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La presente investigación tiene por objeto identificar y determinar la viabilidad de fusionar postres con bebidas alcohólicas para el segmento de consumidores jóvenes y adultos jóvenes, en el cantón Baños de Agua Santa, Ecuador, y de esta manera cubrir un nuevo nicho de mercado con productos innovadores, cual se desarrolla una investigación de tipo cualitativo, se aplicó la técnica de grupo focal a un conjunto de 8 personas con un rango etario de entre 18 y 45 años, concluyendo que; el perfil de consumidor de este tipo de productos son especialmente jóvenes y adultos jóvenes, en su mayoría de otros cantones aledaños a Baños de Agua Santa, residentes, extranjeros americanos y franceses, quiénes tienen preferencia por consumir este tipo de producto innovador, específicamente en la zona rosa de la ciudad debido a que lo degustan como un aperitivo previo a sus actividades de ocio y recreación nocturna.

Resumen Introduccion y objetivos La ventilacion no invasiva (VNI) es capaz de reducir la necesidad de intubacion endotraqueal y la mortalidad de los pacientes con insuficiencia cardiaca aguda (ICA). Sin embargo, de muchos de los ensayos clinicos se ha excluido a los pacientes con ICA secundaria a sindrome coronario agudo o infarto agudo de miocardio (SCA-IAM). El objetivo de este estudio es comparar la efectividad de la VNI entre pacientes con ICA desencadenada por SCA-IAM y por otras causas. Metodos Estudio prospectivo de cohortes, durante un periodo de 20 anos, de todos los pacientes con ICA tratados con VNI ingresados en una unidad de cuidados intensivos. Se agrupo a los pacientes por la presencia o ausencia de SCA-IAM como causante del evento de ICA. Se definio el fracaso de la VNI por la necesidad de intubacion endotraqueal o muerte. Resultados Se analizo a 1.009 pacientes, 403 (40%) con SCA-IAM y 606 (60%) con otras etiologias. La VNI fracaso en 61 casos (15,1%) del grupo de SCA-IAM y 64 (10,6%) del grupo sin SCA-IAM (p = 0,031), sin diferencias en la mortalidad hospitalaria (el 16,6 y el 14,9%; p = 0,478). Conclusiones El SCA-IAM como causa desencadenante de la ICA no influye en el pronostico de los pacientes con insuficiencia respiratoria aguda que precisan asistencia respiratoria no invasiva.

Introduction and objectives Noninvasive ventilation (NIV) has been shown to reduce the rate of endotracheal intubation and mortality in patients with acute heart failure (AHF). However, patients with AHF secondary to acute coronary syndrome/acute myocardial infarction (ACS-AMI) have been excluded from many clinical trials. The purpose of this study was to compare the effectiveness of NIV between patients with AHF triggered by ACS-AMI and by other etiologies. Methods Prospective cohort study of all patients with AHF treated with NIV admitted to the intensive care unit for a period of 20 years. Patients were divided according to whether they had ACS-AMI as the cause of the AHF episode. NIV failure was defined as the need for endotracheal intubation or death. Results A total of 1009 patients were analyzed, 403 (40%) showed ACS-AMI and 606 (60%) other etiologies. NIV failure occurred in 61 (15.1%) in the ACS-AMI group and in 64 (10.6%) in the other group (P = .031), without differences in in-hospital mortality (16.6% and 14.9%, respectively; P = .478). Conclusions The presence of ACS-AMI as the triggering cause of AHF did not influence patients with acute respiratory failure requiring noninvasive respiratory support .

Objectives Identifying early markers of poor prognosis of coronavirus disease 2019 (COVID-19) is mandatory. Our purpose is to analyze by chest radiography if rapid worsening of COVID-19 pneumonia in the initial days has predictive value for ventilatory support (VS) need. Methods Ambispective observational ethically approved study in COVID-19 pneumonia inpatients, validated in a second outpatient sample. Brixia score (BS) was applied to the first and second chest radiography required for suspected COVID-19 pneumonia to determine the predictive capacity of BS worsening for VS need. Intraclass correlation coefficient (ICC) was previously analyzed among three radiologists. Sensitivity, specificity, likelihood ratios, AUC, and odds ratio were calculated using ROC curves and binary logistic regression analysis. A value of p 1.3 points within 10 days of the onset of symptoms doubles the risk for requiring VS in inpatients and 5 times in outpatients (p

el embarazo heterotópico (EH) es una gestación múltiple en la que un embrión se implanta dentro de la cavidad uterina, y otro en cualquier otra parte como un embarazo ectópico (EE). Espontáneo, tiene una incidencia de uno en 30.000 embarazos, y con técnicas de reproducción asistida (TRA) hasta uno en cien. Su diagnóstico temprano permite reducir la morbimortalidad y mejorar el pronóstico para el embarazo intrauterino. El objetivo del artículo es realizar una revisión de la literatura sobre eh y presentar un caso clínico. Se realizó una búsqueda en bases de datos Pubmed y Medline, utilizando combinaciones con operadores booleanos de los términos MESH: heterotopic pregnancy, ectopic pregnancy, therapy, risk factors y prognosis. Los límites de la búsqueda fueron: artículos en texto completo, idiomas español e inglés, publicados en los últimos diez años. Se obtuvieron 275 títulos; luego de eliminar los duplicados y la evaluación del resumen, se utilizaron veintisiete referencias. Se presenta un caso de una paciente gesta 2, antecedente de ee roto, con EH espontáneo y ruptura de gestación tubárica; se describe su manejo y resultado perinatal. El EH puede tener implantación tubárica (más frecuente) o en cualquier otra localización. El diagnóstico debe estar centrado en los factores de riesgo y los criterios de ultrasonido. El manejo puede ser expectante, médico o quirúrgico, teniendo con el primero el peor pronóstico materno, con el segundo, menores tasas de pérdida gestacional y mejores resultados maternos, y con el último mayores tasas de aborto. El diagnóstico del EH se realiza por ultrasonido transvaginal; de acuerdo con cada caso se orienta el tratamiento. El abordaje quirúrgico es la primera línea en la presentación aguda. El manejo expectante o la aspiración guiada por ultrasonido son opciones razonables en la paciente estable. Son necesarias más cohortes de pacientes para evaluar los resultados del manejo en nuestro medio.

En este artículo científico, se hace un análisis crítico jurídico sobre la mutación constitucional que nos permitirá sensibilizarnos en la búsqueda de mecanismos que no quebranten los ordenamientos de reforma y enmienda constitucional. Para evidenciar este argumento, se aplicó una encuesta dirigida a un conjunto de profesionales en materia constitucional y estudio documental, con la aplicación de estas herramientas donde se determinó las principales afectaciones que generó una exégesis ilimitada elaborada por el más alto órgano de control e interpretación constitucional en Ecuador.

El presente trabajo investigativo estudia la tendencia del mercado respecto a las preferencias del turista en un entorno posterior al virus SARS-CoV-2, el cual produjo graves daños al sistema económico universal, siendo la actividad turística una de las primordiales víctimas. Se plantea una herramienta estandarizada validada por expertos que analiza el índice de confianza de 0,91. La población estudiada estuvo conformada por la cifra reportada por el GAD Baños como movimiento turístico en el 2019. Se calculó una muestra de 267 encuestas, asumiendo un nivel de confianza del 95% y un margen de error del 6%. Se concluyó que la pandemia había resaltado la preferencia de los viajeros por alojamientos ubicados en áreas remotas con servicios y tratamientos personalizados y precios competitivos.

Data de publicació electrònica: 20-01-2023 Introduction and objectives: Dual antiplatelet therapy (DAPT) duration after ST-segment elevation myocardial infarction (STEMI) remains a matter of debate. Methods: We analyzed the effect of DAPT on 5-year all-cause mortality, cardiovascular mortality, and cardiovascular readmission or mortality in a cohort of 1-year survivor STEMI patients. Results: A total of 3107 patients with the diagnosis of STEMI were included: 93% of them were discharged on DAPT, a therapy that persisted in 275 high-risk patients at 5 years. Cardiovascular mortality in patients on single antiplatelet therapy vs DAPT at 5 years was 1.4% vs 3.6% (P

La Edad de los Metales es un período que merece más atención en el currículo español de Educación Secundaria, ya que en ella, tienen lugar una serie de cambios profundos en las sociedades prehistóricas que las conducen hacia una mayor complejidad social. En concreto, la sociedad argárica supone para la Península Ibérica y Europa una ruptura con las tradiciones calcolíticas: agregación poblacional en cerros fortificados, ritual de enterramiento individual y dentro del hábitat, producciones cerámicas normalizadas, metalurgia diversificada, categorías sociales, «división social del trabajo». Todo ello supone el establecimiento de formas de explotación socioeconómicas similares a las de los Estados antiguos. A través de una síntesis histórica actualizada, se sugieren diferentes recursos para su implementación en los procesos de enseñanza.

Resumen: el embarazo heterotópico (EH) es una gestación múltiple en la que un embrión se implanta dentro de la cavidad uterina, y otro en cualquier otra parte como un embarazo ectópico (EE). Espontáneo, tiene una incidencia de uno en 30.000 embarazos, y con técnicas de reproducción asistida (TRA) hasta uno en cien. Su diagnóstico temprano permite reducir la morbimortalidad y mejorar el pronóstico para el embarazo intrauterino. El objetivo del artículo es realizar una revisión de la literatura sobre EH y presentar un caso clínico. Se realizó una búsqueda en bases de datos Pubmed y Medline, utilizando combinaciones con operadores booleanos de los términos MESH: heterotopic pregnancy, ectopic pregnancy therapy risk factors y prognosis. Los límites de la búsqueda fueron: artículos en texto completo, idiomas español e inglés, publicados en los últimos diez años. Se obtuvieron 275 títulos; luego de eliminar los duplicados y la evaluación del resumen, se utilizaron veintisiete referencias. Se presenta un caso de una paciente gesta 2, antecedente de EE roto, con EH espontáneo y ruptura de gestación tubárica; se describe su manejo y resultado perinatal. El EH puede tener implantación tubárica (más frecuente) o en cualquier otra localización. El diagnóstico debe estar centrado en los factores de riesgo y los criterios de ultrasonido. El manejo puede ser expectante, médico o quirúrgico, teniendo con el primero el peor pronóstico materno, con el segundo, menores tasas de pérdida gestacional y mejores resultados maternos, y con el último mayores tasas de aborto. El diagnóstico del EH se realiza por ultrasonido transvaginal; de acuerdo con cada caso se orienta el tratamiento. El abordaje quirúrgico es la primera línea en la presentación aguda. El manejo expectante o la aspiración guiada por ultrasonido son opciones razonables en la paciente estable. Son necesarias más cohortes de pacientes para evaluar los resultados del manejo en nuestro medio. Summary: heterotopic pregnancy (HP) involves multiple gestations in which one embryo is implanted within the uterine cavity and another elsewhere, such as an ectopic pregnancy (EP). A spontaneous pregnancy has an incidence of one in 30.000 pregnancies, and with assisted reproduction techniques (ART) up to one in a hundred. Its early diagnosis allowsto reduce morbidity and mortality and improve the prognosis for intrauterine pregnancy. The article aims to perform a review of the literature on HP and present a clinical case. A search was conducted on Pubmed and Medline databases, using combinations with Boolean operators of the terms MESH: heterotopic pregnancy, ectopic pregnancy, therapy risk factors and prognosis. The search limits were: full-text articles, Spanish and English languages, published in the last ten years. 275 titles were obtained; after eliminating duplicates and abstract evaluation, 27 references were used. We present a case of a pregnant patient 2, records of broken EP, with spontaneous HP and rupture of tubal gestation; their management and the perinatal results are described. The HP may have tubal implantation (more frequent) or in any other location. The diagnosis should focus on risk factors and ultrasound criteria; the management can be expectant, medical, or surgical, having with the first the worst maternal prognosis, with the second lower rates of gestational loss and better maternal outcomes, and with the latter higher abortion rates. The diagnosis of HP is performed by transvaginal ultrasound; according to each case, the treatment is oriented. The surgical approach is the first line in the acute presentation. Expectant management or ultrasound-guided aspiration are reasonable options in the stable patient. More cohorts of patients are needed to evaluate management outcomes in our environment. Resumo: a gestação heterotópica (GH) é urna gravidez múltipla na qual um embrião é implantado dentro da cavidade uterina, e outro, em qualquer outro lugar como uma gestação ectópica (GE). Espontânea ocorre em urna de 30.000 gestações, e com técnicas de reprodução assistida, até urna em cem. Seu diagnóstico precoce permite reduzir a morbimortalidade e melhorar o prognóstico para a gestação intrauterina. O objetivo deste artigo é realizar uma revisão da literatura sobre GH e apresentar um caso clínico. Foi realizada urna busca em bases de dados PubMed e Medline, a partir de combinações com operadores booleanos dos termos MESH: heterotopic pregnancy ectopic pregnancy therapy risk factors e prognosis. Os limites da busca foram: artigos em texto completo, em espanhol e inglês, publicados nos últimos dez anos. Foram obtidos 275 títulos; após eliminar os duplicados e a avaliação do resumo, foram utilizadas 27 referencias. É apresentado um caso de urna paciente gesta 2, antecedente de GE rota, com GH espontánea e ruptura da gravidez tubária ectópica; são descritos seu tratamento e resultado perinatal. O GH pode ter implantação tubária (mais frequente) ou em qualquer outra localização. O diagnóstico deve estar centralizado nos fatores de risco e nos critérios de ultrassom. A gravidez pode ser expectante, médica ou cirúrgica, tendo com o primeiro o pior prognóstico materno, com o segundo, menores taxas de perda gestacional e melhores resultados maternos, e com o último maiores taxas de aborto. O diagnóstico do GH é realizado por ultrassom transvaginal; de acordo com cada caso, é orientado o tratamento. A abordagem cirúrgica é a primeira linha na apresentação aguda. O tratamento expectante ou a aspiração guiada por ultrassom são opções razoáveis na paciente estável. São necessárias mais coortes de pacientes para avaliar os resultados do tratamento em nosso contexto.

The impact of hypocapnia in the prognosis of cardiogenic acute pulmonary edema (CAPE) has not been sufficiently studied. The aim of this study was to analyse whether hypocapnia is a risk factor for non-invasive ventilation (NIV) failure and hospital mortality, in CAPE patients CAPE.Retrospective observational study of all patients with CAPE treated with NIV. Patients were classified in three groups according to PaCO1138 patients were analysed, 390 (34.3%) of which had hypocapnia, 186 (16.3%) had normocapnia and 562 (49.4%) had hypercapnia. NIV failure was more frequent in hypocapnic (60 patients, 15.4%) than in eucapnic (16 pacientes, 8.6%) and hypercapnic group (562 pacientes, 10.7%), with statistical significance (p = 0.027), as well as hospital mortality, 73 (18.7%), 19(10.2%) and 83 (14.8%) respectively (p = 0.026). The predicted factors for NIV failure were the presence of do-not-intubate order, complications related to NIV, a lower left ventricular ejection fraction, higher SAPS II and SOFA score and a higher HACOR score at one hour of NIV initiation.Hypocapnia in patients with CAPE is associated with NIV failure and a greater in-hospital mortality.

La investigación tiene como objetivo: analizar la supremacía de la moralidad sobre la legalidad procesal desde los poderes de instrucción del juez en relación con la moralidad y legalidad estableciendo mecanismos alternativos de solución de conflictos antes de acudir a la justicia ordinaria. Fue necesario desarrollar una investigación transversal cuali-cuantitativa con la utilización de herramientas de investigación como son la encuesta, obteniendo como resultado que la legalidad y la moralidad son conceptos diferentes dentro del marco normativo. En los antecedentes bibliográficos, se puede reafirmar, la relevancia de agotar medios alternativos de solución de conflictos que permiten mayor flexibilidad de toma de decisiones apegadas a los aspectos morales antes que a la legalidad.

Innovar en la prestación de servicios turísticos desarrolla una oferta diversificada y ajustada a las tendencias del mercado; este trabajo tiene por objeto describir la importancia de técnicas de pensamiento lateral en el análisis de ideas de negocio turísticos. Se aplica una investigación de paradigma cualitativo de tipo empírica transversal, que mediante la técnica de observación directa, describe la importancia de herramientas como la denominada “seis sombreros para pensar” en la discusión de grupos, previo a emprender. Se concluye que el pensamiento lateral resulta importante para fomentar la creatividad y la innovación, puesto que desarrolla en el emprendedor competencias para la gestión integral de empresas turísticas y la toma de decisión luego de haber contemplado diferentes perspectivas.

Muscle training, a component of pulmonary rehabilitation (PR), improves the physical performance of patients with chronic obstructive pulmonary disease (COPD). Despite the existing evidence, the traditional center-based PR model is applied to a small percentage of patients and presents numerous problems of accessibility, adherence, and costs. This study present a home model of simple muscle training, non-presential, monitored by telephone and individualized, according to the severity of the COPD. In addition, to evaluate the results, simple tests associated with the physical performance of the lower limbs, previously validated in COPD, have been used, such as the four-meter walk, speed test (4MGS) and the five-repetition test sitting and standing (5STS). The objective was to evaluate whether the Individualized Non-Presential Exercise Training PrOgram (NIETO) induces improvements in the 4MGS, 5STS and quadriceps muscle strength (QMS) tests in outpatients with advanced COPD (FEV1 ≤ 50%). After one year, the QMS was significantly higher in the intervention group (IG) than in the control group (CG) (2.44 ± 4.07 vs. 0.05 ± 4.26 kg, p = 0.009). The 4MGS and 5STS tests were significantly shorter in IG than in CG (−0.39 ± 0.86 vs. 0.37 ± 0.96 s, p = 0.001) and (−1.55 ± 2.83 vs. 0.60 ± 2.06 s, p = 0.001), respectively. A home model of simple muscle training monitored by telephone such as NIETO, can improve 4MGS, 5STS, and quadriceps strength tests in outpatients with advanced COPD.

Resumen In Introducción. La incorporación de criterios técnicos para la gestión de complejos turísticos, constituye un valor agregado para oferta turística que posibilita incorporar a un nicho importante de mercado que actualmente se ha incorporado de forma positiva a la demanda turística, especialmente a turistas y visitantes de atención prioritaria. Objetivo. La presente investigación de revisión en el periodo de 2008-2019, analiza a la gestión del turismo accesible, su importancia y herramientas que permitan plantear dimensiones e indicadores esenciales para la gestión del turismo accesible en complejos turísticos del Ecuador. Método y técnica. El estudio emplea una metodología aplicada que incluye un estudio exploratorio-descriptivo, se utilizaron diferentes métodos teóricos (analítico-sintético, bibliométrico, inductivo-deductivo y sistémico-estructural); empíricos (entrevistas, encuestas, observación científica y criterio de especialistas) y estadísticos. Resultados. A partir del análisis de correlación y conglomerado se determinan seis dimensiones e indicadores fundamentales para incorporar criterios de inclusión en la gestión del turismo accesible, los que permiten diagnosticar el estado actual de las organizaciones turísticas con vistas a brindar servicios accesibles inclusivos. Conclusión.Las seis dimensiones esenciales para la gestión del turismo accesible son: humana, legislativa, tecnológica, biótica, abiótica y relacional, que de manera transversal intervienen en los procesos de las organizaciones turísticas específicamente en complejos turísticos. Abstract Introduction. The incorporation of technical criteria for the management of tourist complexes constitutes an added value for the tourist offer that makes it possible to incorporate an important market niche that has now positively incorporated tourism demand, especially tourists and visitors with priority attention. Objective. The present review investigation in the period of 2008-2019, analyzes the management of accessible tourism, its importance and tools that allow the establishment of dimensions and essential indicators for the management of accessible tourism in tourist complexes in Ecuador. Method and technique. The study uses an applied methodology that includes an exploratory-descriptive study, different theoretical methods were used (analytical-synthetic, bibliometric, inductive-deductive and systemic-structural); empirical (interviews, surveys, scientific observation and specialist judgment) and statisticians. Results. From the correlation and conglomerate analysis, six fundamental dimensions and indicators are determined to incorporate inclusion criteria in the management of accessible tourism, which allow diagnosing the current state of tourism organizations with a view to providing inclusive accessible services. Conclusion. The six essential dimensions for the management of accessible tourism are: human, legislative, technological, biotic, abiotic and relational, which in a transversal way intervene in the processes of tourist organizations specifically in tourist complexes.

To characterize the relationship between noise perception, vocal fatigue, and work-related stress among health workers. Cross sectional with the participation of 79 participants. Data regarding noise levels, voice functioning, and stress were collected through validated questionaries. Generalized Linear Models (GLMs) were used to evaluate the associations between the study variables. Our results show that more than 60% of health workers reported that noise conditions were high (47% considered that it did not affect their job performance, and 22% reported that it did). Concerning vocal fatigue, on average, health workers scored 8.30 for factor 1, 2.52 for factor 2, and 5.09 for factor 3, which suggests that participants were not feeling their voices very tired (factor 1), but they have physical discomfort associated with voicing (factor 2) and experienced improvement of symptoms after recovery (factor 3). Regarding stress levels, around 80% of participating health workers reported very high or high stress levels (61% for very high and 18% for high). Health workers are exposed to noise levels that affect their communication and mental health. Health care facilities should strive to keep noise conditions at its lowest levels to keep healthy conditions for communication and mental health.

The possibility of avoiding axillary lymphadenectomy (AL) in patients with breast cancer (BC) after positive sentinel lymph node biopsy (SLNB) and low metastatic burden (ó = 2 positive lymph nodes) has put into question the role of axillary ultrasound due to the risk of overtreatment after positive axillary lymph node biopsy with low metastatic burden. Our aim was to identify clinical and ultrasound features to detect low and high metastatic burden.A retrospective study of 405 BC patients with primary surgical treatment with axillary ultrasound examination and subsequent AL after positive fine needle aspiration (FNA) or SLNB. The low and high tumor burdens after AL were correlated with clinical and ultrasound variables: lymph node morphology (UN1 to UN5), number of suspicious lymph nodes, and Berg level.Positive FNA, lymph node morphology UN4 (focal thickening with displacement of the fatty hilum) or UN5 (complete replacement of the fatty hilum) and2 suspicious lymph nodes were significantly associated with "high metastatic burden". Lymph node morphology UN2 and UN3, even after FNA+, lymph node morphology UN4 after FNA-, and suspicious lymph nodes at Berg level I were low metastatic burden criteria. Lymph node morphology UN5, lymph node morphology UN4 after FNA+, two nodes or more with UN4/UN5 morphology, and suspicious lymph nodes at Berg levels II and III with FNA+ were associated with high metastatic burden.Axillary lymph node ultrasound data for patients with early BC allows predicting the axillary metastatic burden, guiding the optimal clinical management of the axilla.

La investigación se enfoca en realizar un plan estratégico de marketing para el posicionamiento del cantón Ambato como destino turístico a nivel nacional, para mejorar las condiciones económicas de la ciudad, siendo el turismo un sector que puede aportar a la solución del problema. El objetivo fue el diseño de un plan estratégico de marketing para el posicionamiento del cantón mediante acciones que conviertan a la ciudad en destino turístico a nivel nacional; por lo que es necesario realizar un estudio teórico de los componentes de un plan estratégico de marketing, un diagnóstico de la situación actual de la actividad turística y el posicionamiento del cantón a turistas nacionales para estructurar el plan estratégico de marketing eficaz.

El objetivo de la presente investigación es demostrar la pertinencia del cuestionario EFQM para el análisis del entorno interno en la planeación estratégica de empresas del sector turístico. Este instrumento considera las áreas que integran la cadena de valor de una organización y los principales grupos de interés que influyen en el contexto de la empresa. La investigación realizada fue de carácter descriptivo y transversal. Se demostró que mediante la aplicación del cuestionario de autodiagnóstico EFQM es posible identificar las fortalezas y debilidades de las organizaciones con un enfoque más integral y alejado de omisiones y subjetividades.

Background An analysis of cardiac injury markers in patients with OSA who sustain an episode of acute coronary syndrome (ACS) may contribute to a better understanding of the interactions and impact of OSA in subjects with ACS. We compared peak cardiac troponin I (cTnI) levels in patients with OSA and patients without OSA who were admitted for ACS. Methods Blood samples were collected every 6 hours from the time of admission until two consecutive assays showed a downward trend in the cTnI assay. The highest value obtained defined the peak cTnI value, which provides an estimate of infarct size. Results We included 89 patients with OSA and 38 patients without OSA with an apnea-hypopnea index of a median of 32 (interquartile range [IQR], 20.8-46.6/h and 4.8 [IQR, 1.6-9.6]/h, respectively. The peak cTnI value was significantly higher in patients without OSA than in patients with OSA (median, 10.7 ng/mL [IQR, 1.78-40.1 ng/mL] vs 3.79 ng/mL [IQR, 0.37-24.3 ng/mL]; P = .04). The multivariable linear regression analysis of the relationship between peak cTnI value and patient group, age, sex, and type of ACS showed that the presence or absence of OSA significantly contributed to the peak cTnI level, which was 54% lower in patients with OSA than in those without OSA. Conclusions The results of this study suggest that OSA has a protective effect in the context of myocardial infarction and that patients with OSA may experience less severe myocardial injury. The possible role of OSA in cardioprotection should be explored in future studies.

Objetivo: Analizar la eficacia diagnostica e incidencia de complicaciones de la puncion aspiracion con aguja fina (PAAF) guiada por tomografia computarizada (TC) del nodulo/masa pulmonar realizada por residentes de radiodiagnostico. Material y metodo: Estudio descriptivo-retrospectivo entre Enero-2011 y Junio-2016 de PAAF transtoracicas guiadas por TC para el estudio de un nodulo/masa pulmonar efectuada por un residente de radiodiagnostico. Los residentes realizaron esta tecnica de forma consecutiva segun la programacion del servicio, siguiendo el protocolo establecido y supervisados por un radiologo especializado. Para evaluar la eficacia, se incluyeron las PAAF con resultado especifico y para el calculo de las complicaciones, todas las PAAF realizadas. Se usaron la prueba Chi-cuadrado de Pearson o exacta de Fisher, T de Student o Mann-Whitney y los paquetes informaticos SPSS 15.0 y EPIDAT 3.1. Resultados: Se registraron 131 pacientes, realizandose en total 144 PAAF. La eficacia de la prueba diagnostica fue alta (cociente de probabilidad (CP): 7,35), destacando la diferencia entre el pulmon derecho (CP: 15,1) y el izquierdo (CP: 4,27). La sensibilidad y especificidad fueron mayores al 85%. Tuvimos 62 complicaciones (43,1%): 50 (34,7%) neumotorax con una mediana de 10,5mm (4,3-23,7) de diametro maximo y ninguno a tension; y 20 casos (13,9%) de hemorragia pulmonar diagnosticados unicamente por imagen. Conclusion: La PAAF guiada por TC es una herramienta diagnostica de alta precision y baja incidencia de complicaciones graves, que puede ser realizada por un residente de radiodiagnostico bajo supervision sin detrimento de la rentabilidad diagnostica o seguridad de la prueba. Palabras clave: nodulo/masa pulmonar, Tomografia computerizada, Puncion aspiracion con aguja fina guiada por TC, Citologia, Sensibilidad, Especificidad

Resumen Objetivo Investigar las diferencias en la mortalidad a 28 dias y otras variables pronosticas en 2 periodos: IBERICA-Mallorca (1996-1998) y Codigo Infarto-Illes Balears (CI-IB) (2008-2010). Diseno Dos cohortes prospectivas observacionales. Ambito Hospital Universitario Son Dureta, 1996-1998 y 2008-2010. Pacientes Sindrome coronario agudo con elevacion de ST de ≤ 24 h, de localizacion anterior e inferior. Variables principales de interes Edad, sexo, factores de riesgo cardiovascular, localizacion, tiempos de actuacion, tratamiento de reperfusion con fibrinolisis y angioplastia primaria, administracion de acido acetilsalicilico, betabloqueantes e inhibidores de la enzima conversora de la angiotensina. Se incluyeron el grado de Killip, las arritmias malignas, las complicaciones mecanicas y el fallecimiento a los 28 dias. Resultados Se analizaron 442 pacientes de los 889 incluidos en el IBERICA-Mallorca y 498 de los 847 registrados en el CI-IB. La localizacion y el Killip fueron similares en ambas cohortes. Las principales diferencias significativas entre el grupo IBERICA y el CI-IB fueron: edad (64 vs. 58 anos), infarto previo (17,9 vs. 8,1%), tiempo sintomas-primer ECG (120 vs. 90 min), tiempo primer ECG-fibrinolisis (60 vs. 35 min), tratamiento fibrinolitico (54,8 vs. 18,7%), pacientes sin reperfusion (45,9 vs. 9,2%), angioplastia primaria (1,0 vs. 92,0%). La mortalidad a los 28 dias fue inferior en el CI-IB (12,2 vs. 7,2%; hazard ratio 0,560; IC 95% 0,360-0,872; p = 0,010). Conclusion La mortalidad a los 28 dias en el sindrome coronario agudo con elevacion de ST en Mallorca ha disminuido en la ultima decada, probablemente debido a un mayor tratamiento de reperfusion con angioplastia primaria y a una reduccion de los tiempos de reperfusion.

La investigación se realiza con estudiantes de dos modalidades de posgrado de la Universidad Regional Autónoma de los Andes y tiene como objetivo valorar el comportamiento de la producción científica de egresados de maestrías y doctorados de esta universidad. Se trata de un estudio cuantitativo, transversal y descriptivo en el que se trabaja en la confección y aplicación de un cuestionario ad hoc para evaluar las variables.

Additional file 1: Table S1. Codon distribution of the wild-type pernisine sequence from A. pernix and the codon-optimised pernisine sequence from S. rimosus. Figure S1. Tandem mass spectrometry (MS/MS) analysis of the N-termini and C-termini of the codon-optimised prepropernisine (A) and the codon-optimised processed pernisine (B). Individual identified peptides are aligned with the pernisine sequence. Figure S2. Model of the three-dimensional structure of propernisine (A) and processed pernisine (B), with the Ca2+ binding sites indicated (C). Note that the first 31 amino acids are not shown in the model structure of pernisine. Propernisine consists of the proregion (V31-A92; turquois), the catalytic triad (D149, H184, S355), and the Ca2+ ions (green spheres). Processed pernisine form (Q93-V430). Frame C presents four selected Ca2+ binding sites that interact with either amino acids or water (H2O). Figure S3. Production of codon-optimised srT-pernisine (from plasmid construct pVFPER5) in total cell lysates from S. rimosus grown in different media. TSB, tryptic soy broth; MM, minimal medium; G3, G4, G5, complex production media at 3, 4 and 5 days. The protein was transferred onto nitrocellulose membranes as dot blots, and His6-tagged pernisine was detected using anti-His5 antibodies. Figure S4. Amino-acid alignment of pernisine and Tk-subtilisin with the Ca2+ binding sites indicated. Yellow, identical amino acids; green, related amino acids. Known Ca2+ binding sites from Tk-subtilisin are marked with coloured asterisks. Site 1, blue; site 2, red; site 3, black; site 4, green; site 5, violet; site 6, orange; site 7, grey. Figure S5. Comparison of the nucleotide sequences of prepropernisineWT and propernisineCO. The predicted amino-acid sequence of the prepropernisine is indicated in the single-letter amino-acid code. Differences in the DNA sequences are shown in bold letters. Single underlined, amino acids of the signal sequence; double underlined, amino acids of the predicted proregion; remaining amino acids, active pernisine. The amino acids involved in the predicted catalytic triad are in yellow, as Asp149, His184 and Ser355. The start codon is marked with an asterisk (*); the stop codon with a hyphen (−). Note that only ATG was used as the start codon for the heterologous expression.

Summary Background Sleeping is the most critical stage in the psychological and somatic recovery process. Sleep deficiency can lead to changes in the breath pattern that might contribute to the appearance and development of voice disorders. Sleep can also compromise the individual's communicative competence. Work-related stress is a risk factor for serious health and mental issues, including voice and sleep disorders. Recovery from stress is fundamental in order to preserve health, wellbeing, and work performance. No systematic review of the literature or meta-analysis concerning this relationship has been performed yet. Objective To define the association of voice disorders with sleep quality and stress among teachers. Methods A systematic review of literature and meta-analysis were performed. Three computerized databases were used to characterize the relationship between voice disorders among teachers with sleep quality and stress. Information such as year of publication, study population, sample size, stress/sleep exposure, voice outcome, and prevalence were extracted from each paper. All the included articles were measured in terms of their methodological quality. Results In total, 10 publications met the criteria for inclusion. The point prevalence of voice disorders ranged widely for both sleep quality (12% to 81%), and for stress (17% to 81%). Teachers who reported stress at work were more likely to report voice disorders. Additionally, teachers who reported having slept more than 6 hours per day were less likely to report a voice disorder. Conclusion This study provides evidence about the relationship between sleep quality and work-related stress with voice functioning. Although, included studies had low quality and the number of studies was low, our results suggest that the increased occurrence of voice disorders among teachers with high stress and work and less than 6 hours/day of sleep. Future investigation should aim to identify how sleep quality and stress interact in relation to voice functioning.

Background and objective Thyroid cancer may be clinically evident as a tumor mass in the neck or as a histopathological incidental finding after thyroid surgery for an apparent benign condition. Our objective was to assess the differences in clinical signs, surgical management, and course between incidental and clinically diagnosed thyroid tumors. Methods A retrospective study was conducted on patients operated on for benign or malignant thyroid disease from January 2000 to March 2014. Among the 1415 patients who underwent any thyroid surgery, 264 neoplasms were found, of which 170 were incidental. A comparison was made of incidental versus non-incidental carcinomas. Among incidental carcinomas, cases whose indication for surgery was Graves’ disease were compared to those with multinodular goiter. Results Incidental carcinomas were in earlier stages and required less aggressive surgery. There were no differences in surgical complications between incidental and clinical tumors, but mortality and relapses were markedly higher in non-incidental cancers (4.4% vs 0% and 13.2% vs 4.8% respectively). Carcinomas developing on Graves’ disease showed no differences from all other incidental tumors in terms of complications, mortality, or relapse after surgery. Conclusions Early stage thyroid cancer has better survival and prognosis after surgical treatment.

Resumen Antecedentes y objetivo El cancer tiroideo puede manifestarse clinicamente por la presencia de un nodulo cervical, o constituir un hallazgo casual en el estudio histologico de la glandula extirpada con diagnostico, a priori, benigno. El objetivo del presente estudio fue estudiar las diferencias clinicas, de manejo quirurgico y curso evolutivo entre los tumores tiroideos incidentales y los tumores detectados clinicamente. Material y metodos Estudio retrospectivo de pacientes intervenidos por enfermedad tiroidea, ya fuese benigna o maligna, en el periodo comprendido entre enero de 2000 y marzo de 2014. De 1.415 pacientes que se sometieron a algun tipo de cirugia tiroidea se identificaron un total de 264 neoplasias, de las cuales 170 fueron incidentales. Se realizo comparacion entre carcinomas incidentales versus no incidentales. Ademas, entre los incidentales se compararon los casos cuya indicacion quirurgica fue enfermedad de Graves frente a bocio multinodular. Resultados Los carcinomas incidentales presentaron estadios mas precoces y requirieron cirugia menos agresiva. No se observaron diferencias en las complicaciones quirurgicas entre ambos grupos, aunque tanto la mortalidad como las tasas de recidiva fueron notablemente mayores en el grupo de no incidentales (4,4% vs 0% y 13,2% vs 4,8% respectivamente). Los carcinomas desarrollados sobre enfermedad de Graves no mostraron diferencias respecto al resto de los tumores incidentales, respecto a complicaciones, mortalidad o recidiva tras la cirugia. Conclusiones El cancer tiroideo en estadios iniciales presenta mayor supervivencia y mejor respuesta al tratamiento quirurgico.

Juan Miguel Sánchez-Nieto,1,2 Rubén Andújar-Espinosa,3 Roberto Bernabeu-Mora,1,2 Chunshao Hu,1 Beatriz Gálvez-Martínez,1 Andrés Carrillo-Alcaraz,1 Carlos Federico Álvarez-Miranda,3 Olga Meca-Birlanga,1 Eva Abad-Corpa4 1Division of Pneumology, Hospital Morales Meseguer, 2University of Murcia, 3Division of Pneumology, Hospital Arrixaca, Murcia, 4Department of Professional Development Unit, Murcia, Spain Background: Self-management interventions improve different outcome variables in various chronic diseases. Their role in COPD has not been clearly established. We assessed the efficacy of an intervention called the self-management program on the need for hospital care due to disease exacerbation in patients with advanced COPD.Methods: Multicenter, randomized study in two hospitals with follow-up of 1 year. All the patients had severe or very severe COPD, and had gone to either an accident and emergency (A&E) department or had been admitted to a hospital at least once in the previous year due to exacerbation of COPD. The intervention consisted of a group education session on the main characteristics of the disease, an individual training session on inhalation techniques, at the start and during the 3rd month, and a written action plan containing instructions for physical activity and treatment for stable phases and exacerbations. We determined the combined number of COPD-related hospitalizations and emergency visits per patient per year. Secondary endpoints were number of patients with visits to A&E and the number of patients hospitalized because of exacerbations, use of antibiotics and corticosteroids, length of hospital stay, and all-cause mortality.Results: After 1 year, the rate of COPD exacerbations with visits to A&E or hospitalization had decreased from 1.37 to 0.89 (P=0.04) and the number of exacerbations dropped from 52 to 42 in the group of patients who received the intervention. The numbers of patients hospitalized, at 19 (40.4%) versus 20 (52.6%) (P=0.26), and those who went to A&E, at 9 (19.1%) versus 14 (36.8%) (P=0.06), due to exacerbation of COPD were also lower in this group. Intake of antibiotics was higher in the intervention group, whereas use of glucocorticoids was slightly lower, though there were no significant differences (P=0.30). There were also no differences between groups in the length of hospital stay (P=0.154) or overall mortality (P=0.191).Conclusion: The implementation of a self-management program for patients with advanced COPD reduced exacerbations that required hospital care. Keywords: self-management, COPD, severe exacerbations

Background For safety reasons multiple sclerosis (MS) treatment guidelines recommend stopping or delaying the onset of disease-modifying therapies (DMT) before a planned pregnancy, but disease stability after DMT discontinuation is not well studied. The objective of this study is to describe the course of MS in patients who interrupted DMT before a planned pregnancy. Methods This was a retrospective study using 2008–2016 data from a multicenter register of pregnancies in women with MS. In this paper, we present data from the subgroup of women with relapsing-remitting MS (RRMS) who interrupted DMT to try to conceive. Data from 1 and 3 years before DMT interruption, the period between DMT interruption and conception or resuming DMT, during pregnancy and one year postpartum were analyzed. Annualized relapse rates (ARR), Expanded Disability Status Scale (EDSS) scores, and magnetic resonance imaging (MRI), obstetric, and neonatal data were collected. Results Twenty-seven women interrupted DMT (19 β-interferon, 5 glatiramer acetate, 2 natalizumab and 1 fingolimod) to try to conceive. After a mean of 10.6 months 6 women stopped trying to conceive and resumed DMT, while 21 women became pregnant after a mean of 7.0 months. In the overall cohort, in the period from when DMT was discontinued to when pregnancy was confirmed or DMT resumed, the ARR was 1.08, which was significantly higher than the ARR 1 year (0.44; p = 0.01) and 3 years (0.4; p = 0.06) before DMT discontinuation. The mean EDSS score when pregnancy was confirmed or DMT resumed was significantly higher than at DMT discontinuation (1.8 vs 1.36, p = 0.011). In the subgroup of patients who became pregnant, the ARR in the untreated period before pregnancy was 0.98, which was significantly higher than the ARR 1 year (0.38; p = 0.03) and 3 years (0.39; p = 0.0077) before DMT discontinuation. The ARR decreased to 0.51 during pregnancy and then increased to 0.76 during the first postpartum trimester (not significant). One year after delivery, the mean EDSS score (1.86) was significantly higher than at DMT cessation (1.35, p = 0.027) or pregnancy confirmation (1.45, p = 0.026). Patients who suffered relapses following DMT cessation before becoming pregnant had an 11-fold higher risk of relapse during pregnancy (relative risk [RR] = 11.1 [95%CI 1.6, 75], p = 0.002) and a 3-fold higher risk during the postpartum year (RR = 3.0 [95%CI 1.3,6.6], p = 0.007) than those who did not suffer relapses in period between DMT withdrawal and pregnancy. Conclusions In this retrospective registry study, discontinuation of DMT (mostly immunomodulatory drugs), to try to conceive resulted in an increase in MS relapse rates and disability progression.