Otosclerosis (OE) is one of the main causes of hearing loss in young adults, with a preponderance of the female sex, with a 2:1 ratio. High-resolution tomography focused on temporal bone is a fundamental tool for diagnosis, allowing subtle changes in density in the ear capsule to be detected. Depending on the location of these findings, EO can be classified into fenestral and retrofenestral. The fourth turn sign provides valuable information for diagnosis, classification, and surgical planning

Introduction: oral hygiene is considered a basic need to protect the health and well-being of the population, with more emphasis for patients under intensive care support. Objective: shortly review the literature about effective role of well-trained professional teams while performing oral care in patients managed in the Intensive Care Unity. Methods: scientific review article, taking as a source of information the current literature published in the PubMed database between 2004 and 2024 including, systematic reviews, meta-analysis, and review studies related with the buccal care procedures, and their relationships with the outcomes of critical ill patients under the infection risks. Results: 28 articles were analyzed, with data of children or adult patients of diverse continents who needed mechanical ventilation, enteral or parenteral feeding, or some invasive procedure favoring the hospital acquired infections, mainly the pneumonias. The reviewed literature most frequently described the lack or insufficient specialized care for the oral cavity of patient with very limited autonomy during hospitalizations. Conclusion: as a whole, there is a need for the dental specialists in the hospital team to personally perform, besides to train in service the nurse staffs and their assistants to carry on the correct methods for the patient daily buccal hygiene, with improvement of general health care and avoiding the worsening during the hospitalization period.

Background There are millions of deaths attributable to low levels of quality and patient safety in healthcare. One of the first steps in the journey to high reliability is to establish a solid patient safety culture. This study sought to determine the level of patient safety culture in the personnel of a specialty Hospital in Ecuador. Methods A cross-sectional study was conducted with a descriptive phase comprising the presentation of results of the patient safety culture level in the staff, and an analytical phase to determine conditioning factors of this aspect. Results 344 hospital staff answers were included in the study. The most significant group of personnel who responded to the survey corresponded to medical staff (39.83%). An overall patient safety culture level of 63.86% was determined, with higher scores observed in leadership positions (73,55%) and among the medical staff (69,90%), followed by support positions (60,97%), Other staff positions (60,44%), and nursing (56,74%). The dimensions of patient safety culture identified as strengths were teamwork and hospital management support in patient safety, and as improvement areas figured response to error, and staffing and work pace. Significant differences were found between the results of the patient safety culture domains and: staff position, working time in the hospital, working time in the current area or unit, weekly working hours, and typical contact with patients during daily activities (p < 0.05). Conclusions The patient safety culture level in the Ecuadorian context was determined, as well as its strengths and improvement areas. In this study, the support of hospital management support in patient safety stands out as a strength. Additionally, aspects of the staff were found to be significantly associated with the results of the patient safety culture dimensions indicating potential areas of focus for efforts to improve patient safety culture.

The incidence of extrapulmonary tuberculosis is growing, and it is estimated that up to 25% of all cases may be extrapulmonary infections, while the reports of genitourinary sites of this infection remain scarce, in special with the epididymis involvement. Bilateral epididymal tuberculosis is an exceeding rare cause of infertility in young, and the GeneXpert MTB/RIF test is considered a useful tool to the diagnosis confirmation. The major routes for scrotal tuberculosis are retrograde extensions from the infections in the prostate or seminal vesicles, and pelvic hematogenous or lymphatic disseminations. Aiming to emphasize the case study of isolated epididymal tuberculosis recently published in this Journal, short additional comments on literature data are presented

Introduction Multiple myeloma is a neoplasm caused by the proliferation of a clone of plasma cells that in most cases produce a monoclonal protein. Due to its decreased incidence of 4-5 cases per 100,000 inhabitants. Case description The General Hospital San Francisco Quito-Ecuador was diagnosed during this time of pandemic: three cases of Multiple Myeloma, with diverse presentation both in clinical manifestations, laboratories and radiographs, taking us to carry out a series of clinical cases with the objective of differentiating the type of clinic, diagnosis and therapy in times of pandemic in 2020. Finding different diagnoses at admission such as acute coronary syndrome, acute pancreatitis and heart failure, which were later discarded and evidenced in general bone pain, hyperamylasemia and hyperglobulinemia, with image changes both in bone punches and pathological fractures that led to the suspicion of Multiple Myeloma and performance of a medullogram for definitive diagnosis. The subspecialty treatment will run without complications. Conclusion The main characteristics are pathological fractures that can present in the form of acute or chronic pain, as well as related to other pathologies; and since the rest of the clinical manifestations mentioned in the literature were not present. It is also worth mentioning that hyperamylasemia was a factor found in our cases that future studies could be related as a prognostic factor and mortality in multiple myeloma

Introduction Mesenteric lymphagioma is a rare, benign, congenital cystic tumor of the lymphatic vessels, which occurs in 2-5% of cases at the abdominal level (75% cervical, 20% axillary), which occurs more frequently during the childhood. It occurs with an incidence of 1: 250,000 during childhood (60% cases before one year of age), the ratio of women to men is 2: 1. They are located mainly in the subperitoneal space, in the mesentery (59% - 68%), omentum (20% - 27%) and retroperitoneum (12% - 14%). This should be suspected as a differential diagnosis of acute abdomen and pediatric abdominal masses. Its complete excision with negative microscopic margins is the treatment of choice, either by conventional means by exploratory laparotomy or by other less invasive techniques such as laparoscopy. Case description A 6-year-old boy presented with abdominal pain and peritonism. Physical exam: positive rebound sign. Paraclinical: leukocytosis, neutrophilia. Ultrasound shows abundant free fluid in the abdomen and pelvis. Patient undergoes an exploratory laparotomy, finding a multicystic mass dependent on the greater omentum, a sample of peritoneal fluid is taken for cytochemical, bacteriological, culture and histopathology. Complete excision of the cyst plus partial omentectomy and incidental appendectomy is performed. Patient with favorable evolution tolerates diet at 24 hours with progression from liquid to soft, undergoes antibiotic treatment for 48 days based on cefazolin (suspended due to negative culture at 48 hours and negative BARR), with hospital discharge on the fourth day. Result of fibrin-filled peritoneal fluid, transudate and negative histopathology for malignancy. Histopathology report: Macroscopic: irregular tissue fragment measuring 10 x 6 cm, greyish-yellow, cystic areas measuring 1.5 and 4 cm; When cut, it drains mucinous material, the rest of the irregular yellowish areas. Microscopic: fibrofatty tissue with congestive vessels and mixed inflammatory infiltrate (lymphocytes and polymorphonuclear cells), compatible with cystic lymphagioma (Fig. 3). Immunohistochemistry positive for marker D 2-40. Patient with follow-up at 7 days; In months 1, 3, 6 and year with favorable evolution, a control ultrasound was performed at the sixth month and at one year without evidence of recurrence. Conclusion: Mesenteric cystic lymphagioma can present with symptoms of acute abdomen. Complete resection is the treatment of choice, minimally invasive procedures are currently performed with favorable results in children, ultrasound is sufficient for long-term follow-up.

Introduction Pulmonary cavitations are defined as a space filled with air, within a pulmonary area of consolidation, a mass or a nodule, they are produced by the expulsion or drainage of the necrotic part of the lesion through the bronchial tree. The most frequent causes are infectious by mycobacteria as in tuberculosis, or bacteria as in necrotizing pneumonia, pulmonary abscesses, although on rare occasions, it can also present in pulmonary embolism with infarction. Neoplasms should always be suspected, being squamous cell carcinoma the one that has been related to a greater extent to pulmonary cavitary lesion, and to a lesser extent to adenocarcinoma. Other less frequent causes are granulomatosis with polyangiitis, lymphomas, pneumoconiosis, silicosis. Case description Patient with respiratory symptoms of one year of evolution, characterized by cough with sporadic yellowish expectoration plus chest pain, in 03/2020 is accompanied by hemoptysis and progressive dyspnea, without weight loss or fever, private physician indicates antibiotic with partial improvement; On 08/2020 she presented hemoptysis, she went to the doctor again and requested a tomographic study in which she showed evidence of pulmonary cavitation associated with consolidation, a new antibiotic scheme was administered, without improvement, and she went to this clinic on 11/2020. New tomographic study showed cavitation with thick walls, preserved renal and hepatic function, infectious profile and negative immunological tests. Bronchoscopy with BAL cytology positive for malignancy, simple and contrasted body tomography and PET SCAN were indicated, showing hypermetabolic mass in the right lower lobe, with no evidence of distant metastasis or affected lymph nodes. Pulmonary function is assessed for surgical resolution, being adequate, right lower lobectomy is performed, showing free surgical edges, with negative regional nodes for malignancy, with pathology reporting lung adenocarcinoma, pathological staging T3N0, and according to the imaging study M0, determining stage IIB. He required chemotherapy and adjuvant radiotherapy. Conclusion Lung cancer symptomatology can be silent and mainly non-specific, in the study by Bradley et al. addressing lung cancer risk by symptomatology and by chest radiography, they conclude that chest radiography has limited sensitivity and that only hemoptysis has a statistically significant predictive value for malignancy. In relation to cavitated lesions as a presentation in lung cancer, they are evidenced in 5 to 15% of all patients. Within primary neoplasms the frequency with which we can observe cavitation of the lesion is related to the histological subtype, it is more frequent in squamous carcinomas (9-38%), rarer in adenocarcinomas (6-15%) and large cell carcinoma, and practically rules out small cell carcinoma. As conclusions, multidisciplinary management allows adequate orientation in both the diagnostic and therapeutic algorithm of patients, which will improve patient survival.

Introduction Introduction: The Antisynthetase Syndrome is a rare entity that is included within the idiopathic inflammatory myopathies, characterized by the presence of antisynthetase antibodies, they can be found in 39.1% of the patients with these myopathies. The affectation is systemic being the main ones at the articular level in 40% -80%. Lung damage occurs in 60% -80%, the most frequent findings being ground glass, predominantly crosslinking in lower segments, probably with a pattern of non-specific interstitial pneumonia, organized pneumonia, or mixed patterns. Regarding muscle involvement, it occurs in 60% -80%. Treatment is based on the use of corticosteroids, immunosuppressants, and biological agents. Case description A 38-year-old female patient with no significant clinical or family history was approached, single (no children), who presented gradual and intermittent joint pain and muscle weakness associated with progressive dyspnea, in the context of The current pandemic was swabbed for SARS-COV-2 on two occasions as well as antibodies for the same virus being negative, with tomographic findings compatible with an alternative pattern, despite the aforementioned, it was treated in a particular way with a scheme directed towards COVID -19, with partial resolution of the symptoms and subsequent exacerbation of the same, for which he went to hospital care, where the swab was repeated obtaining negativity of the same, deciding on this occasion an evaluation by the Pneumology Service and hospitalization. During his stay, an immunological panel was performed where a weak elevation of rheumatoid factor is evidenced, due to logistical issues Myositis panel we are waiting, however, due to the lack of specific etiology, it was decided to perform a lung biopsy reporting a concordant pattern of organized pneumonia With the tomographic diagnosis, the evolution of the patient was favorable with supportive treatment until the results of the external immunological panel were received, evidencing a marked elevation of the anti-Jo antibody, added to the clinical and image manifestations, the picture is cataloged as an Antisynthetase Syndrome. Thus, with the support of rheumatology, treatment with corticosteroids (methylprednisolone), immunosuppressants (mycophenolate) and biological agent (rituximab) is started; with which there was significant clinical improvement, decrease in o2 support as well as lung lesions, with which we proceeded to discharge with the respective follow-up by the services involved. Conclusions: As we evidenced in the clinical case, in a retrospective way, we can assert that it complied with the clinical manifestations of the disease, although we are experiencing a pandemic where lung involvement is important, once it has been ruled out, other diagnostic possibilities must be addressed. As in the patient, it culminated in the presentation of a rheumatological picture with lung damage.

Introduction Acute appendicitis is one of the most common urgent surgical pathologies in the Ecuadorian population, and the atypical presentation of the appendix on the left side is presented as a diagnostic challenge, since it is observed more frequently in congenital anomalies such as malrotation of the midgut, a rare disorder with an incidence of one in 10,000 individuals. Case description We present the clinical case of an 8-year-old girl with no significant pathological history, admitted to the Pediatrics service with a 48-hour history of abdominal pain located in the left hemiabdomen, accompanied by nausea, vomiting, abdominal distention and thermal rise; tender abdomen on palpation in the flank and left iliac fossa, positive Mussy's sign. The patient presented with leukocytosis and neutrophilia; imaging examinations revealed thickening of the mesenteric fat at the level of the left iliac fossa and air-fluid levels at an elevation of the colonic framework. She underwent surgery and the findings were an appendicular plastron made up of a perforated appendix in the distal third and undamaged appendicular base, omentum and distal third of the descending colon; her postsurgical evolution was favorable. Conclusion Acute appendicitis can present with atypical symptoms due to unusual locations of the appendix, one of the unusual presentations can present in malrotation. Most cases are asymptomatic until the development of acute complications and require imaging for diagnosis, becoming a challenge when defining the appropriate and timely treatment.

Introduction Colovesical fistulas (CVF) are pathologic communications between bowel and bladder. They represent 1 in 3000 surgical hospital admissions per year. Imaging studies play a crucial role establishing the site, course and complexity of the fistulas, and in identifying their etiology. The management of CVF depends on the underlying pathology, the site of the intestinal injury, and the preoperative state of the patient. A surgical and non-surgical approach can be performed. Case description A clinical case of an 82-year-old patient with multiple comorbidities is reported, who suddenly presented dysuria, stranguria and fecaluria. The abdominal and pelvic tomography revealed diverticulitis with the presence of a fistulous tract from the colon to the bladder. During his hospitalization, the patient presented septic shock of urinary focus due to colovesical fistula, which required management by intensive therapy. Broad-spectrum antibiotic therapy was started. Once stable, we opted for surgical resolution with partial cystectomy plus fistulectomy and Hartmann-type colostomy. After the procedure, the patient evolved favorably with resolution of the condition. Conclusion The nonsurgical approach may be a viable option in patients with poor preoperative condition, an inability to tolerate general anesthesia, or in cancer patients with a short life expectancy. Spontaneous closure of fistulas occurs in approximately 2% of patients and, since up to 75% may have septic complications, the presence of a FCV is an indication for surgery in all patients without contraindications for it. The most widely used surgical approach consists of resection of the compromised intestinal segment with primary anastomosis, without a protective stoma, and closure of the bladder defect. At present, there is no consensus on which is the best surgical strategy due to the lack of clinical trials. An updated review of the subject and its therapeutic management is carried out.