Spectral Doppler Ultrasonography of Hepatic Vein in a Patient with Atrial Fibrillation and Rapid Ventricular Rate

Background: Point of Care ultrasound (POCUS) is a tool that enables the clinicians to objectively assess hemodynamics at the bedside. Recently, a novel concept of venous excess Doppler ultrasound (VExUS) grading system has been proposed to assess venous congestion at the organ level in real time. This concept evaluates the presence of severe flow abnormalities in 2 or more veins (of the hepatic, portal, and kidney parenchymal veins) with a dilated IVC (≥2 cm). There are reports in literature that tachyarrhythmias alter the flow pattern in the hepatic veins. Case presentation: We present a case of a 88-year-old gentleman with a past medical history of hypertension, paroxysmal atrial fibrillation, CKD and diabetes, who was admitted due to sepsis in the setting of multifocal pneumonia. On admission day 3, the patient developed atrial fibrillation with rapid ventricular response and worsening hemodynamic status. A bedside POCUS was performed as part of the evaluation. Hepatic vein doppler flow showed complete S wave reversal suggesting high right atrial pressures (RAP) and severe intravascular congestion. Diltiazem infusion was started immediately, and diuretics were ordered. Rate control was achieved after 2 hours of diltiazem infusion. Reassessment of hepatic vein Doppler flow showed normalization of S wave with an S \u3c D pattern which is common in atrial fibrillation even in the absence of elevated RAP. A decision was made to discontinue diuretics as S wave reversal was attributed to rapid ventricular rate. Conclusions: VExUS grading is a novel concept, that evaluates intravascular congestion based on IVC diameter, hepatic, portal and kidney veins Doppler waveforms. Awareness of hepatic vein doppler alterations in tachyarrhythmias allows one to avoid misinterpretation of the hepatic vein signal and permits assessment of the impact on right heart hemodynamics

Anthropological view of the decentralization of the Mexican health system

OBJETIVO: Analizar cambios organizacionales, políticos y económicos resultantes de la descentralización del sistema de salud en la población sin seguridad social en México. METODOS: Se visitaron tres estados del país seleccionados por el número de habitantes en condición de pobreza, el partido político en el poder y la etapa de implementación de la descentralización (la primera fue en 1984 y la segunda en 1997). Se realizaron entrevistas durante 2007 con informantes clave de los servicios de salud de los gobiernos estatales, personas que acudieron a consulta en los servicios estatales de salud y líderes comunitarios. Los datos fueron analizados desde una perspectiva antropológica y económica. RESULTADOS: La descentralización ocurrió de forma heterogénea en cada estado, observándose una transferencia de responsabilidades de la federación a los estados, más no así una ruptura con la dependencia del nivel central - federal. Las reformas impulsadas desde el nivel federal para crear un esquema fundamentado en principios de subsidiaridad financiera y democratización en salud enfrentan retos políticos y organizacionales para su consolidación. CONCLUSIONES: El enfoque antropológico muestra la relevancia de considerar factores organizacionales, políticos y económicos como parte del proceso de descentralización.OBJECTIVE: To analyze organizational, political and economic changes resulting from the decentralization of the health system for those in Mexico without health insurance. METHODS: Three states, selected by considering the percentage of the population living in poverty, the political party in power and their stage of decentralization (the first was in 1984 and the second in 1997) were included. Interviews were conducted during 2007 with key informants from the state health care services, users of health care services, and community leaders. Data were analyzed from an anthropological and economic perspective. RESULTS: Decentralization occurred in a heterogeneous way in each state, with responsibilities being transferred from federal to state level but without breaking the dependence on the central-federal level. The reforms driven from the federal level to create a scheme based on a principle of financial subsidies and democratization of the health system face challenges for their political and organizational consolidation. CONCLUSIONS: The anthropological approach adopted in this analysis shows the relevance of considering organizational, economic and political factors as key components of the decentralization process

Propuesta para implementar una estrategia de adquisión y uso eficiente de combustible en una empresa de agregados

La presente investigación se enfoca en desarrollar una estrategia sostenible que permita una mejora continua con las herramientas que toda empresa minera tiene a su alcance con respecto al principal recurso consumible en la ejecución de sus operaciones. En esta investigación se analizará la empresa TZ, la cual se dedica a la extracción, procesamiento y transporte de agregados para concreto a diferentes proyectos de infraestructura. Se ha planteado como finalidad de la presente investigación, ofrecer una herramienta que permita administrar, evaluar y controlar el uso de combustible en las operaciones diarias. En el capítulo 01 se presenta la problemática de la empresa en análisis, la cual inicia desde la adquisición hasta la asignación del recurso para ser usado por la maquinaria. Esta situación no permite una correcta asignación de incidencia en el precio, generando incertidumbre sobre su incidencia en el precio final del producto y el rendimiento de los equipos en cuanto a costos. Por ello, se va a demostrar la incidencia que tiene acciones de mejora en la adquisición y consumo de petróleo en el costo directo del producto. En el capítulo 02 tras el análisis del marco teórico y el análisis propio del problema, se identificará las posibles soluciones analizando su viabilidad técnica y económica. Para el capítulo 03 se evaluará la potencialidad de cada posible solución y se hará un breve análisis de sus implicancias en el costo directo del producto mejorando el rendimiento de la inversión realizada.This research focuses on developing a sustainable strategy that allows continuous improvement with the tools that every mining company has at its disposal with respect to the main consumable resource in the execution of its operations. In this research, the TZ company will be analyzed, which is dedicated to the extraction, processing and transport of aggregates for concrete to different infrastructure projects. The purpose of this research has been to offer a tool that allows you to manage, evaluate and control the use of fuel in daily operations. In chapter 01, the problem of the company under analysis is presented, which begins from the acquisition to the allocation of the resource to be used by the machinery. This situation does not allow a correct allocation of incidence in the price, generating uncertainty about its incidence in the final price of the product and the performance of the equipment in terms of costs. Therefore, the impact of actions to improve the acquisition and consumption of oil on the direct cost of the product will be demonstrated. In chapter 02, after the analysis of the theoretical framework and the analysis of the problem, the possible solutions will be identified by analyzing their technical and economic feasibility. For chapter 03, the potential of each possible solution will be evaluated and a brief analysis of its implications on the direct cost of the product will be made, improving the return on the investment made.Trabajo de suficiencia profesiona

Monitoring degradation mechanisms in PTB7:PC71BM photovoltaic cells by means of impedance spectroscopy

© 2016. This version is made available under the CC-BY-NC-ND 4.0 license http://creativecommons.org/licenses/by-nc-nd/4.0/We have used impedance spectroscopy technique to monitor degradation mechanisms in organic solar cells based on a blend of PTB7:PC71BM. We have measured the impedance of the cell on a periodical basis for almost four months, and experimental data have been modeled using three different circuits. The evolution of the circuital parameters gives information about the device dynamical mechanisms. We have observed at high voltages a low frequency feature that is more pronounced along days of measurement. This low frequency arc has been associated to charge accumulation that is related to a worsening of charge extraction through the contacts. The simultaneous increase of recombination and low frequency resistances at high voltages (around V-oc) results in a decrease of the fill factor and therefore of the efficiency.Peer ReviewedPostprint (author's final draft

A Rare Case of COVID Encephalitis in a Vaccinated Patient

Background and Purpose: SARS-CoV-2 infection is known to cause primarily respiratory symptoms, however, neurological disorders such as anosmia and stroke have been seen. Encephalitis is a rare complication of COVID-19 with a reported incidence of less than 1%¹. Most patients develop both COVID-19 symptoms and encephalitis symptoms during the same period¹. In addition, the majority of reports are from patients with no prior vaccination. Here, we present a case of encephalitis 2 weeks after mild COVID-19 in a fully vaccinated male. Case Presentation: A 68-year-old Hispanic male was brought to the ED due to new onset gaze deviation, generalized tonic posturing, facial drooping, and unresponsiveness. Days prior to his symptoms, family members reported he was found staring blankly, confused, disoriented, and experienced multiple falls. The patient had a positive COVID-19 PCR exam 2 weeks prior to developing the symptoms, despite completing two doses of the Moderna vaccine 6 months prior. His sole symptom at the time was a cough. At admission, SARS-CoV-2 PCR was negative. NIHSS was 15. He was intubated and CT head was negative for active bleeding. tPA was administered for suspected ischemic stroke, however brain perfusion CT and MRI ruled out large vessel occlusion. He was started on Levetiracetam for seizures; 6 days later, Valproate was added. He remained intubated due to an altered state of mind, airway protection, and continuous seizure activity. 24-hour cEEG showed: slower background with multiple sedating agents on. CSF analysis showed elevated: protein (73), glucose (116) and pleocytosis (WBC = 26; of which 87% lymphocytes); Panel was: negative for infectious encephalitis (e.g. CMV, HSV, N. Meningitidis, VZV, Cryptococcus), Anti-NMDA receptor Ab, Anti-LGI1 Ab. Serologies were negative for ANCA, ANA, dsDNA and Anti-Proteinase-3 Ab. Post-COVID encephalitis was suspected and plasmapheresis exchange (PLEX) therapy was started. He completed five treatments of PLEX with marked improvement after therapy. Given the significant clinical improvement, he was successfully extubated. Patient’s neurological status progressively improved, reaching closer to his baseline status. He was transferred to the medical floor and eventually to acute rehab. Conclusion: Post COVID-19 encephalitis should be in the differential for patients with new onset altered mental status (AMS) and prior history of recent SARS-CoV-2 infection. Patients presenting with encephalitis should be tested and questioned for COVID diagnosis, even in those fully vaccinated. The length of stay may be reduced with treatments targeted towards COVID encephalitis and shorter delay in presentation to treatment2. Though a COVID CSF PCR was not done in this case, to date, there are no definitive reports of SARS-CoV-2 detection in CSF3. Additionally, this case supports the use of PLEX therapy, as there are multiple other options that are still being studied for the limited cases reported

A Cross-Sectional Study of Prisoners in Mexico City Comparing Prevalence of Transmissible Infections and Chronic Diseases with That in the General Population.

ObjectivesTo describe patterns of transmissible infections, chronic illnesses, socio-demographic characteristics and risk behaviors in Mexico City prisons, including in comparison to the general population, to identify those currently needing healthcare and inform policy.Materials and methodsA cross-sectional study among 17,000 prisoners at 4 Mexico City prisons (June to December 2010). Participation was voluntary, confidential and based on informed consent. Participants were tested for HIV, Hepatitis B & C, syphilis, hypertension, obesity, and, if at risk, glucose and cholesterol. A subset completed a questionnaire on socio-demographic characteristics and risk behaviors. Positive results were delivered with counseling and treatment or referral.Results76.8% (15,517/20,196) of men and 92.9% (1,779/1,914) of women participated. Complete data sets were available for 98.8%. The following prevalence data were established for transmissible infections: HIV 0.7%; syphilis: Anti-TP+/VDRL+ 2.0%; Hepatitis B: HBcAb 2.8%, HBsAg 0.15%; Anti-HCV 3.2%. Obesity: 9.5% men, 33.8% women. Compared with national age- and sex-matched data, the relative prevalence was greater for HIV and syphilis among women, HIV and Hepatitis C in men, and all infections in younger participants. Obesity prevalence was similar for women and lower among male participants. The prevalence of previously diagnosed diabetes and hypertension was lower. Questionnaire data (1,934 men, 520 women) demonstrated lower educational levels, increased smoking and substance use compared to national data. High levels of non-sterile tattooing, physical abuse and histories of sexual violence were found.ConclusionThe study identified that health screening is acceptable to Mexico City prisoners and feasible on a large-scale. It demonstrated higher prevalence of HIV and other infections compared to national data, though low rates compared to international data. Individual participants benefited from earlier diagnosis, treatment and support. The data collected will also enable the formulation of improved policy for this vulnerable group

Bioassay-guided identification of the antiproliferative compounds of cissus trifoliata and the transcriptomic effect of resveratrol in prostate cancer pc3 cells

The bioassay-guided fractionation of a CHCl3-MeOH extract from the stems of Cissus trifo-liata identified an active fraction against PC3 prostate cancer cells. The treatment for 24 h showed an 80% reduction in cell viability (p ≤ 0.05) by a WST-1 assay at a concentration of 100 µg/mL. The HPLC-QTOF-MS analysis of the fraction showed the presence of coumaric and isoferulic acids, apigenin, kaempferol, chrysoeriol, naringenin, ursolic and betulinic acids, hexadecadienoic and octadecadienoic fatty acids, and the stilbene resveratrol. The exposure of PC3 cells to resveratrol (IC25 = 23 µg/mL) for 24 h induced significant changes in 847 genes (Z-score ≥ ±2). The functional classification tool of the DAVID v6.8 platform indicates that the underlying molecular mechanisms against the proliferation of PC3 cells were associated (p ≤ 0.05) with the process of differentiation and metabolism. These findings provide experimental evidence suggesting the potential of C. trifoliata as a promising natural source of anticancer compounds

The BIDIAP index: a clinical, analytical and ultrasonographic score for the diagnosis of acute appendicitis in children

Background: Pediatric acute appendicitis (PAA) continues to be a diagnostic challenge today. The diagnostic performance of classical indices is only moderate, especially in pediatric population. This study aimed to define a clinical, radiological and analytical index for the diagnosis of PAA. Materials and methods: This prospective study included 151 patients divided into two groups: (1) 53 patients with non-surgical abdominal pain (NSAP) and (2) 98 patients with a confirmed PAA. Sociodemographic and clinical characteristics were compared between groups using the Mann-Whitney U test and the Fisher exact test. To identify the predictors of PAA, we performed a multivariable logistic regression using a forward stepwise analysis and we assigned multiples of integer values to the selected variables. The diagnostic performance of the index was assessed by calculating the area under the receiver operating characteristic curve. Intra-cohort calibration was assessed with the Hosmer-Lemeshow test. Results: We developed the BIDIAP index (BIomarkers for the DIagnosis of Appendicitis in Pediatrics), which included three variables that independently predicted higher odds of PAA: appendiceal caliber (≥ 6.9 mm), systemic immune-inflammation index (≥ 890) and peritoneal irritation, which scored 4, 3 and 2 points, respectively. Mean (SD) score of the participants was 2.38 (2.06) in group 1 and 7.89 (1.50) in group 2. The area under the ROC was 0.97 (95% CI 0.95-0.99). The cut-off point was established at 4 points, resulting in a sensitivity of 98.98% and a specificity of 77.78%. Conclusions: The BIDIAP index has an exceptional diagnostic performance in PAA. The importance of these results lies in its novelty and in the simplicity of the index. Although external validation will be necessary, initial results look promising

Alterations and diagnostic performance of capillary ketonemia in pediatric acute appendicitis: a pilot study

Introduction: The diagnostic performance of capillary ketonemia (CK) has been previously evaluated in context of pediatric acute gastroenteritis. To our knowledge, there is no literature on its performance in the setting of pediatric acute appendicitis (PAA). Materials and methods: In this study, 151 patients were prospectively included and divided into two groups: (1) patients with non-surgical abdominal pain in whom the diagnosis of PAA was excluded (n : 53) and (2) patients with a confirmed diagnosis of PAA (n : 98). In 80 patients (Group 1, n : 23 and group 2, n : 57) a CK was measured at the time of diagnosis. The PAA group was further classified into complicated (n : 18) and uncomplicated PAA (n : 39). Quantitative variables were compared between groups using the Mann-Whitney U test. Diagnostic performance of CK was evaluated with ROC curves. Results: CK values were 0.3 [0.1-0.9] mmol/L in group 1 and 0.7 [0.4-1.4] mmol/L in group 2 (p = 0.01). Regarding the type of PAA, CK values were 0.6 [0.4-0.9] mmol/L in uncomplicated PAA and 1.2 [0.8-1.4] mmol/L in complicated PAA (p : 0.02). The AUC for the discrimination between groups 1 and 2 was 0.68 (95/100 IC 0.53-0.82) (p : 0.24) and the AUC for the discrimination between uncomplicated PAA and complicated PAA was 0.69 (95/100 IC 0.54-0.85) (p : 0.04). The best cut-off point (group 1 vs group 2) resulted in 0.4 mmol/L, with a sensitivity of 80.7/100 and a specificity of 52.2/100. The best cut-off point (non-complicated vs complicated PAA) resulted in 1.1 mmol/L, with a sensitivity of 61.1/100 and a specificity of 76.9/100. Conclusions: This study found significantly higher levels of CK in patients with PAA than in those with NSAP. Similarly, significantly higher levels were observed in patients with complicated than in those with uncomplicated PAA. Nevertheless, the diagnostic performance of CK was only moderate in the two settings analyzed. The potential usefulness of CK determination as a tool to guide the preoperative rehydration regimen of patients with PAA to prevent postoperative hyporexia and vomiting is a promising line of research and should be evaluated in future studies

Current Status of the Insecticide Resistance in Aedes aegypti (Diptera: Culicidae) from Mexico

The mosquito Aedes aegypti (Diptera: Culicidae) is the primary vector of dengue in Mexico and lately virus Chikungunya, although Aedes albopictus is widely distributed; its role in both diseases’ transmission has not been confirmed. The control of mosquitoes in Mexico includes source reduction consisting in the elimination of containers that are favorable sites for oviposition and development of the aquatic stage. The use of insecticides is to control larvae and adulticides as outdoor ultra-low volume applications and indoor residual spray and more recently impregnated materials. The health department regulates the use of insecticides, and such regulations are revised and adapted over time. Since 1999, the vector control regulations gave preference to the use of pyrethroids, a permethrin-based formulation to control adult forms. This insecticide was used as the only adulticide in Mexico for more than 10 years. The consequences of this actions have evolved in a widespread and strong resistance to other insecticides, mainly pyrethroids. We include in this revision evidence of resistance reported in Ae. aegypti in Mexico