ACTA MEDICA PERUANA http://www.amp.cmp.org.pe/index.php/AMP Acta Médica Peruana es la revista científica oficial del Colegio Médico del Perú; tiene como finalidad difundir el conocimiento médico a la comunidad médica y científica a nivel nacional e internacional. en-US actamedicaperuana@cmp.org.pe (Acta Medica Peruana) actamedicaperuana@cmp.org.pe (Asistencia Tecnica - AMP) Thu, 14 May 2020 00:00:00 -0500 OJS 3.1.2.1 http://blogs.law.harvard.edu/tech/rss 60 Risk and death of doctors 100 days after the state of emergency by COVID-19 in Peru http://www.amp.cmp.org.pe/index.php/AMP/article/view/1033 <p>-</p> Eden Galan-Rodas, Augusto Tarazona-Fernandez, Miguel Palacios-Celi Copyright (c) 2020 ACTA MEDICA PERUANA http://www.amp.cmp.org.pe/index.php/AMP/article/view/1033 Wed, 01 Jul 2020 08:56:54 -0500 Overall survival of metastatic colorectal cancer in Lima: relationship with the KRAS gene mutational status http://www.amp.cmp.org.pe/index.php/AMP/article/view/868 <p><strong>Objectives:</strong> the main goal for this study was to evaluate overall survival in mCRC patients with mutated vs. wild type KRAS gene (exon 2) status. <strong>Materials and methods:</strong> between January 2010 and December 2013, data from clinical records of mCRC patients from different hospitals in Lima, stating an assessment of the KRAS gene mutation status (exon 2), were analyzed. Kaplan-Meier survival estimates and Log-Rank or Breslow Test were used to compare the survival curves. <strong>Results:</strong> three-hundred and twenty cases were analyzed. There were 227 patients (70.93%) with wild type KRAS and 93 (29.07%) with mutated KRAS. The overall survival of mCRC patients and mutated KRAS was higher than that of patients with wild type KRAS (HR: 0.73; 95% CI: 0.55–0.98; P= 0.037). <strong>Conclusion:</strong> patients with mCRC and mutated KRAS who were studied in Lima have higher survival rates compared to wild type patients, being this different from what is found in the world literature.</p> Franklin Aldecoa Copyright (c) 2020 ACTA MEDICA PERUANA http://www.amp.cmp.org.pe/index.php/AMP/article/view/868 Wed, 01 Jul 2020 09:06:17 -0500 Knowledge of fibromialgia in Peruvian rheumatology specialists http://www.amp.cmp.org.pe/index.php/AMP/article/view/888 <p><strong>Objective:</strong> to identify knowledge levels of diagnostic criteria for fibromyalgia by Peruvian rheumatologists. <strong>Materials and methods:</strong> this is a cross-sectional descriptive study. One-hundred and fifty Peruvian rheumatologists attended the XX Peruvian Rheumatology Congress, which took place in November 22-24, 2018 in Lima, Peru. Ninety six of these 150 physicians were surveyed. A previously developed and validated questionnaire was administered to them taking into account the 2010 fibromyalgia criteria issued by the American College of Rheumatology. The statistical analysis was performed using the SPSS statistical package. <strong>Results:</strong> most rheumatologists were male (58.3%), aged 25 to 40 years (47.9%). One-third (33.3%) had more than 20 years experience, 43.8% reported that they attend rheumatology conferences once a year, 27.1% are medicine school instructors, and 40.6% declared identifying one to two new cases of fibromyalgia per year. More than half of surveyed physicians (57.3%) showed fair knowledge about fibromyalgia, more than half knew that the diagnosis for this condition is clinical, they also knew the most commonly affected age group, the frequent concomitant conditions as well as associated mental health disorders, in addition to auxiliary tests for the differential diagnosis. However, more than 90% were unaware of other diseases with similar symptoms. No significant differences were found in the level of knowledge on fibromyalgia according to age (p=0.762), sex (p=0.732) or years after qualifying (p=0.615). <strong>Conclusions:</strong> the knowledge level of diagnostic criteria for fibromyalgia by Peruvian rheumatologists is fair.</p> Flavia C. Florian-Conder, Carla V. Machicao-Tello, Fernando M. Runzer-Colmenares, Manuel F. Ugarte-Gil Copyright (c) 2020 ACTA MEDICA PERUANA http://www.amp.cmp.org.pe/index.php/AMP/article/view/888 Wed, 01 Jul 2020 09:12:30 -0500 Association between tomographic appendicular diameter and the pathological diagnosis of acute appendicitis in the Central Military Hospital between 2015-2019 http://www.amp.cmp.org.pe/index.php/AMP/article/view/945 <p><strong>Objective:</strong> to identify the association that exists between tomographic appendicular diameter and pathological diagnosis in patients with clinical suspicion of acute appendicitis from the Central Military Hospital from 2015 to 2019 and determine the diagnostic validity. <strong>Materials and methods:</strong> a cross-sectional analytical study was conducted. The sample was 104 postappendectomized patients from the Central Military Hospital from 2015 to 2019, who had a tomographic report due to clinical suspicion of acute appendicitis and anatomopathological analysis of the operative part. Frequency tables, a bivariate analysis (Fisher's test), prevalence ratios (PR) were estimated using Poisson regression and diagnostic validity tests for each of the tomographic criteria were made. <strong>Results:</strong> of 104 patients, 35% were 18 to 30 years old, 69% were male; 86 patients were confirmed by pathology; of which, 70 of them presented appendicular diameter ≥ 6 mm. It was observed that the appendicular diameter, the wall thickness, the alteration of the periapendicular fat and the free fluid had statistically significant differences in relation to the pathological result. The appendicular diameter had a sensitivity of 81.4%, specificity of 55.5%, positive predictive value of 89.7% and negative predictive value of 38.4%. <strong>Conclusions:</strong> an appendicular diameter ≥ 6 mm is associated with a probability of 1.45 times that the pathological result is positive in patients with clinical suspicion of acute appendicitis.</p> Diego Basaldúa-Chincha, Luis Caparo-Carreno, Fernando M. Runzer-Colmenares, Aldo Ayvar-Fuentes Copyright (c) 2020 ACTA MEDICA PERUANA http://www.amp.cmp.org.pe/index.php/AMP/article/view/945 Wed, 01 Jul 2020 09:23:50 -0500 Copy number variation in development disorders, malformative syndrome and short stature in Peru http://www.amp.cmp.org.pe/index.php/AMP/article/view/915 <p><strong>Objective:</strong> to establish the ratios of the copy number variations and regions of homozygosity through chromosomal microarray analysis (CMA) in children with neurodevelopmental disorders: development delay (DD), intellectual disability (ID), and/or autistic spectrum disorder (ASD), malformative syndrome (MS) and idiopathic short stature (ISS). <strong>Materials and methods:</strong> we evaluated 367 Peruvian children diagnosed clinically with ID, DD, ASD, ISS and MS to whom performed chromosomal microarray analysis in peripheral blood (750K CGH + SNP), between the years 2016-2018. <strong>Results:</strong> patients' age fluctuated between 4.8 months and 18 years old, with an average of 5.6 years old. The most frequent diagnoses were development delay (48%) and intellectual disability (30%). Abnormal results (pathogenic variants, likely pathogenic variants, uniparental disomies and loss of heterozygosity&gt; 2.5%) were reported in 50.3%. The 53.28% of the cases with a diagnosis of intellectual disability and 47.92% of development delay showed abnormal results; while the children with short stature syndromic, malformative syndrome, and autistic disorders spectrum disorders showed abnormal results in 52.38%, 52% and 20% respectively. Additionally, we found that 6.25% of parents were non-declared consanguinity. <strong>Conclusions:</strong> Abnormal results found in our study was a higher ratio than other international reports regardless of the clinical diagnosis. Furthermore, we show a most rate of non-declared consanguinity in relation with previous reports.</p> Hugo H. Abarca Barriga, Flor de Milagros Vásquez Sotomayor, Milana Trubnykova, Felix Chavesta Velasquez, Miguel A. Chavez Pastor, Bertha E. Gallardo Jugo, Julio Poterico Rojas, Nathaly Caballero Bedón, Jorge La Serna Infantes, Tania Vasquez Loarte Copyright (c) 2020 ACTA MEDICA PERUANA http://www.amp.cmp.org.pe/index.php/AMP/article/view/915 Wed, 01 Jul 2020 10:26:37 -0500 Association between albuminuria and mortality in elderly subjects with diabetic foot seen in the outpatient clinic of the Peruvian Navy Medical Center (2010–2015) http://www.amp.cmp.org.pe/index.php/AMP/article/view/944 <p><strong>Objective:</strong> to determine the relationship between albuminuria and mortality in elderly subjects with diabetic foot seen in the outpatient clinic in Cirujano Mayor Santiago Tavara Peruvian Navy Medical Center between 2010 and 2015. <strong>Materials and methods:</strong> this is a quantitative, observational, analytical and retrospective cohort study. Data from 89 elderly subjects who complied with selection criteria was entered. A descriptive analysis was performed in which the following variables were included: death during the study, comorbidities, and sociodemographic data. Afterwards, a bivariate analysis based on survival at the end of the study was performed, where all covariates based on the main variable of the study (mortality) were assessed. <strong>Results:</strong> average age of subjects was 79.3 ± 7.2 years, and they were mainly male (58.4%). We also found that 52 subjects (58.4%) had a past history of albuminuria, and that 7.9% of the studied population died during the study. All of them (100%) had albuminuria. Finally, as it was the case with albuminuria, all subjects who had undergone amputation because of diabetic foot died during follow-up. <strong>Conclusion:</strong> a significant relationship between albuminuria and mortality was found in elderly subjects with diabetic foot who were included in this study.</p> Héctor A. Estremadoyro-Santillan, Fernando M. Runzer-Colmenares, Jose F. Parodi Copyright (c) 2020 ACTA MEDICA PERUANA http://www.amp.cmp.org.pe/index.php/AMP/article/view/944 Wed, 01 Jul 2020 00:00:00 -0500 A description of risk factors for mortality in adults with end-stage chronic kidney disease http://www.amp.cmp.org.pe/index.php/AMP/article/view/980 <p><strong>Objective:</strong> to describe both clinical and demographic characteristics of patients with end-stage kidney disease (ESKD) and the association of such variables with mortality. <strong>Materials and methods:</strong> this is an observational, descriptive, and cross-sectional study with an analytical approach, which was performed in the nephrology service of a private HMO in Florencia-Caqueta. We studied socio-demographic and clinical variables using univariate and bivariate analyses, applying an association test with mortality using the Chi-square test and simple logistic regression, aiming to calculate prevalence rates (PR).<strong> Results:</strong> twohundred and thirteen patients were assessed, their average age was 60.0 ± 1.4 years; 48.3% were female, and the recorded mortality rate was 29.3%. Factors associated with mortality were as follows: LDL-C &lt;70 mg/dL (PR: 0.45, 95% CI: 0.24–0.84) and serum albumin &lt;3.5 g/dL (PR: 12.65; 95% CI: 5.85–27.3). <strong>Conclusion:</strong> hypoalbuminemia and low LDL-C levels are associated with mortality in patients with ESKD in Florencia-Caqueta. Hypoalbuminemia is considered as a risk factor, while LDL levels &lt;70 mg/dL are considered as a protective factor.</p> Diego Alvis-Peña, Carlos Calderon-Franco Copyright (c) 2020 ACTA MEDICA PERUANA http://www.amp.cmp.org.pe/index.php/AMP/article/view/980 Wed, 01 Jul 2020 10:50:49 -0500 Medical education during the COVID -19 pandemic: global initiatives for undergraduate, internship, and medical residency http://www.amp.cmp.org.pe/index.php/AMP/article/view/999 <p>The 2019 coronavirus disease pandemic (COVID-19) has posed various challenges to the strata of society and medical education has been no exception. Globally, universities have proposed various initiatives in undergraduate and medical internships such as the partial virtualization of their curricular content, the modification of their curriculum and educational activities and the incorporation of students from the last years to the management of COVID-19 patients. In medical residency, surgical specialties and those that base their learning on procedures are the most affected. Residents of different specialties have been incorporated into healthcare tasks different from their specialty and some of their learning activities have been virtualized. Peru must make an evaluation of these strategies and the possible adaptation to our reality.</p> Percy Herrera-Añazco, Carlos J. Toro-Huamanchumo Copyright (c) 2020 ACTA MEDICA PERUANA http://www.amp.cmp.org.pe/index.php/AMP/article/view/999 Wed, 01 Jul 2020 10:57:42 -0500 Management of diabetes mellitus in the era of COVID-19 http://www.amp.cmp.org.pe/index.php/AMP/article/view/962 <p>Diabetes mellitus is a worldwide public health problem which is associated with an increase in morbidity and mortality in the affected population due the development of micro and macrovascular complications. Currently, the SARS-CoV-2 epidemic is constantly increasing in many countries, causing the collapse of healthcare systems by leading to an increased demand for care, as well as an upsurge in the associated mortality. Available reports describe that patients with diabetes mellitus have an increased risk of unfavorable progression, development of complications and even an increase in mortality rate. Some physiological mechanisms have been proposed to try to explain this special evolution in patients with diabetes. Given the presence of 2019 coronavirus disease in our country and an important group of high-risk patients, a review of the pathophysiology and management considerations of this association is presented.</p> Jose Paz Ibarra Copyright (c) 2020 ACTA MEDICA PERUANA http://www.amp.cmp.org.pe/index.php/AMP/article/view/962 Wed, 01 Jul 2020 11:01:25 -0500 Clinical classification and early therapy for COVID-19. Cases reported from Hospital de Emergencias Villa el Salvador, Lima-Peru http://www.amp.cmp.org.pe/index.php/AMP/article/view/968 <p>The disease caused by SARS-CoV-2 is a pandemic characterized for being highly contagious and lethal in groups at risk. In less than three months, mankind had to fight against this virus without knowing its pathogenicity and therapy. We present the experience with five cases seen in the Hospital de Emergencias Villa el Salvador in Lima, Peru, and we emphasize the importance of the clinical classification of the disease in four stages: mild, moderate, severe, and critical. We reviewed the current antiviral, immunomodulatory, and antithrombotic therapy approaches. Antiviral therapy using hydroxichloroquine and azithromycin led to favorable outcomes in four cases, particularly when it was early instituted. Nonetheless, its efficacy is still controversial and results from randomized clinical trials are eagerly awaited. Meanwhile, its use during the early phases of mild or moderate disease should be maintained.</p> Alberto Mendoza-Ticona, Gustavo Valencia Mesias, Ana Quintana Aquehua, Belén Cerpa Chacaliaza, Gladys Garcia Loli, Christian Alvarez Cruz, Juan P. Riveros Vallenas Copyright (c) 2020 ACTA MEDICA PERUANA http://www.amp.cmp.org.pe/index.php/AMP/article/view/968 Fri, 15 May 2020 00:00:00 -0500 Tetanus and botulinum toxin use: report of a case http://www.amp.cmp.org.pe/index.php/AMP/article/view/822 <p>Tetanus is a condition affecting the central nervous system which is characterized by muscle spasms caused by toxins from Clostridium tetani, an anaerobe bacillus which is usually found on soil and whose spores may survive in the environment and lead to infection when contaminating open wounds. The objective of this case report is to review on the basic characteristics of this condition, focusing on functional improvement with the administration of type A botulinum toxin for generalized spasticity and lockjaw (trismus). We present the case of an 81-year-old woman with generalized tetanus and lockjaw after she suffered a head injury, she fell and hurt her head, with no loss of consciousness; and that was 15 days before admission. During her hospital stay she was managed by a multidisciplinary team. The patient did well, and she is currently being followed-up in the outpatient clinic.</p> Diego J. Alvis-Peña, Martha C. Hernandez-Ortiz Copyright (c) 2020 ACTA MEDICA PERUANA http://www.amp.cmp.org.pe/index.php/AMP/article/view/822 Tue, 23 Jun 2020 00:00:00 -0500 Montelukast-induced alveolar hemorrhage: report of a case http://www.amp.cmp.org.pe/index.php/AMP/article/view/919 <p>Diffuse alveolar hemorrhage is a pathological finding, defined as a consequence of a lesion in pulmonary microcirculation which occurs with non-specific symptoms, and sometimes it may show no symptoms. Three histopathological diagnoses are to be differentiated. The most common is capillary inflammation, which is secondary to autoimmune conditions. We present the case of a patient with image studies and bronchoalveolar lavage compatible with diffuse alveolar hemorrhage, in whom autoimmune and infectious causes were ruled out. The history of the patient indicated recent use of montelukast, being this time-related with the patient’s clinical condition. The patient responded when the drug was withheld, image studies showed particular findings, and results in the Naranjo ADR scale supported the diagnosis.</p> Carlos M. Martinez Montalvo, Laura C. Gutierrez Rueda, Daniela Florez Remolina Copyright (c) 2020 ACTA MEDICA PERUANA http://www.amp.cmp.org.pe/index.php/AMP/article/view/919 Tue, 23 Jun 2020 11:35:51 -0500 Implications in selective sentinel node biopsy in internal mammary chain in breast cancer http://www.amp.cmp.org.pe/index.php/AMP/article/view/1031 <p>Metastatic lymph node involvement is the most important prognostic factor in breast cancer. To know the degree of infiltration of the same involved progression-free survival, global survival and risk of early recurrence of the disease, and this in turn would help to know the adjuvant therapies that patients will receive. We present a case with a diagnosis of stage IB invasive ductal carcinoma of the left breast undergoing selective sentinel lymph node biopsy showing lymphocentellography, single migration to the internal mammary gland without access to it due to its retrocostal anatomical location, and axillary exploration and dissection were decided because this is what our protocol includes, based on cases like this, it forces us to carry out a review and update of the subject, and thus readjust our action protocols with the introduction of novel techniques in our country and the results of our first accumulated experiences. The internal mammary chain may be the only lymph node territory involved in selective sentinel lymph node biopsy and, in view of the results, it could obviate lymph node study at the axillary level when there is no clinical or radiological suspicion of involvement.</p> Claudia Gonzales Espinosa, Orlando Valdes Guerrero, Maria C. Campos Bernardo, Carlos Calderón Marin, Braulio F. Mestre Fernandez Copyright (c) 2020 ACTA MEDICA PERUANA http://www.amp.cmp.org.pe/index.php/AMP/article/view/1031 Wed, 01 Jul 2020 11:16:17 -0500 The ageless stress between the individual and the collective: the case of corruption in Peru http://www.amp.cmp.org.pe/index.php/AMP/article/view/1036 <p>Peru is a varied and convulsed country, and our republican history is a proof for that. The Peruvian health system has just been built during the 20th century. However, its development has been continuously affected by inadequate government policies and by corrosive and constant corruption acts. Now, in the 21st century, the health system has undergone some sort of reconstruction, but still with a very low budget and continuing venal practices that impede its proper functioning. This paper attempts to describe the anthropological basis underlying the human actions leading to corruption. It also reviews some of the main corruption modalities within the whole Peruvian healthcare system, a fragmented entity both in its public area and in its private counterpart. Also, some influencing factors are dealt with, as it is the case for the pharmaceutical industry. The resulting situation of the Peruvian healthcare system makes it quite vulnerable when facing sanitary crisis such as that generated by Covid-19. Finally, some proposals for change are outlined.</p> Aldo Vivar-Mendoza Copyright (c) 2020 ACTA MEDICA PERUANA http://www.amp.cmp.org.pe/index.php/AMP/article/view/1036 Wed, 01 Jul 2020 11:23:04 -0500 Regarding the lack of transparency in technical documents for the treatment of patients with COVID-19 in Peru http://www.amp.cmp.org.pe/index.php/AMP/article/view/982 <p>The Peruvian Ministry of Health (MINSA, in Spanish) has published ministerial resolutions (MR) with the aim of regulating the treatment of people affected by COVID-19. These MR include the use of specific drugs for COVID-19, such as tocilizumab, corticosteroids, enoxaparin, hydroxychloroquine, and ivermectin. These guidelines do not make clear what process was followed to make decisions, how each of these decisions was justified, who their authors are or their potential conflicts of interest. It is important to make an effort to promptly make these data transparent, especially in a subject in which there is still not much evidence, such as COVID-19. In this article, we present controversies on the use of specific drugs for COVID-19 established by MINSA, as well as recommendations on the decision-making process.</p> Alvaro Taype-Rondan, Percy Herrera-Añazco, German Malaga Copyright (c) 2020 ACTA MEDICA PERUANA http://www.amp.cmp.org.pe/index.php/AMP/article/view/982 Wed, 01 Jul 2020 11:27:36 -0500 Reusing N95 Respirators: decontamination strategies applicable in COVID-19 pandemics in Peru http://www.amp.cmp.org.pe/index.php/AMP/article/view/970 <p>The SARS-CoV-2 virus, also called COVID-19, was initially considered as an international public health emergency, and later it was declared as a pandemic. Due to the high spread of COVID-19 through droplets, the demand for personal protective equipment (PPE) for healthcare professionals has been remarkable, particularly filtering face-piece particulate respirators. Therefore, it is important to know the decontamination methods proposed for their application in our environment, considering the proper asepsis and antisepsis measures to be used, and also on how to preserve the integrity of the device (straps, nasal bridge and nasal foam material) and counting on its natural degradation process. Adequate methods for disinfecting these devices are as follows: using sterilizing ovens (dry heat), autoclave (steam), ultraviolet radiation (UV) and homemade vaporizers, which should be used according to the needs of the healthcare professionals.</p> Luccio Romani, Jennifer Vilchez-Cornejo Copyright (c) 2020 ACTA MEDICA PERUANA http://www.amp.cmp.org.pe/index.php/AMP/article/view/970 Wed, 01 Jul 2020 11:41:13 -0500 The management of COVID-19: a dilemma between science and therapeutic art http://www.amp.cmp.org.pe/index.php/AMP/article/view/1028 <p>-</p> COVID-19 Maguiña-Vargas, Miguel Palacios-Celi Copyright (c) 2020 ACTA MEDICA PERUANA http://www.amp.cmp.org.pe/index.php/AMP/article/view/1028 Wed, 01 Jul 2020 11:50:27 -0500 Regarding the MINSA recommendations on the pharmacological treatment of COVID-19 in Peru http://www.amp.cmp.org.pe/index.php/AMP/article/view/1030 <p>-</p> Julio A. Chirinos, Vicente F. Corrales-Medina, Gustavo Heresi-Davila, Adrian V. Hernandez, German Malaga, Jorge M. Mallea, J. Jaime Miranda, Oscar O. Morey, Juan E. Rodriguez-Mori, Jesus E. Salinas-Gamero, Jose Serpa-Alvarez, Alvaro Taype-Rondan, Carol Zavaleta Copyright (c) 2020 ACTA MEDICA PERUANA http://www.amp.cmp.org.pe/index.php/AMP/article/view/1030 Wed, 01 Jul 2020 12:00:18 -0500 Role of research ethics committees during the COVID-19 pandemic http://www.amp.cmp.org.pe/index.php/AMP/article/view/954 <p>-</p> Duilio Fuentes-Delgado, Gabriela Minaya, Yolanda Angulo-Bazan Copyright (c) 2020 ACTA MEDICA PERUANA http://www.amp.cmp.org.pe/index.php/AMP/article/view/954 Tue, 23 Jun 2020 11:40:25 -0500 Importance of the implementation of the chest tomography to contribute to the early diagnosis and timely triage of patients with COVID-19 in Peruvian hospitals http://www.amp.cmp.org.pe/index.php/AMP/article/view/946 <p>-</p> Juan J. Pareja-Ramos, Sue E. Anicama, Percy Perez-Urrutia, Samuel Pecho-Silva, Jose Amado Copyright (c) 2020 ACTA MEDICA PERUANA http://www.amp.cmp.org.pe/index.php/AMP/article/view/946 Wed, 01 Jul 2020 12:07:42 -0500 Feasibility of serological tests for the diagnosis of COVID-19 in deceased persons http://www.amp.cmp.org.pe/index.php/AMP/article/view/955 <p>-</p> Yolanda Angulo-Bazan, Gilmer Solis Copyright (c) 2020 ACTA MEDICA PERUANA http://www.amp.cmp.org.pe/index.php/AMP/article/view/955 Wed, 01 Jul 2020 12:13:31 -0500 COVID-19: Protection measures in maternal health http://www.amp.cmp.org.pe/index.php/AMP/article/view/938 <p>-</p> Valery Damacen-Oblitas, Diayan Castro-Gomez, Jessica Rojas-Silva, Jennifer Rojas-Vega, Victor Moquillaza-Alcantara Copyright (c) 2020 ACTA MEDICA PERUANA http://www.amp.cmp.org.pe/index.php/AMP/article/view/938 Thu, 14 May 2020 12:04:45 -0500 TikTok: A new educational tool in the fight against COVID-19? http://www.amp.cmp.org.pe/index.php/AMP/article/view/998 <p>-</p> Naysha Becerra-Chauca, Alvaro Taype-Rondan Copyright (c) 2020 ACTA MEDICA PERUANA http://www.amp.cmp.org.pe/index.php/AMP/article/view/998 Wed, 01 Jul 2020 12:21:25 -0500