Antibiotic point prevalence survey and antimicrobial resistance in hospitalized patients across Peruvian reference hospitals.

BACKGROUND: Peru reports higher levels than other countries in Latin America of resistance to antimicrobials among Gram-positive and Gram-negative bacteria, however data on antibiotic use in Peru are scarce. This study aims to estimate the prevalence and quality of antibiotic prescription in hospitalized patients and to determine the antibiotic susceptibility rates of bacteria causing key bacterial infections. METHODS: We carried out a point prevalence survey of antibiotic prescription at ten public hospitals in nine regions of Peru. Data was collected from patients hospitalized during a 3-week period, with details about antibiotic use, patient information, and antimicrobial susceptibility. RESULTS: 1620 patient charts were reviewed; in 924 cases antibiotics were prescribed (57.0 %, range 45.9-78.9 %). Most of the antibiotics (74.2 %) were prescribed as empirical treatment, only 4.4 % as targeted treatment. For 9.5 % of cases the reason for antibiotic use was unknown. Cephalosporins were the most prescribed (30.0 %), followed by carbapenems (11.3 %). Ninety-four blood cultures were positive for bacterial growth, 48.8 % of the Staphylococcus aureus were methicillin-resistant, among Escherichia coli and Klebsiella pneumoniae, 51.7 % and 72.7 % were resistant to third-generation cephalosporins (3GC), 3.4 % and 18.2 % were resistant to carbapenems, respectively. Among bacteria isolated from urine cultures (n = 639), 43.9 % of E. coli and 49.2 % of K. pneumoniae were resistant to 3GC, and 0.9 % of E. coli and 3.2 % of K. pneumoniae were resistant to meropenem. CONCLUSIONS: The overall proportion of hospitalized patients receiving antibiotics in hospitals from different regions in Peru was high, with only a small proportion receiving targeted treatment. Cephalosporins and carbapenems were the most frequently prescribed antibiotics, reflecting high resistance rates against 3GC and carbapenems in Enterobacterales isolated from blood and urine.

Diferencias laborales entre personas con discapacidad adquirida y sobrevenida en edad adulta. Análisis secundario de la Encuesta Nacional de Discapacidad ­ ENEDIS 2012 / Labor differences between people with congenital and adulthood acquired disability. Secondary analysis of the National Disability Survey - ENEDIS 2012

Objetivo: Evaluar diferencias laborales entre personas con discapacidad adquirida y discapacidad sobrevenida en edad adulta. Material y Métodos: Estudio transversal analítico secundario de la Encuesta Nacional de Discapacidad (ENEDIS) 2012. Se incluyeron personas entre 14 y 65 años de edad, agrupándolas según discapacidad (adquirida, sobrevenida temprana, sobrevenida adulta). Se consideraron como resultados finales de interés: tener trabajo, ser trabajador dependiente o independiente, contar con contrato y tener ingresos superiores a la remuneración mínima vital. Se realizo análisis bivariados y múltiples considerando el muestreo complejo de los datos. Resultados: Se estudiaron a 16060 personas, 27,92 % presentaron discapacidad adquirida, 10,45 % sobrevenida temprana y 61,63 % sobrevenida adulta. Se encontró que aquellas con discapacidad sobrevenida adulta tenían una mayor frecuencia de: tener trabajo (34,93 vs 23,20 %, p < 0,001), contar con contrato (50,40 vs 27,74 %, p < 0,001) y tener mayores ingresos (18,18 vs 13,29 %, p=0,048), respecto a las personas con discapacidad adquirida. Al realizar el análisis de regresión múltiple, las diferencias del ingreso económico y tipo de contrato disminuyen (p<0,05), pero la probabilidad de tener trabajo en la discapacidad sobrevenida adulta se invierte de 51% más a 8% menos (p=0,057). Conclusiones: Las personas con discapacidad sobrevenida en edad adulta presentan más empleo e ingresos económicos que aquellas con discapacidad adquirida. Aparentemente esto no depende del tiempo de discapacidad (que es menor en la discapacidad sobrevenida adulta) sino principalmente a factores como edad, sexo, grado de instrucción, región de residencia y tipo de limitación.

Objetive: To evaluate labor differences between people with congenital and adulthood acquired disability. Material and Methods: Secondary analytical cross-sectional study of the National Disability Survey (ENEDIS) - 2012. People between 14 and 65 years of age were included, grouping them according to their disability (congenital, early acquired, adulthood acquired). The final results of interest were considered: to have a job, being a dependent or independent worker, to have a contract and to have an income higher than the minimum living wage. Bivariate and multivariate analyzes were performed to evaluate the differences raised. Results: 16060 people were studied, 27,92% presented congenital disability, 10,45% early acquired and 61,63% adulthood acquired. It was found that those with adulthood acquired disability had a higher frequency of to have a job (34,93 vs 23,20 %, p <0,001), to have a contract (50,40 vs 27,74 %, p <0.001) and have income higher (18,18 vs 13,29 %, p = 0,048), with respect to people with congenital disability. When performing the multivariate analysis, the differences in economic income and type of contract decrease (p<0,05), but the probability of to have a job in adulthood acquired disability reverses from 51% more to 8% less (p = 0.057). Conclusions: People with adulthood acquired disability have more employment and income than those with congenital disability. Apparently this does not depend on the time of disability (which is less in adulthood acquired disability) but mainly to factors such as age, sex, level of education, region of residence and type of limitation

Tratamiento percutáneo de la hemoptisis. Anatomía, fisiopatología y metodología / Percutaneous treatment of hemoptysis. Anatomy, physiopathology and methodology

Resumen Se presentan los resultados de 105 pacientes con hemoptisis amenazante tratados mediante embolización arterial por cateterismo percutáneo por vía arterial sistémica y/o arterial pulmonar. Se describe la técnica del procedimiento y los hallazgos angiográficos. Se muestra la utilidad de la fibrobroncoscopía y de la radiografía de tórax para identificar la zona sangrante como diagnóstico previo al procedimiento. Entre mayo 2000 y septiembre 2015 se admitieron en el Servicio de Hemodinamia 105 pacientes con diagnóstico de hemoptisis amenazante, 76 masculinos (72.4%); edad media: 41 (±18.65 DS) años. El 93% (98/105) fue tratado con éxito. En el 90% (88/98) se efectuó embolización por arterias bronquiales y/o no bronquiales sistémicas y en el 10% (10/98) por vía arterial pulmonar. Cuando la afección era bilateral la angiografía sola no posibilitó identificar el sitio de sangrado. Al 60% (63/98) se le hizo fibrobroncoscopía flexible y se pudo ubicar el pulmón sangrante en el 84% (56/63). Cuando la afección era unilateral, la radiografía de tórax previa al procedimiento facilitó la ubicación del área de sangrado en el 47%. No se observaron complicaciones graves ni muertes vinculadas al procedimiento. El tratamiento de la hemoptisis masiva por vía percutánea tiene alto porcentaje de éxito primario con muy baja tasa de complicaciones. El tratamiento por vía arterial pulmonar es un abordaje alternativo. La fibrobroncoscopía flexible es un importante complemento en esta entidad.

Abstract We present the results of 105 patients with life-threatening hemoptysis who were treated with the systemic arterial and/or pulmonary artery routes. We also describe the procedure techniques and the angiographic findings. We show the usefulness of the flexible fiberoptic bronchoscopy and chest radiography to identify the bleeding zone previous to the procedure. From May 2000 to September 2015, a total of 105 patients were admitted to the Catheterization Laboratory with a diagnosis of life-threatening hemoptysis; 76 were male (72.4%) and mean age was 41 ± 18.65 years. Treatment was successful in 93% (98/105). In 90% (88/98) the approach was via the bronchial arteries and/or non-bronchial systemic arteries, and in 10% (10/98) the approach was via the pulmonary artery. In bilateral affection angiographic images alone could not identify accurately the site of the lung bleeding. Flexible fibrobronchoscopy was performed in 60% (63/98) and located the bleeding area in 84% (56/63). In unilateral affection, chest radiography previous to the procedure located the bleeding area in 47%. No complications or death were related to the procedure. The treatment of life threatening hemoptysis by a percutaneous way has a high percentage of primary success with a very low incidence of complications. Pulmonary arterial route treatment is an alternative approach. Flexible fibrobronchoscopy is an important complement to this entity.

[Percutaneous treatment of hemoptysis. Anatomy, physiopathology and methodology]. / Tratamiento percutáneo de la hemoptisis. Anatomía, fisiopatología y metodología.

We present the results of 105 patients with life-threatening hemoptysis who were treated with the systemic arterial and/or pulmonary artery routes. We also describe the procedure techniques and the angiographic findings. We show the usefulness of the flexible fiberoptic bronchoscopy and chest radiography to identify the bleeding zone previous to the procedure. From May 2000 to September 2015, a total of 105 patients were admitted to the Catheterization Laboratory with a diagnosis of life-threatening hemoptysis; 76 were male (72.4%) and mean age was 41 ± 18.65 years. Treatment was successful in 93% (98/105). In 90% (88/98) the approach was via the bronchial arteries and/or non-bronchial systemic arteries, and in 10% (10/98) the approach was via the pulmonary artery. In bilateral affection angiographic images alone could not identify accurately the site of the lung bleeding. Flexible fibrobronchoscopy was performed in 60% (63/98) and located the bleeding area in 84% (56/63). In unilateral affection, chest radiography previous to the procedure located the bleeding area in 47%. No complications or death were related to the procedure. The treatment of life threatening hemoptysis by a percutaneous way has a high percentage of primary success with a very low incidence of complications. Pulmonary arterial route treatment is an alternative approach. Flexible fibrobronchoscopy is an important complement to this entity.

Se presentan los resultados de 105 pacientes con hemoptisis amenazante tratados mediante embolización arterial por cateterismo percutáneo por vía arterial sistémica y/o arterial pulmonar. Se describe la técnica del procedimiento y los hallazgos angiográficos. Se muestra la utilidad de la fibrobroncoscopía y de la radiografía de tórax para identificar la zona sangrante como diagnóstico previo al procedimiento. Entre mayo 2000 y septiembre 2015 se admitieron en el Servicio de Hemodinamia 105 pacientes con diagnóstico de hemoptisis amenazante, 76 masculinos (72.4%); edad media: 41 (±18.65 DS) años. El 93% (98/105) fue tratado con éxito. En el 90% (88/98) se efectuó embolización por arterias bronquiales y/o no bronquiales sistémicas y en el 10% (10/98) por vía arterial pulmonar. Cuando la afección era bilateral la angiografía sola no posibilitó identificar el sitio de sangrado. Al 60% (63/98) se le hizo fibrobroncoscopía flexible y se pudo ubicar el pulmón sangrante en el 84% (56/63). Cuando la afección era unilateral, la radiografía de tórax previa al procedimiento facilitó la ubicación del área de sangrado en el 47%. No se observaron complicaciones graves ni muertes vinculadas al procedimiento. El tratamiento de la hemoptisis masiva por vía percutánea tiene alto porcentaje de éxito primario con muy baja tasa de complicaciones. El tratamiento por vía arterial pulmonar es un abordaje alternativo. La fibrobroncoscopía flexible es un importante complemento en esta entidad.

Neurological Symptoms of Congenital Portosystemic Shunt Reversed by Venous Endovascular Intervention: A Six Years Follow-Up Study.

Congenital portosystemic shunt (CPSS) is a rare disorder characterized by a diversion of Porto-mesenteric blood into systemic veins. Type I is an end to side fistula between the portal vein and the inferior vena cava. Type II is a side to side fistula between the main portal vein or its branches and mesenteric, splenic, gastric, and systemic veins. Clinical presentation of these patients varies. Treatment and management are guided by the type of malformation and clinical presentation. Herein, we present a case of CPSS Type IIb with neurological symptoms, treated with endovascular occlusion with 6-year follow-up without remission.

Transcriptional portrait of M. bovis BCG during biofilm production shows genes differentially expressed during intercellular aggregation and substrate attachment.

Mycobacterium tuberculosis and M. smegmatis form drug-tolerant biofilms through dedicated genetic programs. In support of a stepwise process regulating biofilm production in mycobacteria, it was shown elsewhere that lsr2 participates in intercellular aggregation, while groEL1 was required for biofilm maturation in M. smegmatis. Here, by means of RNA-Seq, we monitored the early steps of biofilm production in M. bovis BCG, to distinguish intercellular aggregation from attachment to a surface. Genes encoding for the transcriptional regulators dosR and BCG0114 (Rv0081) were significantly regulated and responded differently to intercellular aggregation and surface attachment. Moreover, a M. tuberculosis H37Rv deletion mutant in the Rv3134c-dosS-dosR regulon, formed less biofilm than wild type M. tuberculosis, a phenotype reverted upon reintroduction of this operon into the mutant. Combining RT-qPCR with microbiological assays (colony and surface pellicle morphologies, biofilm quantification, Ziehl-Neelsen staining, growth curve and replication of planktonic cells), we found that BCG0642c affected biofilm production and replication of planktonic BCG, whereas ethR affected only phenotypes linked to planktonic cells despite its downregulation at the intercellular aggregation step. Our results provide evidence for a stage-dependent expression of genes that contribute to biofilm production in slow-growing mycobacteria.

Transcriptional and Mycolic Acid Profiling in Mycobacterium bovis BCG In Vitro Show an Effect for c-di-GMP and Overlap between Dormancy and Biofilms.

Mycobacterium tuberculosis produces mycolic acids which are relevant for persistence, recalcitrance to antibiotics and defiance to host immunity. c-di-GMP is a second messenger involved in transition from planktonic cells to biofilms, whose levels are controlled by diguanylate cyclases (DGC) and phosphodiesterases (PDE). The transcriptional regulator dosR, is involved in response to low oxygen, a condition likely happening to a subset of cells within biofilms. Here, we found that in M. bovis BCG, expression of both BCG1416c and BCG1419c genes, which code for a DGC and a PDE, respectively, decreased in both stationary phase and during biofilm production. The kasA, kasB, and fas genes, which are involved in mycolic acid biosynthesis, were induced in biofilm cultures, as was dosR, therefore suggesting an inverse correlation in their expression compared with that of genes involved in c-di-GMP metabolism. The relative abundance within trehalose dimycolate (TDM) of α-mycolates decreased during biofilm maturation, with methoxy mycolates increasing over time, and keto species remaining practically stable. Moreover, addition of synthetic c-di-GMP to mid-log phase BCG cultures reduced methoxy mycolates, increased keto species and practically did not affect α-mycolates, showing a differential effect of c-di-GMP on keto- and methoxy-mycolic acid metabolism.

A Bayesian decision procedure for testing multiple hypotheses in DNA microarray experiments.

DNA microarray experiments require the use of multiple hypothesis testing procedures because thousands of hypotheses are simultaneously tested. We deal with this problem from a Bayesian decision theory perspective. We propose a decision criterion based on an estimation of the number of false null hypotheses (FNH), taking as an error measure the proportion of the posterior expected number of false positives with respect to the estimated number of true null hypotheses. The methodology is applied to a Gaussian model when testing bilateral hypotheses. The procedure is illustrated with both simulated and real data examples and the results are compared to those obtained by the Bayes rule when an additive loss function is considered for each joint action and the generalized loss 0-1 function for each individual action. Our procedure significantly reduced the percentage of false negatives whereas the percentage of false positives remains at an acceptable level.

Endovascular treatment of an aortoiliac tuberculous pseudoaneurysm.

We report a rare case of a tuberculous mycotic aortoiliac pseudoaneurysm treated with an endovascular procedure and follow-up of 36 months. The patient was a white 72-year-old man with pulmonary tuberculosis and a former smoker with hypertension, chronic renal failure, and dyslipidemia. A computed tomographic scan of the abdomen and pelvis revealed a left paravertebral cavity with fluid content and involvement of vertebrae L2-L4. After a surgical repair attempt, the patient was treated with the implant of a bifurcated endoprosthesis. Because it is unlikely that any center has extensive experience in the management of this rare manifestation of the disease, we reviewed the literature for similar cases.

Flexions of the popliteal artery: technical considerations of femoropopliteal stenting.

Popliteal artery morphology changes while undergoing knee motion. A main flexion (i.e., the 'hinge point') and other flexions (termed 'accessory flexions') were described as a result of popliteal artery adaptation to knee flexion. Knee dynamics challenge the outcome of popliteal artery endovascular procedures. Complications such us stent fractures were reported despite rapidly improving technology. Understanding popliteal artery dynamics allows us to develop an endovascular technique that facilitates the avoidance of the difficulties of one of the most mobile arteries in the body. Here we report two cases with a novel stent implantation technique in the popliteal artery. The method includes diagnostic angiography, lesion angioplasty, and stenting using both extended and flexed knee in lateral view. The pressure gradients were measured with knee in extension and flexion before and after each step. A successful outcome was achieved in both cases. This method allows us: 1) to identify the flexions of the popliteal artery and its relationship with the lesions; 2) to detect those obstructions not visible with an extended knee; 3) to understand that the hinge point and accessory flexions can develop undesired and unexpected artery obstruction after a stent implantation only observed in knee flexion; and 4) to identify the morphological changes caused in the popliteal artery and its subsequent solution.

Consumo de cafeína en estudiantes de medicina y su coexistencia con sintomatología ansiosa y depresiva / Caffeine consumption in medical students and it’s coexistence with depressive and anxious symptomatology

Objetivo: Determinar el consumo de cafeína y su relación con sintomatología ansiosa y depresiva en estudiantes de medicina de una universidad privada en Lima, Perú. Material y métodos: Se realizó un estudio descriptivo transversal. Participaron 384 personas de cuatro años de estudio de la facultad de medicina de una universidad privada en Lima, Perú; excluyéndose a 6. Se utilizó una encuesta estructurada para la evaluación de consumo de cafeína, y la Escala de Ansiedad y Depresión de Goldberg -EADG, siendo los puntos de corte 4 para ansiedad y 3 para depresión. Resultados: El 96,3% de participantes consumen cafeína en un nivel promedio de 147,35 mg/día, 34,13% presentó sintomatología ansiosa, 29,89% depresiva y 20,63% síntomas de ambas. No se encontró relación entre el grado de consumo de cafeína y la presencia de sintomatología ansiosa y depresiva. Conclusiones: El consumo de cafeína en estudiantes de medicina resultó igual o inferior a lo descrito en otros estudios. No se encontró relación entre el consumo de cafeína y la presencia de sintomatología ansiosa y depresiva. (AU).

Objetive: To evaluate the caffeine intake, anxious and depressive symptoms, and its relation, on medical students. Material and methods: A transversal descriptive study was performed with 384 persons from four different grades from School of Medicine of Universidad Peruana Cayetano Heredia, 6 were excluded following the exclusion criteria. A structured questionnaire was used for the evaluation of caffeine intake and the Goldberg’s Anxiety and Depression Scale, using as cut off 4 for anxiety and 3 for depression. Results: 96.3% have caffeine consumption, with mean intake of 147.35 mg/day, 34.13% present anxious symptoms; 29.89% depressive symptoms and 20.63% both. No statistical relation was found between caffeine consumption and anxious or depressive symptoms. Conclusions: The medical students’ caffeine intake was equal or less than other reports. There was no statistic relation between caffeine intake and anxious or depressive sintomatology. (AU).

Pulmonary artery access embolization in patients with massive hemoptysis in whom bronchial and/or nonbronchial systemic artery embolization is contraindicated.

The objective of this paper is to present an alternative therapeutic approach for the treatment of patients with massive hemoptysis in whom bronchial and/or nonbronchial systemic arterial embolization is not possible. We describe a percutaneous procedure for pulmonary segmental artery embolization. Between May 2000 and July 2006, 27 adult patients with hemoptysis underwent percutaneous treatment at our department; 20 of 27 patients were embolized via bronchial and or nonbronchial systemic arteries and 7 patients were embolized via pulmonary artery. Femoral arterial access for systemic artery catheterization and femoral vein access for pulmonary arterial catheterization were used. Gelfoam particles and coils were used for embolization. In this study, we report on three cases of massive hemoptysis from a systemic arterial source in whom bronchial and/or nonbronchial arteries embolization was not possible. Percutaneous embolization via the pulmonary artery access was successful in all three patients. In conclusion, embolization via pulmonary artery is presented as an alternative approach for the management of hemoptysis in patients in whom bronchial arterial embolization is not possible.

Retrograde rotablator in limb salvage: a new technique using an open approach.

Conventional vascular surgery and balloon angioplasty have poor results in severe and diffuse atherosclerotic disease of the infrapopliteal arteries. High-speed rotational atherectomy (Auth Rotablator) has not succeeded either, because of poor long-term patency and the non-reflow phenomenon. We report a case of limb salvage with long occlusion of the three infrapopliteal vessels. The anterior tibial artery was treated with retrograde Auth Rotablator atherectomy by an open approach through the pedal artery, resulting in full patency of the anterior tibial artery and healing of the skin lesions. The microparticulate debris from the ablation was drained out through the pedal arteriotomy, avoiding the complications associated with conventional antegrade high-speed rotational atherectomy.

Flexions of the popliteal artery: dynamic angiography.

BACKGROUND: Stenting of popliteal artery (PA) with self-expandable stents is a therapeutic option in selected patients with arterial disease. Fractures of these stents may occur, and they are thought to be related to development of hinge points (HPs) secondary to knee flexion. However, it remains obscure how movements of the knee affect the morphology of the PA and where HPs occur. OBJECTIVE: To describe the morphologic changes of the PA during knee flexion and their relationship with bone structures using dynamic angiography (DA). PATIENTS AND METHODS: All DA procedures performed in our institution between February 2000 and July 2003 were reviewed. Dynamic angiography consisted of a static phase (during which the knee was bent at 100 degrees) and a dynamic phase (during which the leg was passively extended to total extension following opacification of the PA). RESULTS: Sixty-three PAs in 57 patients with arterial disease were evaluated. In 62 PAs (98.2%), presence of an HP was identified and the pre-HP and post-HP segments also were defined. HPs were never observed at the level of the knee joint line. We developed a geometric model to establish a relationship of proximity between a bone structure and the HP. The HP was the main and most acute angled curve observed during knee flexion. Accessory flexions (AFs) were observed when the knee was bent in 46 PAs (73%). Presence of AFs was associated with high blood pressure (p < 0.01). CONCLUSION: We identified HPs of the PA as the main curve observed during knee flexion as well as a large number of AFs. DA appears to be a useful diagnostic tool for obtaining the most accurate morphologic information about the PA during knee flexion.

Luxación recidivante anterior de hombre / Anterior recidivant luxation of the shoulder

Estudio retrospectivo de 21 casos con diagnóstico de luxación recidivante anterior de hombro, durante el periodo de los años 1987 a 1992. Se revisaron historias clínicas, reportes operatorios y radiografías. Este tipo de luxación predomina en el sexo masculino 100 por ciento, con incremento en la edad entre 20 - 29 años del 71.44 por ciento. La principal causa de luxación inicial se produjo durante actividad atlética y/o deportiva en 66.66 por ciento en el 71.44 por ciento no recibieron ningún tipo de tratamiento inicial. La recidiva previa a la cirugía se presentó más de 10 veces en 66.66 por ciento. El tratamiento quirúrgico más utilizado fue la técnica de Magnuson-Stack modificada en 57.15 por ciento.

Registro regional de tumores malignos para el sur de Sonora / Malignant tumors regional register for south Sonora

Se inició un registro regional de tumores malignos, para el sur de Sonora, México, con una población de 750 000 habitantes. Se hizo una pesquisa de cada caso nuevo de cáncer informado por centros hospitalarios, consulta externa y laboratorios de anatomía patológica, así como en certificados de defunción, durante el periodo de 1982 a 1983 (del 15 de marzo al 14 de marzo siguiente). Se informan cifras de cada grupo de tumores por sitio de origen, sexo y decenios de la vida en que se presentan. Se encontraron en total 1 123 casos, o sea una frecuencia de 1 497.3 por obs: 1 000 000 de habitantes por año, y entre éstos se encontraron 570 defunciones, que constituyen una tasa de mortalidad de 760 por obs: 1 000 000 por año. Fueron 490 los casos (43.6%) en varones y 633 (56.4%) en mujeres. La máxima frecuencia ocurrió a partir de los 40 años. El tumor más frecuente fue el del cuello uterino, 246 casos (21.9%), y lo siguieron los de bronquios y pulmón, glándula mamaria, los linfomas, las leucemias y de piel con 130 (11.6%), 92 (8.2%), 90 (8%) y 86 (7.6%) casos, respectivamente

Implementación red sistema movil Oruro Nuevatel

El presente trabajo de ingenieria esta orientado al diseño y descripción de los procesos necesarios para la implememtación de una red de telefonía movil, con tecnologia GSM.Este proyecto esta basado en los trabajos que fueron realizados por mi persona en la empresa Telegen, contratados por NOKIA.Mi participación en la citada empresa fue en el diseño de una red para la ciudad de Oruro, instalación, ajuste y puesta en servicio de equipos con tecnologia GSM para la red celular de la empresa Nuevatel, en las ciudades de La Paz, Cochabamba y Santa Cruz.