Cumplimiento del lavado de manos por parte del personal del servicio de clínica del Hospital Vicente Corral Moscoso, 2008, Cuenca-Ecuador

Con un diseño descriptivo se incluyó a 74 personas del Departamento de Clínica: 15 médicos tratantes titulares, 5 tratantes asociados, 10 residentes, 12 internos, 9 enfermeras y 23 auxiliares de enfermería, a quienes se observó anónimamente durante 20 minutos para detectar el cumplimiento de lavado de manos y la técnica empleada. Resultados: las mujeres fueron el 54,1% (n = 50) y los varones el 45,9 (n = 34). Los médicos tratantes titulares fueron el 20,3% (n = 15), los tratantes asociados 6,8% (n=5) médicos residentes 13,5% (n =10), los internos el 16.2% (n = 12), las enfermeras el 12,2% (n = 9) y las auxiliares de enfermería el 31,1% (n=23). Cumplieron con el lavado de manos, antes o después de realizar un procedimiento, el 43.24% (n = 32) de los observados y de ellos ningún individuo cumple con la técnica correcta. Las enfermeras fueron las que más cumplieron con el lavado de manos (P menor que 0,05) pero la utilización de la técnica correcta no fue ejecutado por ningún individuo que cumplieron con el lavado de manos. Todos utilizaron jabón líquido en dispensador, único recurso disponible en el hospital, y todos los que utilizaron la técnica correcta se secaron con toalla individual de papel. Conclusión: a pesar de la vigencia del lavado de manos dentro de los hospitales su cumplimiento por parte del personal es muy bajoMédicoCuenc

Measurement of the cosmic ray spectrum above 4×10184{\times}10^{18} eV using inclined events detected with the Pierre Auger Observatory

A measurement of the cosmic-ray spectrum for energies exceeding $4{\times}10^{18}$ eV is presented, which is based on the analysis of showers with zenith angles greater than $60^{\circ}$ detected with the Pierre Auger Observatory between 1 January 2004 and 31 December 2013. The measured spectrum confirms a flux suppression at the highest energies. Above $5.3{\times}10^{18}$ eV, the "ankle", the flux can be described by a power law $E^{-\gamma}$ with index $\gamma=2.70 \pm 0.02 \,\text{(stat)} \pm 0.1\,\text{(sys)}$ followed by a smooth suppression region. For the energy ($E_\text{s}$) at which the spectral flux has fallen to one-half of its extrapolated value in the absence of suppression, we find $E_\text{s}=(5.12\pm0.25\,\text{(stat)}^{+1.0}_{-1.2}\,\text{(sys)}){\times}10^{19}$ eV.Comment: Replaced with published version. Added journal reference and DO

Energy Estimation of Cosmic Rays with the Engineering Radio Array of the Pierre Auger Observatory

The Auger Engineering Radio Array (AERA) is part of the Pierre Auger Observatory and is used to detect the radio emission of cosmic-ray air showers. These observations are compared to the data of the surface detector stations of the Observatory, which provide well-calibrated information on the cosmic-ray energies and arrival directions. The response of the radio stations in the 30 to 80 MHz regime has been thoroughly calibrated to enable the reconstruction of the incoming electric field. For the latter, the energy deposit per area is determined from the radio pulses at each observer position and is interpolated using a two-dimensional function that takes into account signal asymmetries due to interference between the geomagnetic and charge-excess emission components. The spatial integral over the signal distribution gives a direct measurement of the energy transferred from the primary cosmic ray into radio emission in the AERA frequency range. We measure 15.8 MeV of radiation energy for a 1 EeV air shower arriving perpendicularly to the geomagnetic field. This radiation energy -- corrected for geometrical effects -- is used as a cosmic-ray energy estimator. Performing an absolute energy calibration against the surface-detector information, we observe that this radio-energy estimator scales quadratically with the cosmic-ray energy as expected for coherent emission. We find an energy resolution of the radio reconstruction of 22% for the data set and 17% for a high-quality subset containing only events with at least five radio stations with signal.Comment: Replaced with published version. Added journal reference and DO

Measurement of the Radiation Energy in the Radio Signal of Extensive Air Showers as a Universal Estimator of Cosmic-Ray Energy

We measure the energy emitted by extensive air showers in the form of radio emission in the frequency range from 30 to 80 MHz. Exploiting the accurate energy scale of the Pierre Auger Observatory, we obtain a radiation energy of 15.8 \pm 0.7 (stat) \pm 6.7 (sys) MeV for cosmic rays with an energy of 1 EeV arriving perpendicularly to a geomagnetic field of 0.24 G, scaling quadratically with the cosmic-ray energy. A comparison with predictions from state-of-the-art first-principle calculations shows agreement with our measurement. The radiation energy provides direct access to the calorimetric energy in the electromagnetic cascade of extensive air showers. Comparison with our result thus allows the direct calibration of any cosmic-ray radio detector against the well-established energy scale of the Pierre Auger Observatory.Comment: Replaced with published version. Added journal reference and DOI. Supplemental material in the ancillary file

Multiple Scenario Generation of Subsurface Models:Consistent Integration of Information from Geophysical and Geological Data throuh Combination of Probabilistic Inverse Problem Theory and Geostatistics

Neutrinos with energies above 1017 eV are detectable with the Surface Detector Array of the Pierre Auger Observatory. The identification is efficiently performed for neutrinos of all flavors interacting in the atmosphere at large zenith angles, as well as for Earth-skimming \u3c4 neutrinos with nearly tangential trajectories relative to the Earth. No neutrino candidates were found in 3c 14.7 years of data taken up to 31 August 2018. This leads to restrictive upper bounds on their flux. The 90% C.L. single-flavor limit to the diffuse flux of ultra-high-energy neutrinos with an E\u3bd-2 spectrum in the energy range 1.0 7 1017 eV -2.5 7 1019 eV is E2 dN\u3bd/dE\u3bd < 4.4 7 10-9 GeV cm-2 s-1 sr-1, placing strong constraints on several models of neutrino production at EeV energies and on the properties of the sources of ultra-high-energy cosmic rays

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Summary Background Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. Methods We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung’s disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. Findings We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung’s disease) from 264 hospitals (89 in high-income countries, 166 in middleincome countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in lowincome countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality. Interpretation Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between lowincome, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030

Global burden of 288 causes of death and life expectancy decomposition in 204 countries and territories and 811 subnational locations, 1990–2021: a systematic analysis for the Global Burden of Disease Study 2021

BACKGROUND Regular, detailed reporting on population health by underlying cause of death is fundamental for public health decision making. Cause-specific estimates of mortality and the subsequent effects on life expectancy worldwide are valuable metrics to gauge progress in reducing mortality rates. These estimates are particularly important following large-scale mortality spikes, such as the COVID-19 pandemic. When systematically analysed, mortality rates and life expectancy allow comparisons of the consequences of causes of death globally and over time, providing a nuanced understanding of the effect of these causes on global populations. METHODS The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 cause-of-death analysis estimated mortality and years of life lost (YLLs) from 288 causes of death by age-sex-location-year in 204 countries and territories and 811 subnational locations for each year from 1990 until 2021. The analysis used 56 604 data sources, including data from vital registration and verbal autopsy as well as surveys, censuses, surveillance systems, and cancer registries, among others. As with previous GBD rounds, cause-specific death rates for most causes were estimated using the Cause of Death Ensemble model-a modelling tool developed for GBD to assess the out-of-sample predictive validity of different statistical models and covariate permutations and combine those results to produce cause-specific mortality estimates-with alternative strategies adapted to model causes with insufficient data, substantial changes in reporting over the study period, or unusual epidemiology. YLLs were computed as the product of the number of deaths for each cause-age-sex-location-year and the standard life expectancy at each age. As part of the modelling process, uncertainty intervals (UIs) were generated using the 2·5th and 97·5th percentiles from a 1000-draw distribution for each metric. We decomposed life expectancy by cause of death, location, and year to show cause-specific effects on life expectancy from 1990 to 2021. We also used the coefficient of variation and the fraction of population affected by 90% of deaths to highlight concentrations of mortality. Findings are reported in counts and age-standardised rates. Methodological improvements for cause-of-death estimates in GBD 2021 include the expansion of under-5-years age group to include four new age groups, enhanced methods to account for stochastic variation of sparse data, and the inclusion of COVID-19 and other pandemic-related mortality-which includes excess mortality associated with the pandemic, excluding COVID-19, lower respiratory infections, measles, malaria, and pertussis. For this analysis, 199 new country-years of vital registration cause-of-death data, 5 country-years of surveillance data, 21 country-years of verbal autopsy data, and 94 country-years of other data types were added to those used in previous GBD rounds. FINDINGS The leading causes of age-standardised deaths globally were the same in 2019 as they were in 1990; in descending order, these were, ischaemic heart disease, stroke, chronic obstructive pulmonary disease, and lower respiratory infections. In 2021, however, COVID-19 replaced stroke as the second-leading age-standardised cause of death, with 94·0 deaths (95% UI 89·2-100·0) per 100 000 population. The COVID-19 pandemic shifted the rankings of the leading five causes, lowering stroke to the third-leading and chronic obstructive pulmonary disease to the fourth-leading position. In 2021, the highest age-standardised death rates from COVID-19 occurred in sub-Saharan Africa (271·0 deaths [250·1-290·7] per 100 000 population) and Latin America and the Caribbean (195·4 deaths [182·1-211·4] per 100 000 population). The lowest age-standardised death rates from COVID-19 were in the high-income super-region (48·1 deaths [47·4-48·8] per 100 000 population) and southeast Asia, east Asia, and Oceania (23·2 deaths [16·3-37·2] per 100 000 population). Globally, life expectancy steadily improved between 1990 and 2019 for 18 of the 22 investigated causes. Decomposition of global and regional life expectancy showed the positive effect that reductions in deaths from enteric infections, lower respiratory infections, stroke, and neonatal deaths, among others have contributed to improved survival over the study period. However, a net reduction of 1·6 years occurred in global life expectancy between 2019 and 2021, primarily due to increased death rates from COVID-19 and other pandemic-related mortality. Life expectancy was highly variable between super-regions over the study period, with southeast Asia, east Asia, and Oceania gaining 8·3 years (6·7-9·9) overall, while having the smallest reduction in life expectancy due to COVID-19 (0·4 years). The largest reduction in life expectancy due to COVID-19 occurred in Latin America and the Caribbean (3·6 years). Additionally, 53 of the 288 causes of death were highly concentrated in locations with less than 50% of the global population as of 2021, and these causes of death became progressively more concentrated since 1990, when only 44 causes showed this pattern. The concentration phenomenon is discussed heuristically with respect to enteric and lower respiratory infections, malaria, HIV/AIDS, neonatal disorders, tuberculosis, and measles. INTERPRETATION Long-standing gains in life expectancy and reductions in many of the leading causes of death have been disrupted by the COVID-19 pandemic, the adverse effects of which were spread unevenly among populations. Despite the pandemic, there has been continued progress in combatting several notable causes of death, leading to improved global life expectancy over the study period. Each of the seven GBD super-regions showed an overall improvement from 1990 and 2021, obscuring the negative effect in the years of the pandemic. Additionally, our findings regarding regional variation in causes of death driving increases in life expectancy hold clear policy utility. Analyses of shifting mortality trends reveal that several causes, once widespread globally, are now increasingly concentrated geographically. These changes in mortality concentration, alongside further investigation of changing risks, interventions, and relevant policy, present an important opportunity to deepen our understanding of mortality-reduction strategies. Examining patterns in mortality concentration might reveal areas where successful public health interventions have been implemented. Translating these successes to locations where certain causes of death remain entrenched can inform policies that work to improve life expectancy for people everywhere. FUNDING Bill & Melinda Gates Foundation

Incidencia y factores asociados a apendicitis perforada en menores de 16 años. Hospitales Vicente Corral Moscoso y José Carrasco Arteaga. Cuenca, 2014

Objetivo: Determinar la incidencia y factores asociados de apendicitis perforada en menores de 16 años atendidos en el Servicio de Cirugía Pediátrica de los Hospitales Vicente Corral Moscoso y José Carrasco Arteaga. Materiales y métodos: estudio descriptivo de corte transversal llevado a cabo en 172 pacientes que fueron atendidos en el servicio de Pediatría del Hospital Vicente Corral Moscoso; los datos fueron recogidos en un formulario; se tabularon en el programa SPSS versión 15 y para el análisis se usaron frecuencias, porcentajes, medidas de tendencia central y de ubicación, la asociación se evaluó mediante el valor de chi cuadrado y para medir el riesgo razón de prevalencias. Resultados: La frecuencia de apendicitis perforada fue de 34,9% siendo más frecuente en los siguientes grupos poblacionales: escolares y lactantes con 45% cada grupo; de sexo masculino 61,7%; residentes en el área urbana 71,7%; con sobrepeso 6,7% y con madres con un nivel de instrucción primaria y secundaria con el 46,7% cada grupo. Se encontró que los factores de riesgo estadísticamente significativos para apendicitis perforada fueron: el haber sido remitido al domicilio tras la valoración inicial RP 1,5 (1,03-2,3) y diagnóstico inicial erróneo RP 1,6 (1,09-2,4). Conclusiones: el retraso en la atención médica sumado al error en el diagnóstico inicial son los principales factores de riesgo para apendicitis perforadaObjective: To determine the incidence and associated factors of perforated appendicitis in children under 16 years old treated at the Pediatric Surgery Department of Vicente Corral Moscoso and José Carrasco Arteaga Hospitals. Materials and Methods: Descriptive study and of cross section conducted on 172 patients who were treated in the Pediatric Department of Vicente Corral Moscoso Hospital; Data was collected on a form; tabulated in version 15 of SPSS program and for the analysis we used: frequencies, percentages, measures of central tendency and location, the association was evaluated using the chi-square value and to measure risk we used prevalence ratio. Results: The frequency of perforated appendicitis was 34,9%, being more frequent in the following population groups: school kids and infants with 45% each group; 61,7% male; 71,7% residing in urban areas; 6,7% with overweight and 46,7% of mothers with a level of primary and secondary education each group. It was found that statistically significant risk factors for perforated appendicitis were: have been sent home after initial assessment RP 1,5 (1,03 to 2,3) and wrong initial diagnosis 1.6 RP (1,09- 2,4). Conclusions: Delay in medical care combined with the error in the initial diagnosis are the main risk factors for perforated appendicitisEspecialista en PediatríaCuenc

Síndrome de muerte súbita del lactante: una revisión narrativa

La definici&oacute;n del S&iacute;ndrome de Muerte S&uacute;bita del Lactante(SMSL) es la muerte inesperada de un ni&ntilde;o antes de los 12meses durante el sue&ntilde;o y a la que no se le encuentra unacausa durante la evaluaci&oacute;n postmortem a trav&eacute;s de la autopsia,historia cl&iacute;nica completa y revisi&oacute;n del lugar del suceso.Su incidencia var&iacute;a dependiendo de la poblaci&oacute;n estudiaday tambi&eacute;n de si dicha regi&oacute;n ha recibido recomendacionesen referencia a los h&aacute;bitos del sue&ntilde;o del ni&ntilde;o. Su patogeniaha sido discutida a lo largo de los a&ntilde;os y en la actualidad semanejan diferentes teor&iacute;as, una de ellas es la inmadurez delsistema respiratorio para dar respuesta a los est&iacute;mulos excitatoriosde forma correcta durante el sue&ntilde;o, sin embargo,las diferentes teor&iacute;as no han dado respuestas por s&iacute; solas aestos eventos imprevistos, sino que deben estar asociadosa factores de riesgo que condicionen un ambiente propiciopara que ocurra. Dentro de &eacute;stos se encuentran prematuridad,posici&oacute;n al dormir, acostarlo en la cama con otras personas,elementos sobre el lugar en donde duerme el ni&ntilde;ocon los que tiene contacto, alcoholismo materno durante lagestaci&oacute;n, tabaquismo en el hogar, entre otros. Del mismomodo, se han encontrado factores protectores entre los queresaltan principalmente la lactancia materna, uso de chupetey una posici&oacute;n adecuada al dormir. Por lo tanto, es indispensableque la familia sea instruida por el m&eacute;dico tratante durantela gestaci&oacute;n y posteriormente al nacimiento en el cualse le indica c&oacute;mo se debe acostar al ni&ntilde;o y de esta maneraevitar de forma considerable el desarrollo de este s&iacute;ndrome