The International Association for the Study of Lung Cancer Staging Project for Lung Cancer: Proposals for the Revision of the M Descriptors in the Forthcoming Ninth Edition of the TNM Classification for Lung Cancer.

INTRODUCTION: This study analyzed all metastatic categories of the current TNM classification of NSCLC to propose modifications of the M component in the next edition (ninth) of the classification. METHODS: A database of 124,581 patients diagnosed between 2011 and 2019 was established; of these, 14,937 with NSCLC in stages IVA to IVB were available for this analysis. Overall survival was calculated using the Kaplan-Meier method, and prognosis was assessed using multivariable-adjusted Cox proportional hazards regression. RESULTS: The eighth edition M categories revealed good discrimination in the ninth edition data set. Assessments revealed that an increasing number of metastatic lesions were associated with decreasing prognosis; because this seems to be a continuum and adjustment for confounders was not possible, no specific lesion number was deemed appropriate for stage classification. Among tumors involving multiple metastases, decreasing prognosis was found with an increasing number of organ systems involved. Multiple assessments, including after adjustment for potential confounders, revealed that M1c patients who had metastases to a single extrathoracic organ system were prognostically distinct from M1c patients who had involvement of multiple extrathoracic organ systems. CONCLUSIONS: These data validate the eighth edition M1a and M1b categories, which are recommended to be maintained. We propose the M1c category be divided into M1c1 (involvement of a single extrathoracic organ system) and M1c2 (involvement of multiple extrathoracic organ systems).

Alteration of the ankle brachial index, follow-up of patients at risk of peripheral arterial disease, a descriptive longitudinal study.

Background The objective of this study was to detect peripheral arterial disease (PAD) by measuring the ankle-brachial index (ABI) in patients attending medical offices in primary health care who presented a moderate or high risk on the risk scale of Framingham. Design longitudinal descriptive. Setting urban health center. Materials and methods Patients at risk of peripheral arterial disease of the lower limbs: diabetes mellitus (DM), cardiovascular disease (CVD), high cardiovascular risk (HCR) (SCORE>5%), and/or compatible symptoms. Consecutive sampling, n=136 (expected prevalence 8%, alpha 0.05, precision 0.95, projected losses 20%). Dependent variable: ankle-brachial index (ABI). Independent variables: hypertension (HBP), age, sex, CVD, DM, glycosylated hemoglobin (HbA1C), hyperlipidemia (HLP), LDL cholesterol (LDL), smoking, body mass index (BMI), pulses, treatment. Multivariate analysis: linear regression. Confidence level 95%. Results From a sample of 136 patients, 90 were male (66.2%) and 46 were female (33.8%), with a mean age of 72.2 years (in 2021), and a standard deviation (SD) of 7. The prevalence of abnormal ABI (ABI <0.9) was 11%, with a mean ABI of 0.7 (SD 0.18). The bivariate analysis showed a significant relationship between abnormal ABI and pulse palpation (p<0.0001). Excluding patients with ABI ≥ 1.4, in the multivariate analysis (coefficient of determination 0.977), the B coefficients and their 95% confidence intervals (CI) are as follows: age B=0.006, 95% CI (0.002-0.010) (p=0.003); diabetes B=0.289, 95% CI (0.1-0.479) (p=0.003); pulse palpation B= -0.199, 95% CI (-0.289- -0.11) (p<0.0001). Conclusions Doctor consultations in primary care are a favorable context for making an early diagnosis of PAD, by measuring the ABI. The performance of the ABI should be included as part of the annual examination for chronic patients who regularly attend consultations, particularly those with moderate or high cardiovascular risk. In this way, preventive measures could be intensified to prevent future cardiovascular complications in these patients. The predictors of ABI are age, diabetes, and palpation of pulses.

Economic evaluation of a multimorbidity patient centered care model implemented in the Chilean public health system.

Multimorbidity and patient-centered care approaches are growing challenges for health systems and patients. The cost of multimorbidity patients and the transition to a new care strategy is still sightly explored. In Chile, more than 70% of the adult population suffer from multimorbidity, opening an opportunity to implement a Multimorbidity patient-centered care model. The objective of this study was to perform an economic evaluation of the model from the public health system perspective.The methodology used a cost-consequence evaluation comparing seven exposed with seven unexposed primary care centers, and their reference hospitals. It followed three steps. First, we performed a Time-Driven Activity-Based Costing with routinely collected data routinely collected. Second, we run a comparative analysis through a propensity score matching and an estimation of the attributable costs to health services utilization at primary, secondary and tertiary care and health outcomes. Third, we estimated implementation and transaction costs.Results showed savings in aggregate costs of the total population (-0.12 (0.03) p < 0.01) during the period under evaluation. Costs in primary care showed a significant increase, whereas tertiary care showed significant savings. Health outcomes were associated with higher survival in patients under the new care model (HR 0.70 (0.05) p < 0.01). Implementation and transaction costs increased as the number of pilot intervention centers increased, and they represented 0,07% of the total annual budget of the Servicio de Salud Metropolitano Sur Oriente. After three years of piloting, the implementation and transaction cost for the total period was USD 1,838,767 and 393,775, respectively.The study's findings confirm the purpose of the new model to place primary health care at the center of care for people with non-communicable chronic diseases. Thus, it is necessary to consider implementation and transaction costs to introduce a broad health system multimorbidity approach. The health system should assume some of them permanently to guarantee sustainability and facilitate scale-up.

Evaluation of a Transitional Care Strategy Implemented in Adults With High-Risk and Multimorbidity in Chile.

OBJECTIVES: Fragmentation of continuity of care impacts the health system's efficiency and increases inequity. It severely affects high-risk patients with multimorbidity, requiring coordinated care to avoid preventable complications. The Centro de Innovación en Salud ANCORA UC, together with the Servicio de Salud Metropolitano Sur Oriente, and the National Health Fund, implemented a transitional care strategy for high-risk adults with multimorbidity at 3 hospitals in the southeast of Santiago. The study aimed to evaluate the impact on length of hospital stay, consultations with primary care physicians and contacts after discharge, and also to describe the implementation process of the transition nurse activities. METHODS: A cohort study was performed between 2017 and 2019, with 137 hospitalizations from exposed patients and 167 hospitalizations from unexposed patients. The results of the study showed a significant decrease in the length of hospital stays and an increase in consultations with physicians. RESULTS: The results of the implementation process showed that the transition nurse followed-up in a mean of 24 hospitalizations monthly, and 91% of the discharged patients were contacted via the telephone within 7 days. The implementation process showed that the transition nurse's tasks merged with the daily clinical activities in which training on case management, transition care, and continuous support were key aspects of success. CONCLUSION: We conclude that transitional care intervention has a strong potential in addressing fragmentation of care and is feasible to install and sustain over time in the Chilean context. Finally, this study provides a detailed description of the intervention strategy contributing to its spread and scale-up.

Toward sustainability and resilience in Chilean cities: Lessons and recommendations for air, water, and soil issues.

Achieving sustainability and resilience depends on the conciliation of environmental, social, and economic issues integrated into a long-term perspective to ensure communities flourish. Many nations are transitioning toward both objectives, while at the same time addressing structural concerns that have not allowed them to look after the environment in the past. Chile is one of these nations dealing with such challenges within a particular administrative context, an increasing environmental awareness, and a set of unique and complex geophysical boundaries that impose a plethora of hazards for cities, ecosystems, and human health. This paper presents recent accomplishments and gaps, mostly from an environmental perspective, on issues related to air pollution, the urban water cycle, and soil contamination, in the path being followed by Chile toward urban sustainability and resilience. The focus is on the bonds between cities and their geophysical context, as well as the relationships between environmental issues, the built environment, and public health. The description and diagnosis are illustrated using two cities as case studies, Temuco and Copiapó, whose socioeconomic, geographical, and environmental attributes differ considerably. Particulate matter pollution produced by the residential sector, drinking water availability, wastewater treatment, stormwater management, and soil contamination from the mining industry are discussed for these cities. Overall, the case studies highlight how tackling these issues requires coordinated actions in multiple areas, including regulatory, information, and financial incentive measures. Finally, the policy analysis discusses frameworks and opportunities for Chilean cities, which may be of interest when conceiving transitional paths toward sustainability and resilience for other cities elsewhere.

Radon Dynamics and Effective Dose Estimation in a Touristic Volcanic Cave: La Cueva del Viento, Tenerife (Canary Islands, Spain).

La Cueva del Viento is a volcanic lava tube located in Tenerife Island (Canary Islands, Spain). Its touristic section, 180 m long, receives more than 28,200 visitants each year. According to the European and Spanish legislation, a radon monitoring program is required to minimize the radon exposition of workers, tourists, and cavers. In this work, we studied the radon concentration dynamics in the touristic section of the cave for ca. 1 year, using both passive and active radon detectors. Pluviometry and external air temperature played an important role in the seasonal and daily variations of indoor radon concentrations. Daily fluctuations during the dry season were analyzed using time series (Box-Jenkins methodology) and frequency analysis (Fourier and Wavelet transforms) methods. The experimental radon time-series was well-fitted using a seasonal autoregressive integrated moving average model: Seasonal Auto-Regressive Integrated Moving Average (2,0,1) (2,1,0)24, and its value, in a short-time window (ca. 1 week) was conveniently forecasted. Finally, this work revealed that the annual effective doses received, during the observation period (1 year), by the touristic guides and visitors was ca. 2 mSv/yr and 4 µSv/hr, respectively. We concluded that the touristic exploitation of La Cueva del Viento is safe for both tourists and guides. However, based on our results, La Cueva del Viento had to be classified as a "Monitoring zone" and a regular monitoring program should be implemented.

Evaluating the contribution of satellite-derived evapotranspiration in the calibration of numerical groundwater models in remote zones using the EEFlux tool.

Assessment of groundwater resources is crucial for developing water management practices for its sustainable exploitation, both for current and future needs. Numerical models are useful tools for such purpose. However, the lack of continuous monitoring networks, mainly due to difficult access to some remote locations, poses a challenge in developing and calibrating groundwater models. Remote sensing offers an alternative for acquiring information on hydrological and climatic variables at multiple spatiotemporal scales that has the potential to strengthen groundwater modeling. The aim of this study is to develop a methodology that uses remote sensing products to support model calibration. With this aim, we used the Parameter Estimation software (PEST) to calibrate a hydrogeological model of an unexploited basin located in the arid Chilean Altiplano using observed groundwater levels and evapotranspiration (ET) derived from the Earth Engine Evapotranspiration Flux (EEFlux) tool as observations. Our results show that the best model calibration is achieved using both EEFlux-ET and heads as observations to calibrate the hydraulic properties (normalized root mean square error = 4.1 %). We analyzed the effect of EEFlux-ET on the calibration of these properties and found a direct effect on specific yield parameters, which regulate the fluctuations of the water table over time. Incorporating EEFlux-ET estimates in the calibration resulted in lower values of specific yield across the aquifer. Therefore, incorporating remotely sensed ET as observations in the calibration of the groundwater model contributes to a better simulation of the spatiotemporal head variations in the basin.

Description of basic competencies in clinical ultrasound imaging for emergency departments. / Competencias básicas de la ecografía clínica en los servicios de urgencias y emergencias.

TEXT: Recent years have seen great advances in the use of clinical ultrasound imaging in both hospital emergency departments and out-of-hospital settings. However, all new techniques require up-to-date definitions of competencies relevant to the clinical realities of different specialties and the geographic settings in which specialists work. To that end, a group of experts in clinical ultrasound reviewed the evidence available in the literature and strictly applied the Delphi method to define the competencies relevant to emergency physicians. The group worked with the starting premise that clinical ultrasound imaging should be a common competency across the specialty.

TEXTO: En los últimos años, la ecografía clínica (EC) ha sufrido un avance muy importante en su implantación dentro de los servicios de urgencias, tanto hospitalarios como extrahospitalarios, pero como toda técnica requiere un ámbito competencial definido, actualizado y enmarcado, tanto en la realidad clínica de la especialidad que desempeñamos como en la geográfica del país donde ejercemos. Por ello, un grupo de expertos en la materia ha desarrollado el presente documento en el que basándose por un lado en la evidencia disponible en la bibliografía científica y por otro en una metodología Delphi, planteó el objetivo de establecer un claro marco competencial base para todos los urgenciólogos, asumiendo como premisa inicial que la EC debería ser una competencia transversal común.

Extension of Duplexed Single-Ended Distributed Temperature Sensing Calibration Algorithms and Their Application in Geothermal Systems.

Fiber-optic distributed temperature sensing (DTS) has been widely used since the end of the 20th century, with various industrial, Earth sciences, and research applications. To obtain precise thermal measurements, it is important to extend the currently available DTS calibration methods, considering that environmental and deployment factors can strongly impact these measurements. In this work, a laboratory experiment was performed to assess a currently available duplexed single-ended DTS calibration algorithm and to extend it in case no temperature information is available at the end of the cables, which is extremely important in geothermal applications. The extended calibration algorithms were tested in different boreholes located in the Atacama Desert and in the Central Andes Mountains to estimate the geothermal gradient in these regions. The best algorithm found achieved a root mean square error of 0.31 ± 0.07 °C at the far end of a ~1.1-km cable, which is much smaller than that obtained using the manufacturer algorithm (2.17 ± 0.35 °C). Moreover, temperature differences between single- and double-ended measurements were less than 0.3 °C at the far end of the cable, which results in differences of ~0.5 °C km-1 when determining the geothermal gradient. This improvement in the geothermal gradient is relevant, as it can reduce the drilling depth by at least 700 m in the study area. Future work should investigate new extensions of the algorithms for other DTS configurations and determining the flow rate of the Central Andes Mountains artesian well using the geothermal profile provided by the DTS measurements and the available data of the borehole.

Water Flux Prediction in Direct Contact Membrane Distillation Subject to Inorganic Fouling.

Freshwater is a limited resource, which has driven the development of new purification and water-reuse technologies. One promising technology for water treatment is membrane distillation (MD). One of the main problems of MD, and of many desalination technologies, is membrane fouling, which reduces the performance of the membrane. This work presents a mathematical model that aims to predict distillate fluxes in direct-contact MD when fouling occurs as salts are deposited onto the membrane surface, forming an inorganic fouling layer. The mathematical model uses a heat- and mass-transfer formulation for prediction of the distillate flux under steady state conditions, and it is combined with the cake-filtration theory to represent the distillate fluxes after the onset of membrane fouling. Model results agree well with experimental observation of distillate fluxes, both before (~12-14 kg m-2 h-1) and after the onset of membrane fouling, with root-mean-square errors smaller than 1.4 kg m-2 h-1 in all the experiments. These results suggest that the cake-filtration theory can be used to represent water flux decline in MD membranes prone to inorganic fouling. From our experiments and from the modelling exercise, we found that the onset of membrane failure was relatively constant; the precipitation reaction constant is conditioned by the physicochemical interaction between the feed solution and the membrane; and the rate of flux decline after membrane fouling depends on flow conditions as well as on the precipitation compound. However, the proposed model has limitations that must be addressed in future investigations to validate it under a wider range of operating conditions, for membranes composed by other materials and with different feed solutions to address organic, biological, and/or colloidal fouling, which typically occur under real conditions.

Impact of a high-risk multimorbidity integrated care implemented at the public health system in Chile.

During recent years, multimorbidity has taken relevance because of the impact of causes in the system, people, and their families, which has been a priority in the health care plan. Interventions strategies and their implementation are still an emerging topic. In this context, Centro de Innovación en Salud ANCORA UC, together with Servicio de Salud Metropolitano Sur Oriente, implemented as a pilot study High-Risk Multimorbidity Integrated Care strategy. This study aimed to evaluate the impact of this strategy in terms of health services utilization and mortality. A cohort study was conducted with high-risk patients with multimorbidity, stratified by ACG®, intervened between April 2017 and December 2019. The studied population was 3,933 patients who belonged to similar size and location primary care centers. The impact analysis was performed used generalized linear models. Results showed that intervened patients had a significantly lower incidence in mortality (OR 0.56; 95% CI 0.40-0.77), hospital admissions, length of stay, and the number of hospital emergency consultancies. With the proper barriers and facilitators of a real context intervention, the implementation process allowed the systematization and consolidation of the intervention provided in this study. The training for new roles and the constant implementation support from the Centro de Innovación en Salud ANCORA UC team were essential in the progress and success of the intervention. A complete description of the high-risk intervention strategy is provided to contribute to this emerging topic and facilitate its scale-up. We can conclude that this complex intervention was feasible to be implemented in a real context. The Ministry of Health has taken the systematization and consolidation of the conditions for the national scale-up.

A New Current-Shaping Technique Based on a Feedback Injection Mechanism to Reduce VCO Phase Noise.

Inductor-capacitor voltage controlled oscillators (LC-VCOs) are the most common type of oscillator used in sensors systems, such as transceivers for wireless sensor networks (WSNs), VCO-based reading circuits, VCO-based radar sensors, etc. This work presents a technique to reduce the LC-VCOs phase noise using a new current-shaping method based on a feedback injection mechanism with only two additional transistors. This technique consists of keeping the negative resistance seen from LC tank constant throughout the oscillation cycle, achieving a significant phase noise reduction with a very low area increase. To test this method an LC-VCO was designed, fabricated and measured on a wafer using 90 nm CMOS technology with 1.2 V supply voltage. The oscillator outputs were buffered using source followers to provide additional isolation from load variations and to boost the output power. The tank was tuned to 1.8 GHz, comprising two 1.15 nH with 1.5 turns inductors with a quality factor (Q) of 14, a 3.27 pF metal-oxide-metal capacitor, and two varactors. The measured phase noise was -112 dBc/Hz at 1 MHz offset. Including the pads, the chip area is 750 × 850 µm2.

Three new endemic species of Lepanthes (Orchidaceae, Pleurothallidinae) from the highlands of Ecuador.

Three new species of Lepanthes from Ecuador are described and illustrated. These additions to the Ecuadorean flora were recorded in evergreen montane forest and páramo as part of three different research projects conducted during the last five years (2016-2021). Lepanthesoro-lojaensis was discovered in the southwest of El Oro province and is similar to L.jimburae, differing mainly in the much smaller plants, inflorescences and floral parts. Lepanthesmicroprosartima from the western slopes of Pichincha volcano in northern Ecuador resembles L.obandoi but differs in the coloration of the leaves, the inflorescence that are shorter than the leaves and the smaller floral appendix. Lepanthescaranqui, found in eastern Pichincha and Imbabura, is most similar to L.pachychila but differs from it in its much larger plants and different shape of the petals and the floral appendix. Preliminary assessments of the conservation status of the three taxonomic novelties are provided, using the IUCN Red List Categories and Criteria.

Obeticholic Acid and Fibrates in Primary Biliary Cholangitis: Comparative Effects in a Multicentric Observational Study.

INTRODUCTION: Obeticholic acid (OCA) and fibrates therapy results in biochemical improvement in placebo-controlled trials in patients with primary biliary cholangitis and insufficient response to ursodeoxycholic acid. There is scarce information outside of clinical trials. Therefore, we have assessed the effectiveness and adverse events of these treatments. METHODS: Data from patients included in the ColHai registry treated with OCA, fibrates, or both were recorded during a year, as well as adverse events and treatment discontinuation. RESULTS: Eighty-six patients were treated with OCA, 250 with fibrates (81% bezafibrate; 19% fenofibrate), and 15 with OCA plus fibrates. OCA group had baseline significantly higher alkaline phosphatase (ALP) (P = 0.01) and lower platelets (P = 0.03) than fibrates. Both treatments significantly decreased ALP, gamma-glutamyl transferase (GGT), and transaminases and improved Globe score. Albumin and immunoglobulin type M improved in the fibrates group. ALP decrease was higher under fibrates, whereas alanine aminotransferase decline was higher under OCA. Although baseline transaminases and GGT were higher in patients with OCA plus fibrates, significant ALP, GGT, alanine aminotransferase, and Globe score improvement were observed during triple therapy. Adverse events were reported in 14.7% of patients (21.3% OCA; 17.6% fenofibrate; 10.7% bezafibrate), mainly pruritus (10.1% with OCA). Discontinuation was more frequent in fenofibrate treatment mainly because of intolerance or adverse events. DISCUSSION: Second-line therapy with OCA or fibrates improves hepatic biochemistry and the GLOBE score in primary biliary cholangitis patients with suboptimal response to ursodeoxycholic acid. Simultaneous treatment with OCA and fibrates improved ALP as well.

Long-term spatiotemporal variability in high Andean wetlands in northern Chile.

High Andean wetlands of the elevated plateaus of the Andes Mountains of Chile, Argentina, Perú and Bolivia are true oases that sustain life in this arid region. Despite their ecological value, they have been rarely studied and are vulnerable to climate change and human activities that require groundwater resources. One such activity that may be intensified in the near future is mining for nonmetallic minerals such as lithium, whose worldwide demand is expected to increase with the rise of electric vehicles that need batteries. To determine a baseline of the natural dynamics of these systems, which allows sustainable management, it is essential to understand the spatiotemporal dynamics of these wetlands. In this article, we studied the temporal and spatial dynamics of high Andean wetlands of Chile, with the aim of identifying the key processes that govern their dynamics. To do this, we used time series of Landsat data from 1984 to 2019 to study 10 high Andean wetlands. Furthermore, to characterize the climate variability in these systems, we studied the long-term relation between the changes in water and vegetation areas with rainfall and evaporation variability. It was found that the groundwater reservoir plays a key role in sustaining the high Andean wetlands. Wet years with a period of occurrence of 20-30 years are the years in which the groundwater reservoirs are actually recharged, and in between wet years, the groundwater reservoirs gradually release the water that sustains the aquatic ecosystems. Hence, groundwater exploitation should be carefully designed from a long-term perspective, as groundwater levels could take decades to recover.

Tratamiento intervencionista con stents en recién nacidos con cardiopatías congénitas complejas / Interventionist treatment with stents in newborns with complex congenital heart disease

Introducción: La colocación de stents mediante cateterismo cardiaco en recién nacidos con ciertas cardiopatías congénitas complejas constituye un puente hacia la cirugía correctiva, paliativa o trasplante cardiaco. Objetivo: Evaluar el resultado del implante percutáneo de stents en pacientes recién nacidos con cardiopatías congénitas complejas. Presentación de los casos: Se colocó stents en cinco pacientes; a uno de ellos en la aorta y a los cuatros restantes en el ductus arterioso. Un primer paciente con hipoplasia de cavidades izquierdas en el que predominaba el bajo gasto se le colocó stent en el ductus e inmediatamente se le condujo al salón de operaciones para cerclaje pulmonar. Otro paciente con la misma enfermedad, pero en el que predominaba el hiperflujo pulmonar, se intervino de forma inversa, medió 47 días entre uno y otro proceder. A un tercer paciente, portador de coartación aórtica, se le colocó stent en la aorta y se le hizo cerclaje pulmonar 14 días después del proceder hemodinámico. Las condiciones clínicas del cuarto paciente, con síndrome de hipoplasia de cavidades izquierdas solo permitió colocar stent en el ductus. Esta paciente fallece en evento no relacionado con el cateterismo cardiaco. El último paciente intervenido, portador de una atresia pulmonar, tolera la colocación del stent en el ductus y la evolución clínica posterior demostró que no requería realizar cerclaje pulmonar. Conclusiones: La colocación de stent en el grupo de pacientes analizado es factible y el momento de su implante según el evento hemodinámico apremiante pudiera ser una forma alternativa del cateterismo cardiaco(AU)

Introduction: The paliative placing of stents by cardiac catetherism in new borns with specific congenital hearts diseases is a bridge through a new kind of corrective, paliative surgery or heart transplant. Objective: To evaluate the result of the percutaneous implant of stents in newborn patients with complex congenital heart diseases. Cases presentation: There were placed stents in 5 patients, to one of them in the aorta and to the other four in the ductus arteriosus. The first patient with hypoplasia of the left cavities in which low output predominated had an stent placing in the ductus and he was immediately taken to OR to perform a pulmonary cerclage. Another patients with the same disease but with predominance of pulmonary hyperflow was intervened in the inverse way; there were 47 days between both procedures. A third patient, carrier of aortic coarctation, had an stent placing in the aorta and he also had pulmonary cerclage 14 days after the hemodynamic procedure. The clinical conditions of the fourth patient, who had syndrome of left cavities´ hypoplasia, just allowed to place the stent in the ductus. This patients died in a procedure not related to heart catetherism. The last intervened patient, who was a carrier of pulmonary atresia, tolerated the stent placing in the ductus and the subsequent clinical evolution showed that it was not needed pulmonary cerclage. Conclusions: The stent placing in the analized group of patients is suitable and the moment for its implantation according to the hemodynamic event can be an alternative form of heart catetherism(AU)