Algunos síndromes epilépticos se caracterizan por crisis frecuentes de difícil control que asocian un retraso en el desarrollo neuropsicomotor y deterioran la calidad de vida de los pacientes y la familia [1]. A pesar de la correcta utilización de los fármacos antiepilépticos disponibles en la actualidad, el 30% de los pacientes no logra un adecuado control de sus crisis [2]. El uso del cannabidiol como una terapia coadyuvante en el tratamiento de las epilepsias refractarias se ha ido extendiendo a través de estas últimas décadas. Se han identificado las propiedades terapéuticas del cannabidiol a través de estudios preclínicos, y se han demostrado efectos anti convulsionantes [1-4], antiinflamatorios y antioxidantes. Además, se ha notificado una mejoría en la funciones neurocognitivas, como un mayor estado de alerta, mejor memoria, mejor estado de ánimo y mejor calidad del sueño [1]. El cannabidiol se presenta como una nueva diana terapéutica segura. Carece de efecto psicoactivo y se tolera bien debido a los leves efectos adversos comunicados [2-5].

Ecuador es un país con recursos limitados con respecto a tecnologías sanitarias, en el proceso de esta crisis se debe invertir en estas tecnologías, de acuerdo al contexto de este país. Las estrategias que se manejen deben instaurarse en varios niveles: nacional, gobiernos locales, comunitarias y familiares/individuales. Cualquier acción dirigida a una acción médica, tiene que ser valorada como una tecnología en salud y para que un gobierno decida invertir o incluso desinvertir tiene que existir un proceso de evaluación económica de las tecnologías, para lo cual se usa el plano de costo efectividad..

La colecistectomía laparoscópica es uno de los procedimientos quirúrgicos más comunes en la actualidad. En los Estados Unidos, aproximadamente 700 mil colecistectomías se realizan anualmente, el 70% de las cuales se llevan a cabo por vía laparoscópica. La morbilidad postoperatoria, mortalidad y estancia hospitalaria se reducen con la colecistectomía laparoscópica, por lo cual ha tomado el lugar de la colecistectomía abierta como el procedimiento operativo estándar para colecistitis [1]; sin embargo, conlleva una mayor incidencia de lesión de la vía biliar, debido a que el procedimiento laparoscópico ofrece una limitada visibilidad en tres dimensiones y en el sentido táctil [2–5]. Por otra parte, las anomalías y variaciones anatómicas de los conductos biliares y del sistema vascular representan retos operatorios y un riesgo para complicaciones posoperatorias. Las anomalías de los segmentos hepáticos derechos representan un 20% de las variantes anatómicas biliares. Sin embargo, la total independencia de un segmento hepático o de un sector supone sólo un 2% de las malformaciones congénitas del árbol biliar. Aunque un conducto hepático aberrante que desemboca en el conducto cístico no es especialmente raro, el conducto hepático derecho que desemboca en el conducto cístico es extremadamente infrecuente, con sólo seis casos reportados hasta el momento [6, 7].

El lupus eritematoso sistémico (LES) es una enfermedad crónica que afecta a múltiples sistemas, entre ellos el sistema nervioso, con eventos neurológicos y psiquiátricos que podrían unir en la adherencia al tratamiento y los resultados a largo plazo de la enfermedad.Evaluar la adherencia al tratamiento de los pacientes con trastornos neuropsiquiátricos difusos asociados con el LES. Se llevó a cabo un estudio descriptivo transversal que evaluó el grado de adherencia al tratamiento con el test de Morisky en pacientes con trastornos neuropsiquiátricos difusos asociados con LES (alteración cognitiva, psicosis, trastornos del ánimo y ansiedad). Se incluyó a pacientes con trastornos neuropsiquiátricos difusos asociados con LES, de los cuales (,%) tuvieron adherencia alta,(%) adherencia media y (,%) presentaron baja adherencia al tratamiento. En este estudio se idéntico que más de la mitad de los participantes (,%) presentaron bajaadherencia al tratamiento.

Estudiar las características clínicas de la esclerosis tuberosa en pacientes de un hospital pediátrico en Ecuador. Pacientes y métodos Se realizó una búsqueda de historias clínicas de pacientes con esclerosis tuberosa entre los años 2012 y 2016 en un hospital pediátrico de Ecuador; se seleccionó a 31 pacientes que cumplieron los criterios de diagnóstico definitivo. Se analizaron el diagnóstico inicial, el curso clínico y las manifestaciones clínicas y radiológicas de la TSC en los distintos órganos, con particular interés sobre la patología del sistema nervioso central y su relación con los aspectos neurológicos y neuropsiquiátricos.

Se presenta el caso de una paciente de 65 años de edad, atendida en consulta externa del Hospital Carlos Andrade Marín por dolor abdominal epigástrico de diez años de evolución, acompañado de tos, distención abdominal y sensación de llenura precoz. Un mes antes del ingreso manifiesta vómitos a repetición y pérdida de peso. Se diagnostica mediante endoscopía digestiva y tomografía axial computarizada un lipoma duodenal que ameritó tratamiento quirúrgico para enuclear el lipoma mediante laparotomía. Los lipomas duodenales son raros, la mayoría son asintomáticos y se descubren accidentalmente durante una endoscopia o cirugía.

Currently, the evaluation of mental disorders in patients with Systemic lupus erythematosus (SLE) is essential in the management of the illness because of their impact in morbimortality. The main purpose of this study was to determine the prevalence of mental disorders in a group of patients with SLE in a tertiary referral hospital in Quito-Ecuador. The main diffuse central nervous system psychiatric syndromes in SLE (psychosis, anxiety and mood disorders) and cognitive dysfunction were evaluated with the MINI International Neuropsychiatric Interview and the Montreal scale, respectively. This was a descriptive, cross-sectional study which included patients 15 years and older diagnosed with SLE in a tertiary referral hospital in Quito, Ecuador. 85 patients diagnosed with SLE attending the internal medicine outpatient clinic during October 2017–May 2018 were included. A bivariate analysis of possible associations between these mental disorders with corticosteroid use, antiphospholipid syndrome (APS), and quality of life was also studied. Eighty-five patients, with an average age of 34.12 ± 11.5 years were included, of which 94% were females. 71% of participants (60 patients) had at least one mental disorder evaluated in this study. The most frequent was cognitive impairment (n=43, 51%) followed by anxiety disorders (n=35, 41%), mood disorders (n=34, 40%) and psychosis (n=1; 1%). 38% presented mild cognitive impairment and 13% had moderate cognitive impairment.

Objetivo Evaluar las causas atribuibles que originan oportunidades perdidas de vacunación (OPDV) en centros de primer nivel de atención de un Distrito de Salud de la ciudad de Quito. Material y métodos Se realizó un estudio transversal de las OPDV a través de una encuesta a 368 padres o cuidadores de niños de 5 años o menores en el año 2017, en los centros de salud de primer nivel de atención del Distrito 17D05 de la ciudad de Quito, Ecuador. Se llevó a cabo un análisis univariado y bivariado para la descripción de la población del estudio y los posibles factores de riesgo relacionados. Resultados De los 368 niños con carné de vacunación, 123 (33,4%) tenían carné de vacunación incompleto, y 44 (35,7%) de estos fueron susceptibles de ser vacunados, pero solo 21 (44,7%) fueron vacunados. Las causas atribuibles a no vacunación fueron que el padre o cuidador refiere no haber traído a vacunar (76,2%) y causas atribuibles a los conocimientos del personal de salud (19%). Al evaluar los factores de riesgo para OPDV, la edad del cuidador resultó como el único factor estadísticamente significativo. Conclusiones Las OPDV se atribuyeron principalmente a causas relacionadas con la demanda del servicio, es decir, a motivos generados de los padres o cuidadores, y en menor medida a las actitudes del personal de salud estudiadas desde el punto de vista del usuario.

Objective: The aim of this study was to estimate the direct cost per episode and the annual cost for upper respiratory tract infection (URTI) in children in Ambulatory Health Centers of the Ministry of Public Health (MSP) of Ecuador. Methods: A cost of illness study with a provider perspective was carried out through a micro-costing of health resources and valuated in international dollars. Medical visits, laboratory tests, imaging examinations, and other procedures were valued using the tariff framework of services for the National Health System, and for prescribed medication a reported cost registry of pharmacy purchases made in the year of study was used. Results: We included 380 electronic health records of children. We found a re-consultation rate of 22.89%, a medicine prescription rate of 95.52%, and an antibiotic prescription rate of 45.26%. The first medical consultation accounted for 71.9% of the total cost of URTI, the following visits accounted for 11.82%, and medication accounted for 14.68%. Antibiotics accounted for 58.92% of the total cost of medication. Conclusion: The direct medical cost to the MSP of Ecuador of 1 episode of URTI in children in primary care was around I$37.28 (2017 dollars) (95% CI: I$35.81-I$38.75). The total cost of URTI cases in children to the MSP in 2017 was at least I$50.478 million (2017 dollars) (95% CI I$48.527m-I$52.523m). Re-consultation and the prescription of medication represent an important component of the direct cost of medical care of URTI.

Clinical guidelines (CG) are used to reduce variability in practice when the scientific evidence is sparse or when multiple therapies are available. The development and implementation of evidence-based CG is intended to organize and provide the best available evidence to support clinical decision making in order to improve quality of care. Upper respiratory tract infections (URTI) are the leading cause of misuse of antibiotics and a CG may reduce the unnecessary antibiotic prescription. The aim of this quasi-experimental, before-after study was to analyze the short- and long-term effects of the implementation of a CG to decrease the rate of antibiotic prescription in URTI cases in the emergency department of a third level private hospital in Quito, Ecuador The study included 444 patients with a main diagnosis of URTI. They were distributed in three groups: a baseline cohort 2011 (n = 114), a first post-implementation cohort 2011 (n =114), and a later post-implementation cohort 2018 (n = 216). The implementation strategy consisted of five key steps: acceptance of the need for implementation of the CG, dissemination of the CG, an educational campaign, constant feedback, and sustainability of the strategy through continuous training. The results of this study show a 42.90% of antibiotic prescription rate before the CG implementation. After the implementation of the CG, the prescription rate of antibiotics was significantly reduced by 24.5% (42.9% vs 18.4%, p<0.0001) and the appropriate antibiotic prescription rate was significantly increased by 44.2%

Background: Upper respiratory tract infections are the leading cause of misuse of antibiotics, a problem that leads to unnecessary adverse events and antibiotic resistance. Antibiotic prescription in Ecuador was analyzed in order to evaluate the state of antibiotic prescribing for upper respiratory tract infections. Both the appropriateness and adequacy of prescribing was evaluated. Appropriateness represents the percentage of prescriptions that are indicated; adequacy refers to the percentage of patients requiring antibiotics who are treated. Methods: The aim of the study is to analyze the appropriateness and adequacy of antibiotic prescription for upper respiratory tract infections in the Ambulatory Health Centers of the Ministry of Public Health of Ecuador. This is a cross-sectional study of patients from one Health Center of the Ministry of Public Health in the District 17D03 in Ecuador during 2015 with upper respiratory tract infection as a primary diagnosis. Results: We included a total of 1393 patients in the analysis. Out of the 1393 patients identified, 523 were prescribed antibiotics, constituting an antibiotic prescription rate of 37.5%, and 51 required antibiotics, reflecting a real need of antibiotics of 3.7%. Appropriateness: Of these 523 patients who were treated, 51 required an antibiotic, resulting in an appropriate antibiotic prescription rate of 9.75%. Adequacy: When analyzing each individual case, 33 of these 51 patients received an antibiotic, constituting an adequate prescription rate of 64.7%.

Introduction: Studies have shown that pneumococcal disease significantly increases morbidity and mortality rates in children 5 years old and under. These infections constitute the main cause of preventable deaths in the world, considering the availability of vaccination. Considering that Ecuador is in a high incidence region, despite the introduction of the vaccine, this study aims to describe the burden of hospitalized pneumococcal disease and related mortality in our country between 2005 and 2015, to help decision-making processes for the health authorities. Methods: This cross-sectional study analyzes morbidity, mortality, and the situation in Ecuador caused by pneumococcal disease in children 5 years old and under between 2005 and 2015 using national databases. Results: A total of 163,852 cases of children 5 years old and under were reported to have been hospitalized due to pneumococcal-related diseases. Males comprised 54.7% of the cases and females 45.3%. In 36% of the cases, thepatients were 1 year old or under. The mortality rate due to pneumococcal disease in Ecuador in children aged 5 and under decreased in 48% during 2005-2015. Conclusion: The decrease in mortality can be related to the introduction of the vaccine and an increase in access to health care by the general population in the country. It is important to study the specific impact of the vaccine in the reduction of morbidity and mortality of children in Ecuador.

Introduction: Adolescent pregnancy is associated to school desertion, violence, termination of pregnancy under suboptimal conditions, obstetric complications and other consequences that can put the woman's quality of life at risk and of those that surround her. The purpose of this study is to describe the situation and tendencies of adolescent pregnancies, abortions and maternal deaths between 2013 and 2016 in Ecuador. Methods: This cross-sectional study uses secondary data from national Ecuadorian vital statistics reports of adolescents between 10 and 19 years old. The data sources used register all the births, deaths and hospital discharges in the country at both public and private health establishments. We performed a descriptive analysis of qualitative and quantitative variables. Results: Ecuador has approximately 1.5 million female adolescents that gave birth to 256,561 newborns between 2013 and 2016, resulting in an average annual birth rate in early adolescence of 13.9 live births per 1000 and in late adolescence of 86.6 per 1000 live births. The number of registered abortions among adolescents between 2013 and 2016 was of 19,214. The estimated annual abortion rate in late stage adolescents is 6.3 abortions per 1000 women between 15 and 19. The estimated abortion ratio for this same age group is 72.9 per 1000 live births. Of all the adolescents that gave birth, 84.9% self-identified as mestiza, while 71.9% of Ecuador's general population identifies as such. Only 7% of the general population in Ecuador self-identifies as indigenous, while 21.6% of pregnancies come from this population.

Background: Inappropriate prescriptions of antibiotics lead to ineffective and unsafe treatments and worsening of diseases. Medical students may have deficiencies in their prescription skills and they may need further training in the use of antibiotics for their practice. Medical skills in prescribing antibiotics can be improved through continuous medical education. The aim of this study was to assess the current levels of knowledge, attitudes, and practices (KAP) in antibiotic prescription in upper respiratory tract infections (URTI) among postgraduate family medicine students in Ecuador.Methods: A cross-sectional study with an on-line survey, based on micro-curricular contents, to evaluate KAPs regarding antibiotic prescription in URTI among postgraduate family medicine students in 5 provinces of Ecuador.Results: Two hundred and seventy-three physicians responded (94.1%). Most physicians treated between 1 and 5 URTI cases per day. The odds for inadequate knowledge and inappropriate practices in URTI among postgraduate family medicine students were 8.74 (95%CI, 4.94-15.46, P < .001) and 5.99, (IC95%, 2.66-13.50, P < .001) in physicians who were students of the first half of the stud program. Conclusion: The knowledge in URTI was limited among physicians. Nonetheless, they expressed a positive attitude toward not using antibiotics in URTI. A postgraduate program can significantly improve the knowledge and practices related to antibiotic prescriptions in URTI.

Background: Pneumococcal conjugate vaccines (PCV) reduce the burden of invasive pneumococcal disease and pneumonia hospitalizations. However, there is limited evidence of the effect of PCVs on pneumonia mortality in children. It is anticipated that indirect effects resulting from PCV use among children might further reduce the remaining burden of adult pneumococcal disease caused by pneumococcal serotypes contained in PCV. Whether this will result in reduced pneumonia mortality in children and adults is still not known. Methods: We investigated the impact of PCV on pneumonia hospitalization and mortality in in Ecuador, where PCV was introduced in 2010, considering national data from secondary data sources from 2005 to 2015. Time series analysis using regression models were used to evaluate the decline in the number of all-cause pneumonia hospitalizations and deaths in the period post-PCV introduction. The target populations were children under 5 years and adults aged 50 years and over. Outcomes of interest were hospitalizations and mortality in which the main cause of hospital admission and death, respectively, were coded as ICD10 codes J12-18 (pneumonia). Three different models were fitted. Results: We demonstrate a sizeable impact of PCV in pneumonia hospitalization in children < 1 year (27% reduction, 95%CI 12–42%), and < 5 years of age (33% reduction, 95%CI 11–43%).