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Prolonged waiting to access health care is a primary concern for nations aiming for comprehensive effective care, due to its adverse effects on mortality, quality of life, and government approval. Here, we propose two novel bargaining frameworks to reduce waiting lists in two-tier health care systems with local and regional actors. In particular, we assess the impact of 1) trading patients on waiting lists among hospitals, the 2) introduction of the role of private hospitals in capturing unfulfilled demand, and the 3) hospitals' willingness to share capacity on the system performance. We calibrated our models with 2008-2018 Chilean waiting list data. If hospitals trade unattended patients, our game-theoretic models indicate a potential reduction of waiting lists of up to 37%. However, when private hospitals are introduced into the system, we found a possible reduction of waiting lists of up to 60%. Further analyses revealed a trade-off between diagnosing unserved demand and the additional expense of using private hospitals as a back-up system. In summary, our game-theoretic frameworks of waiting list management in two-tier health systems suggest that public-private cooperation can be an effective mechanism to reduce waiting lists. Further empirical and prospective evaluations are needed.

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BACKGROUND: As of June 15, 2020, a cumulative total of 7,823,289 confirmed cases of COVID-19 have been reported across 216 countries and territories worldwide. However, there is little information on the clinical characteristics and outcomes of critically ill patients with severe COVID-19 who were admitted to intensive care units (ICUs) in Latin America. The present study evaluated the clinical characteristics and outcomes of critically ill patients with severe COVID-19 who were admitted to ICUs in Mexico. METHODS: This was a multicenter observational study that included 164 critically ill patients with laboratory-confirmed COVID-19 who were admitted to 10 ICUs in Mexico, from April 1 to April 30, 2020. Demographic data, comorbid conditions, clinical presentation, treatment, and outcomes were collected and analyzed. The date of final follow-up was June 4, 2020. RESULTS: A total of 164 patients with severe COVID-19 were included in this study. The mean age of patients was 57.3 years (SD 13.7), 114 (69.5%) were men, and 6.0% were healthcare workers. Comorbid conditions were common in patients with critical COVID-19: 38.4% of patients had hypertension and 32.3% had diabetes. Compared to survivors, nonsurvivors were older and more likely to have diabetes, hypertension or other conditions. Patients presented to the hospital a median of 7 days (IQR 4.5-9) after symptom onset. The most common presenting symptoms were shortness of breath, fever, dry cough, and myalgias. One hundred percent of patients received invasive mechanical ventilation for a median time of 11 days (IQR 6-14). A total of 139 of 164 patients (89.4%) received vasopressors, and 24 patients (14.6%) received renal replacement therapy during hospitalization. Eighty-five (51.8%) patients died at or before 30 days, with a median survival of 25 days. Age (OR, 1.05; 95% CI, 1.02-1.08; p<0.001) and C-reactive protein levels upon ICU admission (1.008; 95% CI, 1.003-1.012; p<0.001) were associated with a higher risk of in-hospital death. ICU length of stay was associated with reduced in-hospital mortality risk (OR, 0.89; 95% CI, 0.84-0.94; p<0.001). CONCLUSIONS: This observational study of critically ill patients with laboratory-confirmed COVID-19 who were admitted to the ICU in Mexico demonstrated that age and C-reactive protein level upon ICU admission were associated with in-hospital mortality, and the overall hospital mortality rate was high. TRIAL REGISTRATION: ClinicalTrials.gov, NCT04336345.

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AIM: To study the blood-brain barrier integrity, brain edema, animal behavior and ammonia plasma levels in prehepatic portal hypertensive rats with and without acute liver intoxication. METHODS: Adults male Wistar rats were divided into four groups. Group I: sham operation; II: Prehepatic portal hypertension, produced by partial portal vein ligation; III: Acetaminophen intoxication and IV: Prehepatic portal hypertension plus acetaminophen. Acetaminophen was administered to produce acute hepatic injury. Portal pressure, liver serum enzymes and ammonia plasma levels were determined. Brain cortex water content was registered and trypan blue was utilized to study blood brain barrier integrity. Reflexes and behavioral tests were recorded. RESULTS: Portal hypertension was significantly elevated in groups II and IV. Liver enzymes and ammonia plasma levels were increased in groups II, III and IV. Prehepatic portal hypertension (group II), acetaminophen intoxication (group III) and both (group IV) had changes in the blood brain-barrier integrity (trypan blue) and hyperammonemia. Cortical edema was present in rats with acute hepatic injury in groups III and IV. Behavioral test (rota rod) was altered in group IV. CONCLUSION: These results suggest the possibility of another pathway for cortical edema production because blood brain barrier was altered (vasogenic) and hyperammonemia was registered (cytotoxic). Group IV, with behavioral altered test, can be considered as a model for study at an early stage of portal-systemic encephalopathy.

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Las investigaciones citogenéticas en Leucemia Linfoblástica Aguda (LLA) permiten identificar alteraciones recurrentes específicas en los cromosomas y correlacionarlas con la información biológica. Además, contribuyen a la comprensión de los mecanismos de leucogénesis, como factores pronósticos independientes, y aportan bases para futuras investigaciones terapéuticas.Se analizaron las alteraciones cromosómicas adquiridas en la médula ósea de 44 niños (entre un mes y 14 años) con LLA, diagnosticada clínica e histopatológicamente entre 1998 y 2001 en la Unidad de Hematología Infantil, Hospital San Vicente de Paúl, de Medellín, y cuyas muestras de médula ósea fueron procesadas y analizadas en la Unidad de Genética Médica, de la Facultad de Medicina de la Universidad de Antioquia.El estudio reveló que 17 pacientes (41,5 por ciento) presentaban cariotipo normal y 24 (58,5 por ciento) lo tenían anormal. De estos últimos 18 (75 por ciento) tenían un mosaicismo cromosómico, 4 (16,7 por ciento) exhibían cariotipos hiperdiploides y 2 (8.3 por ciento) presentaban otras alteraciones cromosómicas.No se encontraron asociaciones significativas entre los tipos de leucemia (L1,L2,L3) y el cariotipo.

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1. Current evidence supports that C-type natriuretic peptide (CNP) is the brain natriuretic peptide. Natriuretic peptide receptors and mRNA CNP have been reported in the liver and in discrete areas and nucleus of the central nervous system involved in the regulation of gastrointestinal physiology. In the present work, we sought to establish the role of CNP in the central regulation of bile secretion in the rat and to delineate the possible pathways and mechanisms involved. 2. To examine the role of CNP on bile secretion, the peptide was applied in the brain lateral ventricle (1, 10, and 100 ng/microL) and bile samples were collected every 15 min for 60 min. The role of the autonomic nervous system in CNP response was assessed by atropine or combined phentolamine and propranolol administration. 3. Centrally applied CNP diminished basal as well as bile salt-evoked bile flow in a dose-dependent manner. CNP reduced bile acid output as well as sodium and potassium excretion, supporting CNP effect on bile acid-dependent flow. CNP also decreased chloride excretion and increased bile pH. The excretion of total glutathione was not affected by centrally applied CNP suggesting that this peptide does not alter bile acid-independent flow. Neither parasympathetic nor sympathetic blockade abolished CNP inhibitory response on bile secretion. Mean arterial pressure and portal venous pressure were not modified by CNP. 4. Present findings show that centrally applied CNP modulates bile secretion in a dose-dependent fashion. CNP alkalinized bile and reduced bile acid-dependent flow without affecting bile acid-independent flow. The inhibitory response of CNP on bile secretion was not mediated by the autonomic nervous system. Present findings give further support to the role of CNP as the brain natriuretic peptide.

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Con el propósito de establecer las medidas directas que permitan discriminar a los pacientes con síndrome de Down (SD) de los no SD, caracterizar los de SD, hallar las diferencias con los no SD, determinar subgrupos dentro de los de SD y comparar las observaciones realizadas por los clínicos, se estudiaron 24 pacientes con SD, de sexo masculino y 5 años de edad, que presentaban trisomía libre del cromosoma 21 y que no tenían anomalías cardíacas congénitas, y 24 niños sanos de la misma edad como controles. Se realizaron 37 medidas directas en cabeza, cara, tronco, miembros superiores e inferiores. Tres de las 37 clasifican y separan a los de SD de los no SD (100 por ciento); cinco observaciones realizadas por los clínicos sólo discriminaron el 79,1 por ciento de los de SD. En la agrupación por variables se conformaron cinco subgrupos en los de SD; sólo uno de ellos contenía las variables utilizadas por los clínicos. Las variables con mayor coeficiente de variación fueron: peso, longitud de la pierna, longitud de la mano, ancho de la oreja, ancho del hélix e índice nasal en el SD; peso, ancho del hélix e índice nasal en los no SD. Los niños con SD presentaron menores talla y peso

Twenty four five year old male children with full 21 trisomy syndrome, without congenital heart anomalies, and twenty four healtly children of the same age and sex, as controls, were studied, in order to define the direct measurements that permit discriminating between Down's syndrome (DS) and no Down syndrome (NDS), to characterize those with DS, to find the differences with the NDS ones, to determine DS subgroups and to compare the observations of the clinicians. Thirty seven direct measurements of head, face, trunk, upper and lower limbs were performed. Out of them three classified and separated DS and NDS children (100%). Five observations performed by clinicians only discriminate 79,1% of the DS children. In the DS children, by grouping the variables, five subgroups were detected; only one of these included the variables used by the clinicians, namely: weight, leg length, hand length, ear width, helix width and nasal index in DS and weigth, helix width and nasal index in NDS had the higher variation coefficient. DS children have lesser weight and size.

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Uno de cada 400 a 500 recién nacidos vivos presenta anormalidades de los cromosomas sexuales. En términos generales, las manifestaciones clínicas por dicha alteración son más leves que las producidas por imbalance autosómico. Posiblemente esta tolerancia del feto en desarrollo al exceso o deficiencia del material presente en el cromosoma X, se debe, por lo menos en parte, a la presencia de mecanismos compensadores mediante los cuales dicho material puede ser o no inactivado (1).Las mujeres con síndrome de Turner presentan baja estatura, amenorrea primaria, tórax amplio, poco desarrollo mamario y además ovarios rudimentarios. Al nacer se destaca el edema de manos y pies, el cual desaparece durante la lactancia. No existe un retardo mental franco asociado con este síndrome, aunque hay evidencias de una disminución en la capacidad para interpretar las relaciones espaciales (2). Todas estas manifestaciones del síndrome tienen una estrecha relación con los hallazgos citogenéticos.El presente trabajo tiene como objetivo describir 4 pacientes atendidas en la Unidad de Genética Médica de la Facultad de Medicina de la Universidad de Antioquia, quienes presentan manifestaciones de Síndrome de Turner y un mosaicismo cromosómico que incluye líneas celulares con cromosoma X en anillo. Este tipo de alteración cromosómica es poco frecuente. Se discuten aspectos del cuadro clínico y los hallazgos citogenéticos en dichas pacientes.

One out of 400 to 500 living newborns show sex chromosome abnormalities. Usually, the clinic characteristics due to alteration of those chromosomes are less severe than those produced by autosomic imbalance. This tolerance of the developing fetus to the excess or deficit in the X chromosome material, may be due, at least in part, to the presence of compensatory mechanisms related with the inactivation or not of the genetic material. Turner's syndrome is characterized by short staFture, primary amenorrea, streak gonads and poor development of secondary sexual characteristics. At birth lymphedema of the dorsal surface of the hands and feet is common, but usually it disappears during lactation. Mental retardation is not a finding of this syndrome, however space-form perceptional deficits are described. All these manifestations of the syndrome have a close relation with the cytogenetic findings. The purpose of this paper is to describe the clinical manifestations and an uncommon X ring chromosome mosaicism in patients with Turner syndrome-like characteristics tended in the Medical Genetics Unit of the Medical School ­ Antioquia University. Clinical and cytogenetics aspects in these patients are discussed

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En el período comprendido entre septiembre 1 de 1996 y octubre 1 de 1997, se recolectó para estudios morfológico y citogenético un total de 84 productos de aborto espontáneo del 1° y 2° trimestres de la gestación, en diferentes servicios de ginecoobstetricia de la ciudad de Medellín. Dieciséis de los 84 se descartaron por contaminación o ausencia de tejidos apropiados para el estudio. De los 68 productos restantes en 60 (88,2 por ciento) Se establecieron cultivos para estudio citogenético, los cuales fueron exitosos en 34 casos (56, 7 por ciento). Diecisiete de los anteriores (50 por ciento) mostraron un cariotipo anormal con las siguientes alteraciones cromosómicas: monosomía X, 10 (58,8 por ciento)mosaicismos 5 (29,4 por ciento), trisomías 1 (5,9 por ciento) y tetraploidía 1 (5,9 por ciento). En 21 de los 68 productos (30,9 por ciento) (3 embriones y 18 fetos) fue posible el estudio morfológico. Doce de éstos, (2 embriones y 10 fetos; 57, 1 por ciento) mostraron alteraciones morfológicas externas o internas. El presente estudio citogenético y morfológico en productos de aborto espontáneo con edad gestacional menor de 20 semanas es el primero que se informa en nuestro medio y sus resultados son similares a los obtenidos en otros reportes que aparecen en la literatura

Eighty tour spontaneous abortion products, with gestational age under 20 weeks, were collected in ditterent obstetric and gynecologic services trom Medellin-Colombia between September 1996 and October 1997; they were studied both morphologically and cytogenetically. Sixteen of those products were discarded because of contamination or absence of suitable tissues for the study In 60 of the remaining 68 products (88°/~) cultures for cytogenetic studies were establishedJ and they were succesful in 34 cases (56J7%). Seventeen of. these (50%) showed an abnormal karyotype with the following chromosomal anomalies: X monosomies 10 (58J8%), mosaicisms 5 (29,4%)J trisomies 1 (5,9%), and tetráploidy 1 (5J9%). From the 68 products, a morphologic study was performed in 21 cases (3 embryos and 18 fetuses). Twelve products (2 embryos and 10 fetuses; 57 J 1 %) had external and/or jnternal anomalies This study of spontaneous abortions with gestational age under 20 weeks is the first in our country, and its results are similar to those published from other centers.

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En este artículo se presentan algunos aspectos relacionados con el aborto espontáneo de etiología cromosómica, haciendo énfasis en los diversos tipos de alteraciones, su frecuencia, su expresión fenotípica y las técnicas modernas de diagnóstico citogenético

This article presents some important issues related with spon~neous abortion with chromosomal aberratiens. The diverse types of alterations along with their frequency, phenotypical expression and modern diagnostic techniques are discussed

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