Criterios de implementación ISO 14001:2015 Caso estudio sector de construcción de vías, donde VICPAR.

Ciclo PHVA, diagrama de flujo, Matriz legislación ambiental aplicable,.Vicpar SA., es una empresa de ingeniería civil ubicada en el departamento de Cundinamarca, la cual, presta sus servicios de construcción de vías, se realiza el estudio de caso con el fin de verificar los requisitos y cumplimiento de la norma ISO 14001;2015. Su política integrada de gestión se basa en el compromiso con la satisfacción de los clientes, las partes interesadas, protección del medio ambiente, prevención de lesiones y enfermedades laborales y el cumplimiento de los requisitos legales y contractuales, mediante la construcción de obras de ingeniería civil y mecánicas, caracterizándose por la seriedad y cumplimiento, con un manejo adecuado de los riesgos, apoyados en un grupo humano competente, mediante procesos ágiles y ecientes, promoviendo el desarrollo y mejora continua del sistema Integrado de Gestión (SST, Medio Ambiente y Calidad). Por tanto, la empresa está comprometida con la legislación actual ambiental en las actividades que se realizan en los procedimientos de construcción de vías, siempre pensando en la protección del entorno ambiental, como también de sus colaboradores.Vicpar SA., Is a civil engineering company located in the department of Cundinamarca, which provides road construction services. The case study is carried out in order to verify the requirements and compliance with the ISO 14001 standard; . Its integrated management policy is based on the commitment to customer satisfaction, stakeholders, environmental protection, prevention of occupational injuries and diseases and compliance with legal and contractual requirements, through the construction of civil engineering works and mechanics, characterized by seriousness and compliance, with an adequate management of risks, supported by a competent human group, through agile and e cient processes, promoting the development and continuous improvement of the Integrated Management System (SST, Environment and Quality ). Therefore, the company is committed to the current environmental legislation in the activities carried out in the construction of roads, always thinking about the protection of the environment, as well as its employees

Critical Care Management of a Severe Acute Respiratory Distress Syndrome COVID-19 Patient With Control Cesarean Section

We share our experience of one 29-year-old female, G2 P1, with acute respiratory distress syndrome (ARDS) and at 30 weeks of pregnancy. The 30-week gravid uterus in combination with a poor ventilation-perfusion ratio creates a restrictive lung pattern that may prove to be lethal for both the mother and baby. Due to her rapid deterioration and increased hemodynamic instability we opted for controlled delivery in the operating room with an ICU physician, a Neonatologist, and an Obstetric team. At 3.27 minutes from induction, the baby was born with Apgar scores of 7 and 8. The mother was placed on a RotoProne® bed, treated with remdesivir, steroids, and was subsequently extubated seven days later. The newborn was admitted to the Neonatal Intensive Care Unit (NICU) after delivery. We have reviewed the literature and provided a concise set of recommendations based on our field experience and current world literature review. Prompt delivery in a controlled environment with multiple resuscitating teams provided expeditious treatment of both patients, maintaining oxygenation and perfusion while keeping hemodynamic stability. The controlled environment and the proximity of all teams avoided deleterious consequences to the unborn baby. This is an example where the risk of keeping the baby in the womb outweighs the premature delivery into a NICU. Both mother and baby were downgraded from their respective Intensive Care Units (ICUs) and discharged home in one month

Correction to: Usefulness of Genetic Testing in Hypertrophic Cardiomyopathy: an Analysis Using Real-World Data

post-print123 K

Usefulness of genetic testing in hypertrophic cardiomyopathy. An analysis using real-world data.

Aims: This study sought to determine the usefulness of genetic testing to predict evolution in hypertrophic cardiomyopathy (HCM) and to assess the role of genetic testing in clinical practice. Methods and Results: Genetic results of 100 HCM patients tested for mutations in ≥10 HCM-causing genes were evaluated. Patients were classified as with poor (Group A) or favourable(Group B) clinical course. Forty-five pathogenic mutations (PM) were identified in 28 patients (56%) from Group A and in 23 (46%) from Group B (p=0.317). Only 40 patients (40%) exhibited PM that had been previously reported and only 15 (15%) had PM reported in ≥10 individuals. PM associated with poor prognosis were identified in just 5 patients from Group A (10%). Conclusion: Genetic findings are not useful to predict prognosis in most HCM patients. By contrast, real-world data reinforce the usefulness of genetic testing to provide genetic counselling and to enable cascade genetic screening.pre-print298 K

Cerclage retention versus removal following preterm premature rupture of membranes and association with amniotic fluid markers

ObjectiveTo evaluate whether amniotic fluid markers can aid the decision of whether to retain or remove a cervical cerclage after preterm premature rupture of membranes (PPROM).MethodsA retrospective cohort study included pregnancies involving PPROM after diagnostic amniocentesis and cerclage placement. Cerclage was retained for more than 12 hours after PPROM in the study group (n = 18); the comparison group comprised women who underwent immediate cerclage removal after PPROM (n = 22). Analyses were performed using concentrations of interleukin (IL)â 6, glucose, and white blood cells (WBCs) in the amniotic fluid to measure relationships with adverse outcomes.ResultsThe latency period from PPROM to delivery was significantly shorter in the group that underwent immediate cerclage removal (P < 0.005). Latency periods of more than 48 hours (P < 0.001) and more than 7 days (P < 0.01), and chorioamnionitis (P < 0.05) were associated with cerclage retention. Neonatal outcomes were not significantly different between the study group and the comparison group. However, elevated ILâ 6 levels were associated with cumulative neonatal morbidity (P < 0.05). Low ILâ 6 (P < 0.001) and WBC (P < 0.05) levels were significantly associated with a latency period of more than 7 days.ConclusionAmniotic fluid levels of ILâ 6 and WBCs may be of clinical value for individualizing the management of patients with PPROM after cerclage.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/135438/1/ijgo37.pd

Perfil clínico y evolución de la amiloidosis cardiaca en un centro español de referencia.

Introducción y objetivos La amiloidosis cardiaca (AC) se produce por depósito de fibras de amiloide en el miocardio. Las formas más frecuentes son la amiloidosis por cadenas ligeras (AL) y por transtiretina (ATTR). Nuestro objetivo es describir la experiencia en el diagnóstico, tratamiento y pronóstico en un centro especializado español. Métodos Se incluyeron todos los pacientes diagnosticados de AC en el XXXX1 desde mayo de 2008 a septiembre de 2018 y se analizaron sus características clínicas, evolución y supervivencia. Resultados Se incluyeron 180 pacientes con AC, de los cuales, 64 (36%) eran AL (50% varones;65±11 años) y 116 ATTR (72% varones;79±11 años, 19 con ATTR hereditaria). La forma de presentación más frecuente fue la insuficiencia cardiaca en ambos grupos (81% AL y 45% ATTR;p<0,01). Otras formas de presentación en pacientes ATTR fueron arritmias auriculares (16%), trastornos de conducción (6%) e incidental (6%). 70 pacientes (40%), tenían otro diagnostico previo establecido. El 72% de los pacientes ATTR pudo diagnosticarse de forma no invasiva. A pesar de que el retraso diagnóstico fue superior en ATTR (2,8±4,3 vs 0,6±0,7 años;p<0,001), la mortalidad fue mayor en los pacientes AL (48% vs 32%;p=0,028). El tipo AL (HR:6,16;IC95%:1,56-24,30;p=0,01), el sexo femenino (HR:2,35;IC95%:1,24-4,46;p=0,01) y la clase funcional NYHA III-IV (HR:2,07;IC95%:1,11-3,89;p=0,02) fueron predictores independientes de mortalidad. Conclusiones La AC constituye un reto en la práctica clínica, con gran variabilidad en su presentación en función del subtipo y con un retraso diagnóstico y una mortalidad elevados. Son necesarias mejoras en el diagnostico temprano y tratamiento de estos pacientes.pre-print298 K

Clinical phenotypes and prognosis of dilated cardiomyopathy caused by truncating variants in the TTN Gene.

Background: Truncating variants in the TTN gene (TTNtv) are the commonest cause of heritable dilated cardiomyopathy. This study aimed to study the phenotypes and outcomes of TTNtv carriers. Methods: Five hundred thirty-seven individuals (61% men; 317 probands) with TTNtv were recruited in 14 centers (372 [69%] with baseline left ventricular systolic dysfunction [LVSD]). Baseline and longitudinal clinical data were obtained. The primary end point was a composite of malignant ventricular arrhythmia and end-stage heart failure. The secondary end point was left ventricular reverse remodeling (left ventricular ejection fraction increase by ≥10% or normalization to ≥50%). Results: Median follow-up was 49 (18–105) months. Men developed LVSD more frequently and earlier than women (45±14 versus 49±16 years, respectively; P=0.04). By final evaluation, 31%, 45%, and 56% had atrial fibrillation, frequent ventricular ectopy, and nonsustained ventricular tachycardia, respectively. Seventy-six (14.2%) individuals reached the primary end point (52 [68%] end-stage heart failure events, 24 [32%] malignant ventricular arrhythmia events). Malignant ventricular arrhythmia end points most commonly occurred in patients with severe LVSD. Male sex (hazard ratio, 1.89 [95% CI, 1.04–3.44]; P=0.04) and left ventricular ejection fraction (per 10% decrement from left ventricular ejection fraction, 50%; hazard ratio, 1.63 [95% CI, 1.30–2.04]; P<0.001) were independent predictors of the primary end point. Two hundred seven of 300 (69%) patients with LVSD had evidence of left ventricular reverse remodeling. In a subgroup of 29 of 74 (39%) patients with initial left ventricular reverse remodeling, there was a subsequent left ventricular ejection fraction decrement. TTNtv location was not associated with statistically significant differences in baseline clinical characteristics, left ventricular reverse remodeling, or outcomes on multivariable analysis (P=0.07). Conclusions: TTNtv is characterized by frequent arrhythmia, but malignant ventricular arrhythmias are most commonly associated with severe LVSD. Male sex and LVSD are independent predictors of outcomes. Mutation location does not impact clinical phenotype or outcomes.pre-print1,66 M

P2 purinergic receptor modulation of cytokine production

Cytokines serve important functions in controlling host immunity. Cells involved in the synthesis of these polypeptide mediators have evolved highly regulated processes to ensure that production is carefully balanced. In inflammatory and immune disorders, however, mis-regulation of the production and/or activity of cytokines is recognized as a major contributor to the disease process, and therapeutics that target individual cytokines are providing very effective treatment options in the clinic. Leukocytes are the principle producers of a number of key cytokines, and these cells also express numerous members of the purinergic P2 receptor family. Studies in several cellular systems have provided evidence that P2 receptor modulation can affect cytokine production, and mechanistic features of this regulation have emerged. This review highlights three separate examples corresponding to (1) P2Y6 receptor mediated impact on interleukin (IL)-8 production, (2) P2Y11 receptor-mediated affects on IL-12/23 output, and (3) P2X7 receptor mediated IL-1β posttranslational processing. These examples demonstrate important roles of purinergic receptors in the modulation of cytokine production. Extension of these cellular observations to in vivo situations may lead to new therapeutic strategies for treating cytokine-mediated diseases

Performance of a dust model to predict the vertical mass concentration of an extreme Saharan dust event in the Iberian Peninsula: Comparison with continuous, elastic, polarization-sensitive lidars

© Elsevier. This manuscript version is made available under the CC-BY-NC-ND 4.0 license http://creativecommons.org/licenses/by-nc-nd/4.0/An intense dusty event unusually occurred in wintertime over the Iberian Peninsula was detected over two Spanish NASA/MPLNET sites: the temporary Torrejón Observational Tower for Environmental Monitoring (TOTEM, 40.5°N 3.5°W) and the Barcelona station (BCN, 41.4°N 2.1°E). The highest dust incidence was observed from 22 to 23 February 2017; this two-day dusty scenario is examined in order to evaluate the performance of the operational NMMB/BSC-Dust model on forecasted mass concentration profiling in comparison with polarized Micro-Pulse (P-MPL) mass estimates for dust particles. First, the optical properties of the dust (DD) were effectively separated from the non-dust (ND) component by using the combined P-MPL/POLIPHON method. Lidar-derived DD optical depths reached maximums of 1.6–1.7 (±0.1) at both stations. Typical features for dust were obtained: linear particle depolarization ratios between 0.3 and 0.4, and lidar ratios in the range of 41–70 sr and 36–66 sr, respectively, for TOTEM and BCN. Lower AERONET Ångström exponents were reported for TOTEM (0.12¿±¿0.04) than at BCN (0.5¿±¿0.3). HYSPLIT back-trajectory analysis showed air masses coming from the Sahara region, mostly transporting dust particles. AERONET-derived Mass Extinction Efficiencies (MEE) under dusty conditions were used for the extinction-to-mass conversion procedure as applied to the P-MPL measurements: MEE values were lower at TOTEM (0.57¿±¿0.01¿m2¿g-1) than those found at BCN (0.87¿±¿0.10¿m2¿g-1). Those results reveal that dust particles were predominantly larger at TOTEM than those observed at BCN, and a longer transport of dust particles from the Sahara sources to BCN could favour a higher gravitational settling of coarser particles before reaching BCN than TOTEM. A comparative analysis between profiles as obtained from the lidar DD component of the mass concentration and those forecasted by the NMMB/BSC-Dust model (25 available dusty profiles) was performed. The degree of agreement between both datasets was determined by the percentage of dusty cases satisfying selected model performance criteria (favourable cases) of two proxies: the Mean Fractional Bias, , and the correlation coefficient, . A good agreement is found (72% and 76%, respectively, of favourable cases); however, large discrepancies are found at low altitudes between the dust model and the lidar observations, mostly at early stages of the arrival of the dust intrusion. Higher model-derived centre-of-mass (CoM) heights are found in 60% of the cases (with differences¿<¿15% w.r.t. the lidar CoM, whose values ranged between 1.8 and 2.3¿km height). In addition, modelled mass loading (ML) values were generally higher than the lidar-derived ones. However, the evolution of the mass loading along the two days, 22 and 23 February, was rather similar for both the model forecasting and lidar observations at both stations. The relative ML differences (<50%) of the mass loading represented 60% of all cases. Discrepancies can be based on the uncertainties in the lidar retrievals (mainly, the use of single extinction-to-mass conversion factors). In general, a moderately good agreement is observed between the P-MPL-derived dust mass concentration profiles and the NMMB/BSC-Dust model ones at both sites; large discrepancies are found at lower altitudes, plausibly due to a lower sedimentation of dust particles coming from upper layers by gravitational settling than that introduced by the NMMB/BSC-Dust model in the simulations. The methodology described for the dust model evaluation against the continuous P-MPL observations can be easily adopted for an operational use of the NMMB/BSC-Dust model for forecasting the mass concentration profiling in frequently dust-affected regions with serious climate and environmental implications, as long as a typical MEE for dust could be accurately specified. Hence, a statistical analysis for determining AERONET-based MEE values over the Iberian Peninsula is on-going.Peer ReviewedPostprint (author's final draft