Challenge of Diagnosing and Treating a Mediastinal Mass in a Young Patient

Background: Germ cell tumors (GCT) are neoplasms arising in the testicles (1). Rarely these tumors can grow outside of the reproductive organs without involving them, acquiring the name of extragonadal GCT (2). Mediastinal extragonadal GCT is further divided into seminomatous, non-seminomatous (yolk sac tumor, choriocarcinoma and/or embryonal cell tumor), mature teratoma, and immature teratoma according to the histological pattern (2). Case Presentation: 24-year-old-male patient presented to the ER with complaints of a persistent cough of one-month duration accompanied by orthopnea, pleuritic chest pain, and worsening shortness of breath. The patient denied weight loss, testicular pain, night sweats, fever, or hemoptysis. Vital signs on admission were stable. CXR showed a large mass-like density overlying the right hilum. CT chest with contrast showed a 13 cm anterior mediastinal mass with a right loculated pleural effusion. Biopsy was performed with immunohistology compatible with nonseminatomous germ cell tumor. Serological tumor markers including Alpha-fetoprotein, LDH and Beta HCG were significantly elevated. AFP 1,680.4, LDH 399, Beta HCG 113 and CEA 1.3 supported this diagnosis. Conclusion: Nonseminomatous extragonadal GCT is a rare but aggressive neoplasm that arises in the anterior mediastinum. Statistically, they occur more often in men than in women, commonly between the ages of 20 and 40 years old. Treatment with chemotherapy followed by surgical resection of the mass is recommended and should be initiated as soon as the diagnosis is made. Our patient opted to be transferred to MD Anderson Cancer Center for a higher level of care

My Achy-Breaky Heart: A Case of Diffuse Large B-Cell Lymphoma Presenting as Impending Cardiac Tamponade in a Hispanic Woman

Background: Mediastinal masses can arise from typical structures within the mediastinal or they can develop secondary to metastasis from other organ systems [1] Primary mediastinal diffuse large B-Cell lymphomas (PMBCL) are uncommon, accounting for 7% of the cases of diffuse large b cell lymphoma. We describe a case of a 35-year-old woman who presented with atypical chest pain and shortness of breath and was diagnosed with PMBCL in the setting of impending cardiac tamponade. Case Report: A 35-year-old woman with history of cutaneous lupus presented with an 8-month history of chest pain with associated worsening shortness of breath. Upon further questioning, the patient reported having night sweats intermittently with an associated 10-lb weight loss. On examination, patient was tachycardic to 140 BPM, dyspneic with SPO2 99% on room air, with a BP of 137/87 mm/Hg. Results: CXR was performed which showed a widened mediastinum and cardiomegaly. LDH 514 IU/L. Echocardiogram was performed which revealed a large mediastinal tumor, pericardial effusion with suspicion of possible diastolic compromise. Patient was taken to OR for an emergent pericardial window and biopsy of the mass. Pathology along with immunostaining positive for CD45, CD20, Bcl1, Bcl6 correlated with a diagnosis of PMBCL. Conclusions: PMBCL can be aggressive but tend to have similar response rates compared to other types of b cell lymphomas when combination chemotherapy and mediastinum irradiation is initiated [3]. Our patient opted to be transferred to MD Anderson for higher level of care. Patient is scheduled to follow-up with the oncology team soon

Moans, Palpable Groin, and Entrapment of Bone: A Case of Malignant Peripheral Nerve Sheath Tumor in an otherwise Healthy Hispanic Male

Background: Malignant peripheral nerve sheath tumors (MPNTs) are rare malignant soft tissue sarcomas that have an incidence of about 0.001 %. MPNTs typically occur in individuals who have neurofibromatosis or secondary to radiation therapy and rarely occur sporadically. We present a case of a previously healthy 56-year-old gentleman who was diagnosed with MPNTs. Case: A healthy 56-year-old gentleman presented with worsening LLQ abdominal pain for 6 months. Associated symptoms included bloating, LLE swelling, early satiety for the past 2 months, and a 5-10lb unintentional weight loss. Patient denied recent cough, night sweats, dyspnea, fever, chills, melena or hematochezia. Vitals were WNL. Physical examination revealed a palpable mass on LLQ extending into the groin and edema of the left leg with diminished strength 3/5. CBC and CMP were unremarkable. CT abdomen showed a large necrotic mass in the left retroperitoneum infiltrating along the iliopsoas musculature, extending into the left hip and into the left side of L3, L4, L5 vertebral bodies and through L4 transverse process measuring up to 24.6 x 11.5 x 13 cm. Pathology revealed spindle cell sarcoma composed of moderately atypical, elongated spindle cells positive for vimentin, with loss of H3/K27me3, and negative for SMA, S-100 consistent with MPNSTs. Conclusions: The is a rare case of a sporadic presentation of MPNTs. Treatment depends on the extent of tumor burden and metastatic disease is typically treated with chemotherapy. CT chest showed innumerable pulmonary nodules. Patient is currently being treated with Doxorubicin and Ifosfamide with minimal response

Acción formativa en el dominio del inglés para docentes de ciencias de la salud de la universidad de Carabobo

En el contexto de formación del profesional de la Facultad de Ciencias de la Salud, el dominio del inglés instrumental constituye una base esencial para la adquisición de información actualizada en las diferentes áreas y para la investigación en diferentes contextos; por ello, además de los procesos de desarrollo de competencias relacionadas con el inglés instrumental, la formación del docente adquiere un valor esencial para la promoción de los saberes en la acción didáctica a partir de la mediación y el modelaje. Por ende, se plantea en esta investigación el objetivo central de desarrollar una acción formativa en el dominio de la lengua inglesa para los docentes de la Facultad de Ciencias de la Salud de la Universidad de Carabobo. Para materializar este propósito, se consideró un diseño no experimental, de campo con apoyo documental, bajo la modalidad de los proyectos factibles. Se diseñó un material formativo sobre la base de los aportes expertos como Cabero y Gisbert (2002) y Medina (2008), en el que se ajustaron detalles de diseño y de estructura para la organización de un prototipo, que a través de una prueba piloto aplicada a seis docentes expertos en tecnología, se le evaluó la interfaz siguiendo los criterios de usabilidad de Nielsen (1993). Como resultado de todo ese proceso, se obtuvo un producto tecnológico adecuado a los requerimientos de los docentes de la mencionada Facultad para posteriormente ser evaluado en las variables aspectos estéticos y técnicos del curso y calidad pedagógica de los contenidos y de los materiales ofrecidos, por una muestra no probabilística, conformada por sesenta docentes voluntarios. En general, el análisis de los resultados reveló que un 90% de los encuestados estuvo bastante de acuerdo en afirmar que la valoración que realizaría del curso desde el punto de vista de la calidad científica de los contenidos y la calidad didáctica-educativa de los contenidos ofrecidos es excelente. Estos hallazgos permiten afirmar que esta investigación constituye el primer paso en la Facultad de Ciencias de la Salud para futuros planes de formación en los que el apoyo de la tecnología abre una puerta para un cambio en la cultura de personas que trabajan día a día en un contexto social que les exige cada vez más innovación en sus contextos laborales para convertirse en mediadores y modelos de los futuros profesionales que harán vida social en el país a mediano y largo plazo.In the context of professional training of health sciences, proficiency in English is an essential instrument for the acquisition of updated information in different areas and research contexts. Thus, besides the processes of skill development in students related to English for Specific Purposes, teacher education has a core value for the promotion of knowledge in the didactic action from mediation and modeling. The need for lifelong learning in regards to comprehension and production skills related to instrumental mastery of English led to the proposal of developing a training action in the domain of the English language for professors in the Faculty of Health Sciences of the University of Carabobo. To achieve this purpose, a non-experimental design, field dependent with documentary support, in the form of feasible projects was considered. We designed a training material on the basis about details of design and structure of experts as Cabero and Gisbert (2002), an online educational material was developed and then evaluated by two methods. Prior to the educational material development, a sample of expert educators evaluated it through the application of Nielsen usability criteria (1993) and a field test, in which details of design and structure were adjusted for the organization of a prototype. As a result of this process, a technological product, adequate to the needs of professors of that faculty was obtained. During the second method of evaluation, after the program implementation, the sample of sixty professors took a questionnaire to evaluate the esthetical and technical details and the pedagogical quality of materials. Research findings revealed, that 90% of the respondents made a rather positive assessment about the excellence of the training course from the point of view of the scientific quality and the educational quality of the offered contents. These findings allow to affirm that this research is the first step in the Health Science Faculty for future training plans in which the support of technology opens the door for a change in the culture of people who work every day in a social context that required more and more innovation in their work contexts to become mediators and models of future professionals who will make social life in the country in the medium and long term

Para entender la macrogestión de liquidez: comentario sobre Inside and Outside Liquidity de Holmström y Tirole

Jean Tirole and Bengt Holmström have published Inside and Outside Liquidity (mit Press, 2011). With their proposal, the conceptual foundations for liquidity management and its associated economic policy are described, with applications in financial markets. The precautionary hoarding of liquidity takes place under restrictions to pledge the cash flow of the firm to investors. When liquidity shocks appear, firms can use their own assets, inside liquidity, to obtain cash; when they are not enough, government intervenes through bonds and measures such as the discount window, deposit insurance, unemployment benefits and other forms of outside liquidity, that are not originated in the balance sheet of the private sector. International financial markets are another source of liquidity, with recourse to the pledgeable inflows from international trade. The authors dedicate an epilogue to the subprime crisis, adding the perspective of the bad quality of the collateral as a cause of evaporation of liquidity. Jean Tirole y Bengt Holmström publicaron Inside and Outside Liquidity (mit Press, 2011). Con sus planteamientos se caracterizan los fundamentos conceptuales y de política económica en la gestión de liquidez, con aplicación en los mercados financieros. La acumulación preventiva de liquidez surge ante restricciones para pignorar los flujos de ingreso empresariales a favor de inversionistas. Ante tensiones de liquidez, las empresas emplean sus propios activos, inside liquidity, para conseguir efectivo; al ser estos insuficientes, el Gobierno actúa mediante bonos y medidas como ventana de redescuento del Banco Central, seguro de depósitos, ayudas de desempleo y otras formas de outside liquidity, que no provienen de la hoja de balance del sector privado. Los mercados financieros internacionales son otra fuente de liquidez, contra flujos pignoraticios del sector transable. Los autores dedican un epílogo a la crisis subprime, añadiendo la perspectiva de mala calidad de colateral en la evaporación de liquidez del mercado

That Which Keeps on Giving - A Case of Class IV Diffuse Proliferative Lupus Nephritis in a Hispanic Woman with underlying Systemic Lupus Erythematosus

Background: Glomerulonephritis is the primary cause of morbidity and mortality of systemic lupus erythematosus (SLE). Lupus nephritis is characterized by immune complex deposition in the mesangium leading to complement activation and hypocomplementemia. Studies show that up to 60% of adults with lupus develop renal involvement and it has been well established that Hispanic patients show poorer outcomes than Caucasians despite advances in treatment. Preserved kidney function with new-onset proteinuria should raise clinical suspicion for acute lupus nephritis. Further evaluation with a kidney biopsy is paramount in establishing a diagnosis, helping to define treatment strategy, and determining response to treatment. Case Presentation: A 41-yo-Hispanic-Woman with a PMH SLE without previous renal involvement, secondary Sjogren\u27s, hypertension, heart failure and cirrhosis presented to the ER with a worsening SOB, difficulty swallowing, and anasarca over two weeks. On evaluation, the patient was hypertensive, tachypneic, had positive JVD, wheezing in lung bases, +1 pitting edema in the lower extremities and skin hyperpigmentation on the face, neck, and upper extremities. Laboratory studies revealed leukocytosis of 11.1 th/uL, Hgb 10 gm/dL, platelets 192 th/uL, Cr 0.9 mg/dL, BUN 17 mg/dL, bicarbonate 19 mmo/L, sedimentation rate 94 mm/hr, and CRP 4.5 mg/L. A urinalysis was performed, which showed 3+ proteinuria with hematuria with a subsequent protein to creatinine ratio demonstrating 2,000 mg/gm. The workup for nephritic range proteinuria revealed an ANA 10U, anti-dsDNA 2.7 IU/mL, negative ANCA, anti-cardiolipin Ab IgMMPL, anti-cardiolipin Ab IgG 14 GPL, and non-reactive HIV, Hepatitis C, and Hepatitis B panels. Despite negative glomerulonephritis workup including anti-dsDNA antibody, a kidney biopsy was pursued and revealed class IV diffuse proliferative lupus nephritis with a component of thrombotic microangiopathy. Conclusion: Kidney biopsies are imperative when establishing a cause of new-onset proteinuria in a patient with a history of SLE. The goal of treatment is induction with immunosuppressive agents to reduce kidney inflammation promptly and prevent flares, decreasing the long-term risk of renal failure. Despite early recognition strategies and advances in treatment, Hispanic patients are likely to be diagnosed with more severe disease at presentation, specifically with class IV or V lupus nephritis. Subsequently, these patients are more likely to develop chronic renal failure compared to Caucasian patients. This case highlights the importance of screening urinalysis for proteinuria for early detection of renal involvement in patients with SLE

Modificación de espacios a partir de la experimentación con materiales, sensaciones y conceptos

Este proyecto, será en gran medida, una investigación práctica y sobretodo experimental, tomando como punto de partida el cinetismo, la geometría, la deconstrucción y las interacciones entre el arte y la ciencia del movimiento, volcados al arte abstracto. Donde se intenta interactuar directamente con el espectador, mediante una obra que no se limite al plano bidimensional y que intenta buscar una conexión entre el espacio que deja el espectador y la obra, con una percepción de desequilibrio.Guedez Torres, W. (2014). Modificación de espacios a partir de la experimentación con materiales, sensaciones y conceptos. http://hdl.handle.net/10251/50608.Archivo delegad

Herbert Simon: racionalidad limitada y mercados financieros eficientes.

El concepto de racionalidad limitada, aportado por el Nobel de Economía 1978, Herbert Simon (1916-2001) es relevante para considerar la conducta de los decisores del mercado financiero, quienes pueden optar por obtener resultados satisfactorios en lugar de óptimos para sus inversionesy la gestión de tesorería en organizaciones. El decisor económico confronta limitaciones de información y computacionales que conducen a que establezca un nivel de aspiración para la variable por optimizar y se conforme con superar cierto umbral, en lugar de considerar más alternativas. Bajo este esquema de conducta, se tiene el coste de oportunidad de ingresos no devengados y se disuade la innovación financiera dentro de la organización. Este modelo de racionalidad limitada puede responder el enigma de por qué las empresas siguen pagando dividendos sujetos a tributación, en lugar de retener utilidades e incrementar la revalorización de la acción (que solo paga impuesto al venderse).

Trastuzumab-Induced Interstitial Pneumonitis

Trastuzumab is a recombinant immunoglobulin G1 monoclonal antibody used to treat human epidermal growth factor receptor 2 (HER2) cancers. Trastuzumab-induced interstitial pneumonitis is a rare adverse effect reported in a few patients. Interstitial pneumonitis presents as symptoms of dyspnea, hypoxia, cough, and fever. If the patient is treated early, corticosteroids can slow or reverse the disease progression. A 41-year-old woman presented with dyspnea and a dry cough three weeks after her third cycle of trastuzumab therapy for breast cancer. A diagnosis of trastuzumab-induced interstitial pneumonitis was made after multiple other disease processes were ruled out. The patient was started on methylprednisolone while inpatient and transitioned to prednisone for outpatient therapy. The patient was maintained on 2-3L of oxygen throughout her hospital stay and was discharged on 3L of oxygen through nasal cannula. Trastuzumab was never restarted after discharge. There have been many trials evaluating the safety, efficacy, and optimal treatment regimen of trastuzumab, but there are only a few reports of interstitial pneumonitis adverse reaction. The lack of correlation and limited cases make this adverse effect very difficult to diagnose and monitor. New trials and case reports can bring an insight into contributing factors, symptoms at onset, and treatment for future patients. With the increase in use of trastuzumab therapy, physicians should be aware of how to diagnose and treat the rare adverse reaction of trastuzumab-induced interstitial pneumonitis