the interview and/or the calendar year prior, and this figure increased to 24.2% in the post-Maria interview. In the regression analysis, the odds of reporting an overdose during the interview year and/or calendar year prior were three times as high post-Maria, relative to pre-Maria (odds ratio 3.25, 95% confidence interval 1.06-9.97). CONCLUSION: Substance use patterns, injection risk behaviors, and overdose episodes and deaths differed after Hurricane Maria, relative to before the hurricane, yet it is unclear to what extent these changes also reflect the simultaneous arrival of fentanyl. In preparation for future natural disasters, it is imperative to strengthen the health infrastructure by enhancing access and curbing barriers to syringe services programs and medications for opioid use disorder, particularly in rural or underserved locations.

Risk of Drug Overdose Mortality for Island-Born and US-Born Puerto Ricans, 2013-2019.

In the United States (US), individuals of Puerto Rican heritage die of drug overdoses at higher rates than other Hispanic groups or non-Hispanic Whites; yet, little is known about the extent to which drug overdose mortality affects island-born, versus US-born, Puerto Ricans. The distinction between Puerto Rican-born and US-born provides a starting point for culturally tailored services and interventions, as place of birth often informs language preferences and cultural identifications. Therefore, this study analyzed 2013-2019 death certificate data from the National Center for Health Statistics for 415,111 US deaths attributed to drug overdose. Drug overdose deaths were compared for island-born Puerto Ricans (N=3516), US-born Puerto Ricans (N=4949), and individuals not of Puerto Rican heritage (N=406,646). Drug overdose mortality rates, including age-specific and directly age-standardized rates, were calculated for each subgroup using population estimates from the US Census Bureau's American Community Survey. Results indicated that age-adjusted drug overdose mortality rates over the period of 2013-2019 were significantly higher for island-born than US-born Puerto Rican men (46.8 versus 34.6, per 100,000), with rates in both groups significantly higher than for men not of Puerto Rican heritage (24.0 per 100,000). For women, in contrast, drug overdose mortality rates were lower for island-born than US-born Puerto Ricans (8.6 versus 11.1, per 100,000). Within stateside Puerto Rican communities, island-born men experience a disproportionate burden of drug overdose mortality, necessitating targeted, culturally appropriate interventions built around the specific norms, circumstances, and lived experiences shared by Puerto Rican migrants who use drugs.

[Behavioral predisposing and social habits related to sexual life in university students]. / Predisponentes conductuales y hábitos sociales relacionados con la vida sexual en estudiantes universitarios.

Background: University students are usually a risk group in terms of their sexual life, either because of social habits or because of the behavioral predisposers to which they are exposed. This article analyse the relationship between these factors. Objective: To establish the frequency and relationship between behavioral and social predisposers with active sexual life (ASL) in university students. Material and methods: Cross-sectional study, carried out in 360 medical students. The data of sexual life and the behavioral and social factors associated with it were analyzed through prevalences with their confidence intervals, as well as the calculation of the Odds Ratio (OR). Results: The results showed that 58.9% (95%CI: 53.7%-63.9%) of the students have ever had sexual intercourse. The only behavioral predisposing associated with ASL was the absence of religious practices (OR: 2.6; 95%CI: 1.6-4.1; p < 0.001), while all the habits and social behaviors analyzed were significantly associated with ASL, the most common being attendance at parties (77.8%) and the consumption of alcoholic beverages (67.2%). Conclusions: Our results show that young people present a wide range of behavioral and social characteristics that influence their sexual life, therefore, implementing strategies aimed at protecting sexual and reproductive health is also necessary in this age group.

Introducción: los estudiantes universitarios suelen ser un grupo de riesgo en cuanto a su vida sexual, ya sea por los hábitos sociales o por los predisponentes conductuales a los que se encuentran expuestos. Este artículo analiza la relación entre estos factores. Objetivo: establecer la frecuencia y relación entre predisponentes conductuales y sociales con la vida sexual activa (VSA) en estudiantes universitarios. Material y métodos: estudio transversal, realizado en 360 estudiantes de Medicina. Los datos de la vida sexual y los factores conductuales y sociales asociados a ella, se analizaron a través de prevalencias con sus intervalos de confianza, así como con el cálculo del Odds Ratio (OR). Resultados: los resultados mostraron que el 58.9% (IC95%: 53.7%-63.9%) de los estudiantes han tenido alguna vez relaciones sexuales. El único predisponente conductual que se asoció con la VSA fue la ausencia de prácticas religiosas (OR: 2.6; IC95%: 1.6-4.1; p < 0.001), mientras que todos los hábitos y conductas sociales analizados, se asociaron significativamente con la VSA, siendo los más comúnes la asistencia a fiestas (77.8%) y el consumo de bebidas alcohólicas (67.2%). Conclusiones: nuestros resultados muestran que los jóvenes presentan una amplia gama de características conductuales y sociales que influyen en su vida sexual, por lo que, el implementar estrategias orientadas a proteger la salud sexual y reproductiva también es necesario en este grupo etario.

Predisponentes conductuales y hábitos sociales relacionados con la vida sexual en estudiantes universitarios / Behavioral predisposing and social habits related to sexual life in university students

Introducción: los estudiantes universitarios suelen ser un grupo de riesgo en cuanto a su vida sexual, ya sea por los hábitos sociales o por los predisponentes conductuales a los que se encuentran expuestos. Este artículo analiza la relación entre estos factores. Objetivo: establecer la frecuencia y relación entre predisponentes conductuales y sociales con la vida sexual activa (VSA) en estudiantes universitarios. Material y métodos: estudio transversal, realizado en 360 estudiantes de Medicina. Los datos de la vida sexual y los factores conductuales y sociales asociados a ella, se analizaron a través de prevalencias con sus intervalos de confianza, así como con el cálculo del Odds Ratio (OR). Resultados: los resultados mostraron que el 58.9% (IC95%: 53.7%-63.9%) de los estudiantes han tenido alguna vez relaciones sexuales. El único predisponente conductual que se asoció con la VSA fue la ausencia de prácticas religiosas (OR: 2.6; IC95%: 1.6-4.1; p < 0.001), mientras que todos los hábitos y conductas sociales analizados, se asociaron significativamente con la VSA, siendo los más comúnes la asistencia a fiestas (77.8%) y el consumo de bebidas alcohólicas (67.2%). Conclusiones: nuestros resultados muestran que los jóvenes presentan una amplia gama de características conductuales y sociales que influyen en su vida sexual, por lo que, el implementar estrategias orientadas a proteger la salud sexual y reproductiva también es necesario en este grupo etario.

Background: University students are usually a risk group in terms of their sexual life, either because of social habits or because of the behavioral predisposers to which they are exposed. This article analyse the relationship between these factors. Objective: To establish the frequency and relationship between behavioral and social predisposers with active sexual life (ASL) in university students. Material and methods: Cross-sectional study, carried out in 360 medical students. The data of sexual life and the behavioral and social factors associated with it were analyzed through prevalences with their confidence intervals, as well as the calculation of the Odds Ratio (OR). Results: The results showed that 58.9% (95%CI: 53.7%-63.9%) of the students have ever had sexual intercourse. The only behavioral predisposing associated with ASL was the absence of religious practices (OR: 2.6; 95%CI: 1.6-4.1; p < 0.001), while all the habits and social behaviors analyzed were significantly associated with ASL, the most common being attendance at parties (77.8%) and the consumption of alcoholic beverages (67.2%). Conclusions: Our results show that young people present a wide range of behavioral and social characteristics that influence their sexual life, therefore, implementing strategies aimed at protecting sexual and reproductive health is also necessary in this age group.

Drug overdose mortality among stateside Puerto Ricans: Evidence of a health disparity.

BACKGROUND: This study compared drug overdose mortality rates in Puerto Rican-heritage and Non-Hispanic (NH) White individuals in the United States (US), examining time trends and recent variation by age, sex, state of residence, and drugs involved in overdose. METHODS: Death certificate data from the National Center for Health Statistics, as well as American Community Survey population estimates, were used to calculate age-specific and age-adjusted drug overdose mortality rates for Puerto Rican-heritage and NH White residents of the 50 United States or District of Columbia (DC). Rates for 2018 were compared between Puerto Rican-heritage and NH White individuals, overall and by sex, age, state, and specific drug involved in overdose. Joinpoint Regression was used to examine trends in drug overdose mortality rates from 2009 to 2018. RESULTS: From 2009 to 2018, the age-adjusted drug overdose mortality rate in stateside Puerto Ricans doubled among women (from 6.0 to 12.5 per 100,000) and nearly tripled among men (from 15.3 to 45.2 per 100,000). In 2018, the age-adjusted drug overdose mortality rate was significantly higher in Puerto Rican-heritage than NH White individuals (28.7 vs. 26.2 per 100,000, respectively). The 2018 drug overdose mortality rate was highest among Puerto Rican-heritage men ages 45-54 (104.1 per 100,000). CONCLUSION: Findings emphasize the necessity of policies, programs, and interventions to mitigate risk of fatal overdose in stateside Puerto Rican communities.

Trends in HIV and HCV Risk Behaviors and Prevalent Infection Among People Who Inject Drugs in New York City, 2005-2012.

BACKGROUND: We assess trends in HIV and hepatitis C virus (HCV) risk behaviors and prevalent infection among people who inject drugs (PWID) in New York City (NYC). METHODS: PWID in NYC were sampled using respondent-driven sampling in 2005, 2009, and 2012 (serial cross sections) for the Centers for Disease Control and Prevention-sponsored National HIV Behavioral Surveillance study. Participants were interviewed about their current (≤12 months) risk behaviors and tested for HIV and HCV. The crude and adjusted risk ratio (RR) and 95% confidence interval (95% CI) for linear time trends were estimated using generalized estimating equations regression with a modified Poisson model. RESULTS: The sample comprised 500, 514, and 525 participants in 2005, 2009, and 2012, respectively. Significant (P < 0.05) linear trends in risk behaviors included a decline in unsafe syringe sources (60.8%, 31.3%, 46.7%; RR = 0.86, 95% CI: 0.81 to 0.92), an increase in all syringes from syringe exchanges or pharmacies (35.4%, 67.5%, 50.3%; RR = 1.15, 95% CI: 1.09 to 1.22), and an increase in condomless vaginal or anal sex (53.6%, 71.2%, 70.3%; RR = 1.14, 95% CI: 1.09 to 1.19). Receptive syringe sharing (21.4%, 27.0%, 25.1%), sharing drug preparation equipment (45.4%, 43.4%, 46.7%), and having ≥2 sex partners (51.2%, 44.0%, 50.7%) were stable. Although HIV seroprevalence declined (18.1%, 12.5%, 12.2%), HCV seroprevalence was high (68.2%, 75.8%, 67.1%). In multivariate analysis, adjusting for sample characteristics significantly associated with time, linear time trends remained significant, and the decline in HIV seroprevalence gained significance (adjusted RR = 0.76, 95% CI: 0.64 to 0.91, P = 0.003). CONCLUSIONS: This trend analysis suggests declining HIV prevalence among NYC PWID. However, HCV seroprevalence was high and risk behaviors were considerable. Longitudinal surveillance of HIV and HCV risk behaviors and infections is needed to monitor trends and for ongoing data-informed prevention among PWID.

Time Since Migration and HIV Risk Behaviors Among Puerto Ricans Who Inject Drugs in New York City.

BACKGROUND: Among people who inject drugs (PWID) in the United States, those who initiated drug injection in Puerto Rico (immigrant Puerto Rican PWID) engage in more injection and sexual risk behaviors, and have higher HIV incidence than non-Hispanic whites. OBJECTIVE: Understand the persistence of these HIV behaviors. METHODS: In a cross-sectional study conducted in New York City (NYC) in 2012 (National HIV Behavioral Surveillance), PWID aged ≥18 years were recruited using Respondent-Driven Sampling, interviewed, and tested for HIV. Participants were categorized into 5 different groups: (1) US-born non-Hispanic PWID, (2) US-born Puerto Rican PWID, (3) recent immigrant Puerto Rican PWID (≤3 years in NYC), (4) medium-term immigrant Puerto Rican PWID (>3 and ≤10 years in NYC), and (5) long-term immigrant Puerto Rican PWID (>10 years in NYC). We examined the relationship between time since migrating on sexual and injection risk behaviors among immigrant Puerto Rican PWID, compared with U.S.-born Puerto Rican PWID and US-born non-Hispanic PWID. Adjusted odds ratios (aOR) and 95% confidence intervals (95% CI) were estimated using logistic regression. RESULTS: A total of 481 PWID were recruited. In adjusted analyses using US-born non-Hispanic PWID as the comparison group, syringe sharing was significantly more likely among medium-term immigrants; and unprotected sex with casual partners was more likely among recent and long-term immigrants. CONCLUSIONS: The risk-acculturation process for immigrant Puerto Rican PWID may be nonlinear and may not necessarily lead to risk reduction over time. Research is needed to better understand this process.

Understanding differences in HIV/HCV prevalence according to differentiated risk behaviors in a sample of PWID in rural Puerto Rico.

BACKGROUND: Blood contained in needles and injection equipment has been identified as a vector for HIV and HCV transmission among people who inject drugs (PWID). Yet, there is often a wide discrepancy in prevalence for both viruses. While microbiological differences between viruses influence prevalence, other variables associated with the way drugs are acquired and used, also play a role. METHODS: Respondent-driven sampling (RDS) methods recruited a sample of 315 current intravenous drug users in rural Puerto Rico. Information about type and frequency of use, HIV and HVC risk behaviors (sharing needles, cookers, cotton, and water), sexual behaviors, and alcohol use was collected. HIV and HCV statuses were assessed via rapid antibody tests. T tests compare means of participants who tested positive (reactive) to those who tested negative. Logistic regression analyses were used to validate the association of the risk factors involved. RESULTS: Tests showed a significant difference in HIV (6%) and HCV (78.4%) prevalence among a population of current PWID. The main risk behaviors in HCV transmission are the sharing of injection "works", (e.g., cookers, cotton, and water). Sharing works occurred more than twice as often as the sharing of needles, and HCV+ and HCV- individuals reported the same needle sharing habits. CONCLUSIONS: Washing and rinsing injection works with water seems to prevent HIV transmission, but it is unable to prevent HCV infection. While education about the need to clean injection equipment with bleach might be beneficial, equipment sharing--and the subsequent risk of HVC--might be unavoidable in a context where participants are forced to pool resources to acquire and use intravenous drugs.

Community Sexual Bridging Among Heterosexuals at High-Risk of HIV in New York City.

Community sexual bridging may influence the socio-geographic distribution of heterosexually transmitted HIV. In a cross-sectional study, heterosexual adults at high-risk of HIV were recruited in New York City (NYC) in 2010 for the Centers for Disease Control and Prevention-sponsored National HIV Behavioral Surveillance system. Eligible participants were interviewed about their HIV risk behaviors and sexual partnerships and tested for HIV. Social network analysis of the geographic location of participants' recent sexual partnerships was used to calculate three sexual bridging measures (non-redundant ties, flow-betweenness and walk-betweenness) for NYC communities (defined as United Hospital Fund neighborhoods), which were plotted against HIV prevalence in each community. The analysis sample comprised 494 participants and 1534 sexual partnerships. Participants were 60.1 % male, 79.6 % non-Hispanic black and 19.6 % Hispanic race/ethnicity; the median age was 40 years (IQR 24-50); 37.7 % had ever been homeless (past 12 months); 16.6 % had ever injected drugs; in the past 12 months 76.7 % used non-injection drugs and 90.1 % engaged in condomless vaginal or anal sex; 9.6 % tested HIV positive (of 481 with positive/negative results). Sexual partnerships were located in 33 (78.6 %) of 42 NYC communities, including 13 "high HIV-spread communities", 7 "hidden bridging communities", 0 "contained high HIV prevalence communities", and 13 "latent HIV bridging communities". Compared with latent HIV bridging communities, the population racial/ethnic composition was more likely (p < 0.0001) to be black or Hispanic in high HIV-spread communities and to be black in hidden bridging communities. High HIV-spread and hidden bridging communities may facilitate the maintenance and spread of heterosexually transmitted HIV in black and Hispanic populations in NYC.

Prescription Drug Diversion: Predictors of Illicit Acquisition and Redistribution in Three U.S. Metropolitan Areas.

OBJECTIVE: Prescription drug diversion, the transfer of prescription drugs from lawful to unlawful channels for distribution or use, is a problem in the United States. Despite the pervasiveness of diversion, there are gaps in the literature regarding characteristics of individuals who participate in the illicit trade of prescription drugs. This study examines a range of predictors (e.g., demographics, prescription insurance coverage, perceived risk associated with prescription drug diversion) of membership in three distinct diverter groups: individuals who illicitly acquire prescription drugs, those who redistribute them, and those who engage in both behaviors. METHODS: Data were drawn from a cross-sectional Internet study (N = 846) of prescription drug use and diversion patterns in New York City, South Florida, and Washington, D.C.. Participants were classified into diversion categories based on their self-reported involvement in the trade of prescription drugs. Group differences in background characteristics of diverter groups were assessed by Chi-Square tests and followed up with multivariate logistic regressions. RESULTS: While individuals in all diversion groups were more likely to be younger and have a licit prescription for any of the assessed drugs in the past year than those who did not divert, individuals who both acquire and redistribute are more likely to live in New York City, not have prescription insurance coverage, and perceive fewer legal risks of prescription drug diversion. CONCLUSION: Findings suggest that predictive characteristics vary according to diverter group.

Perceptions of genetic testing and genomic medicine among drug users.

BACKGROUND: Genetic testing will soon enter care for human immunodeficiency virus (HIV) and hepatitis C virus (HCV), and for addiction. There is a paucity of data on how to disseminate genetic testing into healthcare for marginalized populations. We explored drug users' perceptions of genetic testing. METHODS: Six focus groups were conducted with 34 drug users recruited from syringe exchange programmes and an HIV clinic between May and June 2012. Individual interviews were conducted with participants reporting previous genetic testing. RESULTS: All participants expressed acceptance of genetic testing to improve care, but most had concerns regarding confidentiality and implications for law enforcement. Most expressed more comfort with genetic testing based on individual considerations rather than testing based on race/ethnicity. Participants expressed comfort with genetic testing in medical care rather than drug treatment settings and when specifically asked permission, with peer support, and given a clear rationale. CONCLUSION: Although participants understood the potential value of genetic testing, concerns regarding breaches in confidentiality and discrimination may reduce testing willingness. Safeguards against these risks, peer support, and testing in medical settings based on individual factors and with clear rationales provided may be critical in efforts to promote acceptance of genetic testing among drug users.