El desarrollo económico y la desigualdad en trece economías de América Latina

El presente artículo evalua, mediante un modelo econométrico de datos panel, la relación existente entre entre la desigualdad y el crecimiento económico para trece economías latinomericas. El análisis se efectua para un intervalo temporal que va de 1998 a 2020, en este periodo se estudia el impacto que tuvo el Indice de Gini (desigualdad) sobre la tasa de crecimiento del PIB de las economías bajo estudio. Se realizaron tres estimaciones, la primera de ellas consistió en un modelo general de datos panel (Pool de datos panel). La segunda estimación se realizó considerando efectos fijos por región y tiempo. Finalmente el tercer modelo, consideró una estimación con efectos aleatorios

Simultaneous Brachial Artery Injury and Ulnar Nerve Palsy: A Case Study of an ATV Accident Survivor

Background: All-terrain vehicle (ATV) accidents are a common cause of traumatic elbow injuries due to outstretched arms accepting contact at greater forces. However, their complexity and clinical significance often go unrecognized upon initial evaluation, especially in patients without acute fractures. Sequelae of such injuries can include neurovascular deficits, leading to chronic pain, limb ischemia, and paresthesias. This article aims to present a case study detailing a post-traumatic elbow injury with chronic neurovascular deficits following an ATV accident. Additionally, we address common clinical findings in post-traumatic concomitant brachial artery and ulnar nerve injuries, their evaluation, and respective management plans. Case Presentation: Our patient was a 38-year-old uninsured female who presented with concerns of right upper extremity pain and paresthesias in the setting of an ATV accident six months prior. History was notable for a blood pressure discrepancy, episodic hypertension, dull, deep pain, and paresthesias throughout her right upper extremity prior to presentation. Physical examination was notable for a radial pulse discrepancy and decreased peripheral ulnar nerve sensation in her right upper extremity, raising concern for a chronic neurovascular deficit. Further evaluation was obtained via bilateral Arterial Doppler studies, and the management of her neurovascular injury is detailed furthermore in this article. Conclusion: For traumatic elbow injuries complicated by neurovascular deficits, appropriate identification, and management is key for good long-term outcomes. Additionally, the presence of arterial, neurological, or both arterial and neurological deficits on presentation can impact the long-term outcome of such injuries. Management options for untreated traumatic elbow injuries with chronic neurovascular deficits is a shared decision, largely based on functional capacity and quality of life. However, in rare scenarios, surgical intervention may be warranted

Mystery Case: an effort to diagnose a patient with a decade of relapsing and remitting neurologic symptoms with a comprehensive medical approach

Background: Muscle weakness and numbness are prevalent complaints amongst patients and can have a varying range of diagnoses from benign inconsequential to life-threatening causes. The pattern and intensity of weakness, accompanying symptoms, medication use, and family history assist the physician in determining if a patient\u27s presentation is caused by infectious, neurologic, metabolic, inflammatory, psychiatric, or drug-induced condition. Case Presentation: Our patient is a 37-year-old female who presents to the clinic for a follow-up. The patient has a past medical history of Major Depressive Disorder (MDD), Generalized Anxiety Disorder (GAD), and an undiagnosed neuromuscular weakness for approximately 10 years. The weakness can affect a limb or at times an arm and leg and can last days to weeks. She does not note any precipitating symptoms. She had a complaint of a recent onset of numbness in the outer side of the foot that began a week ago and frequent headaches. On physical examination, there was normal muscle tone and strength testing was 5/5 on all extremities except ankle flexion and extension were 4/5 bilaterally. She had bilateral decreased sensation to pinprick on the lateral sole of the feet. Cranial nerves I-XII were intact. Antinuclear antibody testing screen was negative. Thyroid stimulating hormone testing was normal. White blood cell count mildly elevated at 12.4 with an absolute neutrophil count elevated. She reports over the years she’s had extensive work-up including MRI of the head, muscle biopsy, nerve conduction testing and multiple specialist visits with no formal diagnosis. Her previous history of relapsing and remitting weakness and numbness raises concern for various neuromuscular disorders further discussed in this article. Our differential includes multiple sclerosis, guillan-barre, systemic lupus, fibromyalgia, or other etiology. Conclusion: We are faced with a young woman with nonspecific symptoms of intermittent muscle weakness and numbness that have been present for years. We must not miss certain diagnoses such as Multiple Sclerosis while also keeping in mind a high-value approach to care. It is important to note which features are suggestive of MS such as the relapsing/remitting nature, the onset of age 15-50, optic neuritis, Lhermitte sign (shock-like sensation with flexion of the neck), ophthalmoplegia, fatigue and heat sensitivity. There is also a risk of bias impacting our diagnosis as she has MDD and GAD, we may be quick to jump to Fibromyalgia. There is a reported bidirectional association between fibromyalgia and depression where each disease may increase the likelihood of developing the other. Recent studies on post-COVID had brought more understanding to the pathology and treatment of Fibromyalgia which may help our patient. Comprehensive rehabilitation programs with aerobic exercise have demonstrated improvement in post-COVID symptoms attributed to mental and physical fatigue. Though our search continues for an etiology for our patient’s intermittent muscle weakness, we also are reassured that we have kept the differential broad, we do not see a diagnosis of multiple sclerosis, and we are focusing on continuing her function and activity

Cost Effective Treatment Options for Uninsured Patients with Diabetes

Background: Approximately 37.3 million people in the United States have diabetes, accounting for 14.7% of the US population. Additionally, an estimated 2 million adults with diabetes have no health insurance coverage, which can contribute to chronic co-morbidities and increase all-cause mortality. Given the economic challenges these uninsured patients may face, it is important for healthcare providers to understand the cost-effective treatment options available to improve long-term outcomes. Therefore, this abstract aims to provide a cost-effective treatment algorithm for uninsured patients with diabetes. Case Presentation: Our patient was a 47-year-old uninsured Hispanic female with uncontrolled type 2 diabetes mellitus. The patient’s self-reported daily blood sugar levels ranged from 140-200 mg/dL, and her most recent hemoglobin A1c level was 8.6%, which she attributed to a sedentary lifestyle, poor diet, and the inability to afford her prescription medications due to a lack of insurance. Given her financial constraints, a cost-effective medical optimization strategy was implemented. This included patient education as well as prescribing more affordable medications with the goal of improving her glycemic control and reducing long-term complications related to diabetes. Conclusion: Management of diabetes in the uninsured or financially hard-shipped patient population can be difficult but is feasible through cost-saving coupons and discount pharmacies. Oral treatment options typically include 1st and 2nd-generation sulfonylureas, meglitinides, biguanides, and thiazolidinediones. Insulin, as part of the pharmacologic treatment, is often saved until oral low-cost options fail to aid in managing the disease but also have cost-effective options. However, while cost-saving measures such as coupons and online pharmacies provide a viable solution for uninsured diabetic patients, it is important to note these treatment options may not be as effective as the established gold-standard treatments (DPP-4 inhibitors, SGLT2 inhibitors, GLP-1 agonists, rapid and basal insulins) as per the American Diabetes Association 2023 Standards of Care. Despite this limitation, these cost-effective treatment options can still play a significant role in improving blood sugar management and hopefully limit complications associated with long-term uncontrolled diabetes

Exploration of Treatment Options for a Hispanic Patient with Obesity Class III and Multiple Comorbidities

Introduction: The prevalence of obesity has reached epidemic proportions worldwide, presenting a significant challenge to public health systems and clinicians alike. The CDC published new statistics for the prevalence of obesity in the United States, with numbers reaching 41.9% from 2017-2020. Morbid obesity, indicated by a body mass index (BMI) of 40 kg/m² or higher, is associated with an increased risk of numerous comorbidities, including cardiovascular disease, type 2 diabetes, hypertension, and musculoskeletal disorders. This case report aims to explore the available treatment options for a Hispanic female with Obesity Class III and multiple comorbidities while keeping insurance coverage and population health in mind. Case Presentation: Our patient is a 63 y/o Hispanic female with multiple comorbidities, including Obesity Class III, Heart Failure with Reduced Ejection Fraction, pacemaker placement, stage 5 chronic kidney disease (CKD) on hemodialysis, and type 2 diabetes mellitus. Patient presented to clinic for hospital follow-up after being started on dialysis for treatment of hyperkalemia. Patient is 5ft 2in and weighs 276 lbs. Current BMI is 50.5 kg/m2. Patient\u27s weight remains largely uncontrolled despite lifestyle modifications. Potential interventions at this time present a myriad of problems and risks. Drug Therapy: GLP-1 receptor agonists were recommended but have not been approved for coverage by insurance yet. Patient is unable to pay out of pocket for treatment. Orlistat therapy poses the potential risk of ESRD exacerbation due to oxalate nephropathy. Bariatric Surgery: Our patient could benefit from bariatric procedures. However, due to comorbidities, our patient is at significantly higher risk of post-surgical complications, according to ACS NSQIP Surgical Risk Calculator. Discussion: This patient’s case highlights the challenges of obesity treatment, revealing a complex interplay between obesity and its associated comorbidities. There is a vicious cycle in the pathology of obesity in which complications arising from obesity further hinder the treatment options available. Furthermore, our patients case underscores the alarming prevalence of obesity in the U.S. Hispanic population, with a prevalence of 45.6%, according to the CDC. This case serves as a compelling reminder of the necessity to expand obesity care to ensure early interventions. With proactive treatment of obesity before extensive complications take hold, clinicians can mitigate the burden of obesity on both the patient and the public health system overall

Exacerbation of Acute Angle Closure Glaucoma Symptoms Following SSRI Use

Introduction: General Anxiety Disorder (GAD) is a relatively common disorder in the United States, which affects 6.8 million Americans. Selective Serotonin Reuptake Inhibitors (SSRIs) and Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) are considered the mainstay of pharmacologic treatment of GAD, along with behavioral modifications, such as Cognitive Behavioral Therapy (CBT). However, these medications may cause harmful side effects in unique individuals. This abstract will discuss the unusual side effect of acute angle closure glaucoma in a male while being treated for GAD with an SSRI. Case Presentation: The patient is a 60-year-old male with a history of diabetes mellitus, chronic kidney disease, a right below the knee amputation, and right eye blindness from a prior glaucoma episode who presented with new onset GAD. He complains of insomnia due to his health complications, anxiety, and over thinking. He was prescribed escitalopram, an SSRI, and referred to CBT to treat his symptoms of GAD. After starting the medication, the patient noticed an increase in his glaucoma symptoms in his left eye and the medication was discontinued. This provided relief of his intraocular pain. Patient was switched to mirtazapine 7.5 mg, a tetracyclic antidepressant, with improvement in his anxiety symptoms and no signs of glaucoma. Discussion: SSRIs continue to be used as the first line therapy for GAD and other psychiatric illnesses because of their treatment efficacy. An article published in 2020 suggested that nearly 37 million Americans are on antidepressants, the majority of which are SSRIs. Some of the common side effects of SSRIs include nausea, dry mouth, headache, insomnia, diarrhea, sexual dysfunction, somnolence, sweating, tremor, and weight change. 10 to 20% of people on SSRI discontinue use due to side effects. Research is unclear of the ophthalmologic complications resulting from SSRI use. Previous studies suggest that there is no link between SSRI use and raising intraocular pressure, and others showed a slight association of cataract development with SSRI use. This research brings to question whether the patient could be trialed on a different SSRI as glaucoma does not appear to be a well-proven class side effect. Further research and case studies should be done to determine if SSRIs can exacerbate symptoms in individuals with prior acute angle closure glaucoma attacks. Due to the prevalence of anxiety, depression, and SSRI use, one must be familiar with both common and rare side effects and classify whether they are class side effects or not

Evidence-Based Pediatric Outcome Predictors to Guide the Allocation of Critical Care Resources in a Mass Casualty Event

Objective: ICU resources may be overwhelmed by a mass casualty event, triggering a conversion to Crisis Standards of Care in which critical care support is diverted away from patients least likely to benefit, with the goal of improving population survival. We aimed to devise a Crisis Standards of Care triage allocation scheme specifically for children. Design: A triage scheme is proposed in which patients would be divided into those requiring mechanical ventilation at PICU presentation and those not, and then each group would be evaluated for probability of death and for predicted duration of resource consumption, specifically, duration of PICU length of stay and mechanical ventilation. Children will be excluded from PICU admission if their mortality or resource utilization is predicted to exceed predetermined levels (“high risk”), or if they have a low likelihood of requiring ICU support (“low risk”). Children entered into the Virtual PICU Performance Systems database were employed to develop prediction equations to assign children to the exclusion categories using logistic and linear regression. Machine Learning provided an alternative strategy to develop a triage scheme independent from this process. Setting: One hundred ten American PICUs Subjects: One hundred fifty thousand records from the Virtual PICU database. Interventions: None. Measurements and Main Results: The prediction equations for probability of death had an area under the receiver operating characteristic curve more than 0.87. The prediction equation for belonging to the low-risk category had lower discrimination. R2 for the prediction equations for PICU length of stay and days of mechanical ventilation ranged from 0.10 to 0.18. Machine learning recommended initially dividing children into those mechanically ventilated versus those not and had strong predictive power for mortality, thus independently verifying the triage sequence and broadly verifying the algorithm. Conclusion: An evidence-based predictive tool for children is presented to guide resource allocation during Crisis Standards of Care, potentially improving population outcomes by selecting patients likely to benefit from short-duration ICU interventions. (Pediatr Crit Care Med 2015; XX:00–00) Key Words: intensive care unit length of stay; intensive care unit mortality; mass casualty; palliative care; pandemic preparedness; triag

Progressive dyspnea and a right atrial mass in an 80-year-old man

Hepatocellular carcinoma (HCC) is among the five most frequent causes of cancer death worldwide, according to the WHO. The disease is related to alcohol abuse, viral infections, and other causes of cirrhosis, and unfortunately, in some developed countries, the incidence shows an increasing trend. Although the diagnosis of the HCC often relies upon the context of a chronic hepatopathy, some cases may present a silent course, and the initial symptoms ensue when the disease is in an advanced stage with no chance for any therapeutic attempt. The clinical picture of the HCC is varied, and unexpected forms may surprise the clinician. One of the unusual presentations of the HCC is shock by the blockage of the venous return to the right atrium by the inferior vena cava infiltration. Herein we present a case of an old patient who sought medical care complaining of dyspnea. The clinical workup disclosed a right thorax pleural effusion and imaging exams depicted a mass in the right hepatic lobe, invasion of the inferior vena cava (IVC) and the right atrium (RA). During the attempts of clinical investigation, the patient passed away. The autopsy disclosed an HCC involving the right hepatic lobe, with the invasion of the IVC and the RA. The authors highlight the importance of recognizing the bizarre presentation of not so rare diseases

A coordination model for interactive components

Although presented with a variety of ‘flavours’, the notion of an interactor, as an abstract characterisation of an interactive com- ponent, is well-known in the area of formal modelling techniques for interactive systems. This paper replaces traditional, hierarchical, ‘tree-like’ composition of interactors in the specification of complex interactive sys- tems, by their exogenous coordination through general-purpose software connectors which assure the flow of data and the meet of synchronisation constraints. The paper’s technical contribution is twofold. First a modal logic is defined to express behavioural properties of both interactors and connectors. The logic is new in the sense that its modalities are indexed by fragments of sets of actions to cater for action co-occurrence. Then, this logic is used in the specification of both interactors and coordination layers which orchestrate their interconnection

Notes on bird species in bamboo in northern Madre de Dios, Peru, including the first Peruvian record of acre tody-tyrant (\u3cem\u3eHemitriccus cohnhafti\u3c/em\u3e)

In the southwestern Amazon Basin, large areas of habitat are comprised predominantly of Guadua bamboo. Many bird species occur in or specialize on Guadua-dominated habitats, but little is known about the taxonomy, distribution, and evolutionary history of this avian assemblage. During 2011, we surveyed the surroundings of Iberia, an area with many large Guadua stands in the southern Peruvian Amazon. We found many Guadua specialist bird species and discovered a surprising Andean element to the local avifauna. We present information on Guadua specialists, Andean species, birds of open habitats, and avian migration and reproduction. We provide accounts for species of particular interest and an appendix containing an annotated list of all species detected