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Bilateral adrenal hemorrhage is an uncommon phenomenon with potential catastrophic consequences, such as an adrenal crisis. It has been associated with diverse entities such as sepsis, anticoagulation, malignancy, trauma, antiphospholipid syndrome and postoperative setting, among others. The diagnosis is difficult as patients present with nonspecific signs and symptoms, so high suspi-cion should trigger imaginological test to confirm the diagnosis. We report the case of bilateral adrenal hemorrhage without adrenal insufficiency that occurred in a 71-year old woman during her fifth postoperative day after knee osteosynthesis, who received treatment with enoxaparin as antithrombotic prophylaxis and who presented to the emergency room for 12 hours of coliclike abdominal pain accompanied by nausea without signs of hemodynamic instability.

The present article aims to analyze the competences of young researchers using Geogebra software; Allows to know the shared experience from a quasi-experimental research, in a sample of 27 students of the tenth grade of the educational institution José María Córdoba, 7 of whom were researchers of the proposal "Mathematics Divertida" of the research group "The Pythagoreans" Enrolled in the Swarm project led by the CUN, the purpose was to show the importance of introducing the student in the management of GEOGEBRA as a facilitating tool for the development of mathematical competences as it allows him to visualize and simulate real situations in a dynamic and interactive way; And in turn of the necessity of its incorporation to the curricular plans for the teaching of the mathematics. Results: The referent of the research proposal was the modeling of functions by means of which the student learned to represent mathematically the processes to follow in order to find solutions to a real life problem, besides acquiring the skill to represent the results obtained for A later interpretation and analysis of the results. Conclusion: The student acquired strengths and also detected weaknesses, improved the ability to face new educational realities.

The current Air Traffic Management (ATM) functional approach is changing: ‘time’ is now integrated as an additional fourth dimension on trajectories. This notion will impose on aircraft the compliance of accurately arrival times over designated checkpoints, called Time Windows (TWs). In this context, we review the operational concept of 4D-trajectories, by initially developing an analysis of basic requirements for their implementation in the Communications, Navigation and Surveillance (CNS) systems and then by investigating their management in the future ATM context. We focus on defining the relationships between 4D-trajectories and other concepts and systems of the future ATM framework, and the needs that it will require for its application, detailing the main tools, programs and ATM/CNS systems that must be deployed. We appraise how 4D-trajectories must be managed and planned (negotiation, synchronization, modification and verification processes). Then, based on the degradation of a 4D-trajectory, we define and introduce the necessary corrective measures by evaluating the degradation tolerances and conditions.

The forthcoming integration of Remotely Piloted Aircraft System (RPAS) is one of the cmost omplex challenges for aviation. Europe draws to allow operating RPAS and conventional aircraft in non-segregated airspace by 2025, but this demanding perspective entails a thorough analysis of the different aspects involved. The RPAS integration in non-segregated airspace cannot imply an increase in the safety levels. This paper assesses how the RPAS integration affects safety levels. The goal is to regulate the number of RPAS that can jointly operate with conventional aircraft regarding conflict risk. This approach benchmarks a Calculated Level of Safety (CLS) with a Target Level of Safety (TLS). Monte Carlo (MC) simulations quantify the TLS based on schedules of conventional aircraft. Then, different combinations of conventional aircraft and RPAS provide different CLS. MC simulations are performed based on probabilistic distributions of aircraft performances, entry times and geographical distribution of aircraft. The safety levels are based on a conflict-risk model because the primary metrics are average number of conflicts and average conflict duration. The methodology is applied to one flight level of en-route airspace. The results provide restrictions to the number of RPAS that can jointly operate with conventional aircraft. Particularly, the TLS is quantified for four conventional aircraft and MC simulations provide the combinations of conventional aircraft and RPAS that fulfil the CLS. The same number of RPAS than conventional aircraft shows an increase over 90% average number of conflicts and 300% average conflict time.

Abstract Background The collection of samples from HIV-infected patients is the beginning of the chain of translational research. To carry out quality research that could eventually end in a personalized treatment for HIV, it is essential to guarantee the availability, quality and traceability of samples, under a strict system of quality management. Methods The Spanish HIV BioBank was created with the objectives of processing, storing and providing distinct samples from HIV/AIDS patients, categorized according to strictly defined characteristics, free of charge to research projects. Strict compliance to ethical norms is always guaranteed. Results At the moment, the HIV BioBank possesses nearly 50,000 vials containing different prospective longitudinal study sample types. More than 1,700 of these samples are now used in 19 national and international research projects. Conclusion The HIV BioBank represents a novel approach to HIV research that might be of general interest not only for basic and clinical research teams working on HIV, but also for those groups trying to establish large networks focused on research on specific clinical problems. It also represents a model to stimulate cooperative research among large numbers of research groups working as a network on specific clinical problems. The main objective of this article is to show the structure and function of the HIV BioBank that allow it to very efficiently release samples to different research project not only in Spain but also in other countries.

Fluorocarbon oils are uniquely suited for many biomedical applications due to their inert, bioorthogonal properties. In order to interface fluorocarbon oils with biological systems, non-ionic fluorosurfactants are necessary. However, there is a paucity of non-ionic fluorosurfactants with low interfacial tension to stabilize fluorocarbon phases in aqueous environments (such as oil-in-water emulsions). We developed non-ionic fluorosurfactants composed of a polyethylene glycol (PEG) segment covalently bonded to a flexible perfluoropolyether (PFPE) segment that confer lower interfacial tensions (IFTs) between a fluorocarbon oil, HFE-7700, and water. Synthesis of a panel of surfactants spanning a molecular weight range of 0.64-66 kDa with various hydrophilic-lipophilic balances allowed for identification of minimal IFTs, ranging from 1.4 to 17.8 mN m-1. The majority of these custom fluorosurfactants display poor solubility in water, allowing their co-introduction with fluorocarbon oils and minimal leaching. We applied the PEG5PFPE1 surfactant for mechanical force measurements in zebrafish, enabling exceptional sensitivity., (© 2024 Wiley‐VCH GmbH.)

Localized sources of morphogens, called signalling centres, play a fundamental role in coordinating tissue growth and cell fate specification during organogenesis. However, how these signalling centres are established in tissues during embryonic development is still unclear. Here we show that the main signalling centre orchestrating development of rodent incisors, the enamel knot (EK), is specified by a cell proliferation-driven buildup in compressive stresses (mechanical pressure) in the tissue. Direct mechanical measurements indicate that the stresses generated by cell proliferation are resisted by the surrounding tissue, creating a circular pattern of mechanical anisotropy with a region of high compressive stress at its centre that becomes the EK. Pharmacological inhibition of proliferation reduces stresses and suppresses EK formation, and application of external pressure in proliferation-inhibited conditions rescues the formation of the EK. Mechanical information is relayed intracellularly through YAP protein localization, which is cytoplasmic in the region of compressive stress that establishes the EK and nuclear in the stretched anisotropic cells that resist the pressure buildup around the EK. Together, our data identify a new role for proliferation-driven mechanical compression in the specification of a model signalling centre during mammalian organ development., (© 2024. The Author(s), under exclusive licence to Springer Nature Limited.)

Background: Obesity is commonly associated with increased sympathetic tone, changes in heart geometry, and mortality. The aforementioned translates into a higher and potentially modifiable mortality risk for this specific population., Objectives: The aim of the study was to analyze the extent of changes in the heart ventricular structure following rapid weight loss after bariatric surgery., Setting: Academic, university-affiliated hospital., Methods: We retrospectively reviewed all the patients that underwent bariatric surgery at our institution between 2010 and 2015. Data analyzed included demographics, BMI, and associated medical problems. Preoperative and postoperative echography readings were compared looking at the heart geometry, cardiac volumes, and wall thickness., Results: Fifty-one patients who had bariatric surgery and had echocardiography before and after the surgery were identified. There were 33 females (64.7%). The mean age was 63.4 ± 12.0 years with an average BMI of 40.3 ± 6.3. The mean follow-up was 1.2 years after the procedure. At 1 year follow-up 25 patients (49%, p = 0.01) showed normal left ventricular geometry. The left ventricular mass (229 ± 82.1 vs 193.2 ± 42.5, p<0.01) and the left ventricular end diastolic volume (129.4 ± 53 vs 96.4 ± 36.5, p = 0.01) showed a significant modification following the procedure. There was a significant improvement in the interventricular septal thickness (p = 0.01) and relative wall thickness (p < 0.01) following surgery., Conclusion: The patients with obesity present a significant cardiac remodeling from concentric remodeling to normal geometry after bariatric surgery. The decrease in BMI has a direct effect on improvement of the left ventricular structure. Further studies must be carried out to define the damage of obesity to diastolic function., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Common bile duct injuries (BDI) during laparoscopic cholecystectomy (LC) continue to be the source of morbidity and mortality. The reason for BDI is mostly related to the misidentification of the extrahepatic bile duct structures and the anatomic variability. Near-infrared fluorescent cholangiography (NIFC) has proven to enhance visualization of extrahepatic biliary structures during LCs. The purpose of this study was to describe the most important steps in the performance of NIFC., Methods: In accordance to the most current surgical practice of LC at our institution, a consensus was achieved on the most relevant steps to be followed when utilizing NIFC. Dose of indocyanine green (ICG), time of administration, and identification of critical structures were previously determined based on prospective and randomized controlled studies performed at CCF., Results: The ten steps identified as critical when performing NIFC during LC are preoperative administration of ICG, exposure of the hepatoduodenal ligament, initial anatomical evaluation, identification of the cystic duct and common bile duct junction, the cystic duct and its junction to the gallbladder, the CHD, the common bile duct, accessory ducts, cystic artery and, time-out and identification of Calot's triangle, and evaluation of the liver bed., Conclusions: Routine use of NIFC is a useful diagnostic tool to better visualize the extrahepatic biliary structures during LC. The implementation of specific standardized steps might provide the surgeon with a better algorithm to use this technology and consequently reduce the incidence of BDI., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC part of Springer Nature.)

Background: Bariatric surgery in the elderly population has been reported as feasible and safe. Sleeve gastrectomy (SG) seems to have fewer complications than Roux-en-Y gastric bypass (RYGB) even in the 65 years of age population. We analyzed the difference in weight loss between SG and RYGB in patients age 65 years., Objectives: To analyze and compare outcomes between SG and RYGB in patients 65 years of age and older., Setting: Academic hospital, United States., Methods: After internal review board approval, we retrospectively reviewed 2486 patients who underwent either SG or RYGB between 2005 and 2018 at our institution. Basic demographics, preoperative body mass index (BMI), and co-morbidities were described. We identified all patients age ≥65 years and subsequently divided them into 2 groups based on type of bariatric procedure performed. Analysis and comparison of outcomes between these groups were completed. Postoperative BMI was reviewed at 6, 12, and 24 months and percent excess BMI loss (%EBMIL, as defined by the ASMBS clinical committee) was calculated accordingly. The t test and χ 2 analysis were performed for nominal and categorical variables, respectively., Results: From 2486 patients reviewed, 22.7% (n = 565) were aged ≥65 years. From these, 43.1% (n = 244) underwent SG and 56.8% (n = 321) underwent RYGB. White and female patients were predominant in both groups. Mean age was similar for both populations (SG: 71.1 ± 4.0, RYGB: 71.7 ± 4.5; P = .12). Pre-procedure mean BMI for both groups was close in value, but the difference was statistically significant (40.5 ± 5.5 for SG versus 43.7 ± 7.2 for RYGB; P < .0001). Postoperative follow-up rates were similar in both groups at 12 and 24 months (SG: 51.2% and 31.6%; RYGB: 48.3% and 34.3%; P = .49 and P = .5). The %EBMIL at 6, 12, and 24 months was higher for the RYGB group than the SG group (59.3 ± 27.9, 72.1 ± 29.5, 77.4 ± 26.1 versus 50.2 ± 21.9, 55.2 ± 25.6, 43.9 ± 32.2; P < .01, P < .01, and P < .01, respectively). Complication rates were significantly higher in RYGB versus SG (27.7% versus 9.4%; P < .01). We observed significantly higher anastomotic ulcer and stricture rates for RYGB versus SG (7.2% and 5.9 versus 0% and 0%; P < .01 and P < .01, respectively). RYGB had a higher rate for gastrointestinal obstruction requiring intervention (2.2% versus .4%; P = .07). A similar de novo gastroesophageal reflux disease rate was noted in both procedures (3.7% versus 3.7%; P = .98). No leaks were reported in either group., Conclusions: Both SG and RYGB are effective weight loss procedures for patients aged ≥65 years. RYGB seems to have higher %EBMIL at 1 and 2 years; however, when compared with SG, complication rates appear to be almost 3 times higher., (Copyright © 2021 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Sleeve gastrectomy (SG) has become the most prevalent bariatric-metabolic surgical approach in the United States. Its popularity among surgeons and patients is mainly due to a better safety profile and less overall morbidity, with broad benefits from a systemic and metabolic perspective., Objective: Comprehensively describe the short-term multiorgan metabolic effects of rapid weight loss after SG., Setting: Academic hospital, United States., Methods: We retrospectively reviewed the charts of patients that underwent SG at our institution between 2012 and 2016. We analyzed the required variables to calculate multiple risk scores, such as cardiovascular, hypertension, and diabetes risk scores. Furthermore, the renal and hepatic functions and the metabolic and hematologic profiles were assessed at 12 months of follow-up., Results: A total of 1002 patients were included in the analysis. The percentage of excess body mass index loss was, on average, 65% at 12 months of follow-up. We observed a positive cardio-renal-hepatic improvement, demonstrated by a substantial reduction of the 10-year cardiovascular risk. We noticed an improvement of renal function, which was more significant in chronic kidney disease (stage ≥2), and a significant improvement on liver function tests (measured by decreased aspartate aminotransferase and alanine transaminase) at 12 months of follow-up. Our data also show a positive impact on decreasing the risk of developing hypertension and type 2 diabetes. There was a positive impact on the lipid profile, with the exception of low-density lipoprotein., Conclusion: There are significant short-term benefits on multiorgan metabolic parameters after rapid weight loss in severely obese patients undergoing sleeve gastrectomy., (Copyright © 2020 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Pericardial fat has a local atherosclerotic effect and is associated with both metabolic syndrome (MetS) and coronary artery disease (CAD)., Objectives: The aim of this study is to report changes in pericardial fat thickness (PFT) after bariatric surgery, and to investigate its significance on the risk of developing coronary artery disease (CAD)., Setting: Academic institution., Methods: We retrospectively measured the linear pericardial thickness from patients' computed tomography (CT) scans within 5 years preoperatively and compared to any available CT scan within 5 years postoperatively. The PFT was measured at the right ventricular wall, perpendicular to the myocardium, at the level of the sternum. The risk of developing CAD was estimated by calculating the Framingham risk score (FRS). We divided the patients into 2 groups: laparoscopic sleeve gastrectomy (SG, Group 1), and laparoscopic gastric Roux-en-Y gastric bypass (LRYGB, Group 2). Common demographic characteristics and co-morbidities were collected along with the preoperative and postoperative lipid profiles., Results: A total of 113 patients met the inclusion criteria, with 64 (56.6%) patients in group 1 and 49 (43.3%) patients in group 2. Group 1 consisted of 83.6% (n = 53) female patients versus 75.5% (n = 37) in group 2. The percent excess body mass index loss (%EBMIL) at 12 months was 74.4 ± 35.8% for group 1 versus 67 ± 30.1% for group 2 (P = .292). Pericardial thickness before surgery was 5.6 ± 1.9 mm and 4.6 ± 1.6 mm after surgery (P = .0001). The risk of CAD in females was 9.1% before and 6.6% after surgery. We found statistically significant linear association between pericardial thickness after surgery and a lower risk of CAD (P = .001)., Conclusion: Bariatric surgery decreases the PFT lowering risk of developing CAD. Further studies may be needed to better assess these findings., (Copyright © 2020 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)