The Association of Insomnia and Stress on Cardiovascular Risk Factors during COVID-19 Confinement in the Mexican Population.

During the pandemic confinement, the WHO changed the term "social distancing" to "physical distancing", to help people deal with the lack of social contact. As a result, there was an increase in mental health problems, including insomnia and stress, with a negative impact on cardiovascular health. The objective of this research was to identify the association between insomnia and stress and cardiovascular risk (CVR) during the pandemic in a sample of the general population in Mexico; the participants were chosen using the non-probabilistic method. The data were obtained from an online questionnaire about medical histories focused on cardiovascular risk, according to the Official Mexican Standards and Regulations for patients' clinical records, NOM-004-SSA3-2012, along with an index for the severity of insomnia, measured with a seven-item guide, and an instrument to measure stress. The data were analyzed with descriptive statistics for several different variables: sociodemographics, stress, insomnia, and cardiovascular risk. Cardiovascular risk was compared to insomnia and stress variables, which led to statistically significant differences and correlations between the variables. Participants were divided into four groups with respect to CVR, from low to very high CVR. This research demonstrated that women were more susceptible to stress and cardiovascular risk. However, stress was a more major indicator of CVR than insomnia, but in the high and very high CVR groups, insomnia contributed along with stress; coping strategies reduced the risk in the high CVR group but did not function as expected with respect to reducing risk in the very high CVR group. These findings suggest that sleep patterns and mental health alterations present during the pandemic may persist even when the pandemic was declared as having ended and may contribute to increases in cardiovascular risk in the long-term.

An Acceptance and Commitment Training (ACT) Framework for Teaching Cultural Humility: A Guide for Translating ACT from a Therapeutic Context into a Medical Education Curriculum.

The objective of this project was to train future physicians to work effectively and thoughtfully with diverse populations by teaching them to employ Acceptance and Commitment Training (ACT) skills to increase cultural humility, with the goal of improving attitudes, knowledge, and beliefs about working with diverse patients. We developed ACT for cultural humility online interactive modules as part of an elective course to teach Medical Spanish to 4th-year medical students. Pre- and post-pilot data pertaining to the cultural humility training modules on the Work-Related Acceptance and Action questionnaire, Multidimensional Cultural Humility Scale, knowledge, attitudes, and beliefs were analyzed using paired samples t-tests and Wilcoxon signed-rank tests. We also included descriptive data pertaining to overall satisfaction with the cultural humility modules and intent to apply the material learned to patient care. Our data showed a significant increase in the cultural humility of our participants as well as an increase in psychological flexibility, a higher favorability rating toward various ethnicities, improvements in attitude, and positive changes in beliefs and knowledge following completion of the modules. The modules were well received by the medical students, with high social validity ratings. The ACT for cultural humility curriculum has great potential to enhance medical education in diversity, equity, and inclusion by increasing both the understanding and the cultural humility of medical students and future professionals to work with diverse populations. The current paper provides a framework that can be used by other programs to shape the education of the future medical workforce to help promote culturally humble care.

Impact of SNR, peripheral auditory sensitivity, and central cognitive profile on the psychometric relation between pupillary response and speech performance in CI users.

Despite substantial technical advances and wider clinical use, cochlear implant (CI) users continue to report high and elevated listening effort especially under challenging noisy conditions. Among all the objective measures to quantify listening effort, pupillometry is one of the most widely used and robust physiological measures. Previous studies with normally hearing (NH) and hearing-impaired (HI) listeners have shown that the relation between speech performance in noise and listening effort (as measured by peak pupil dilation) is not linear and exhibits an inverted-U shape. However, it is unclear whether the same psychometric relation exists in CI users, and whether individual differences in auditory sensitivity and central cognitive capacity affect this relation. Therefore, we recruited 17 post-lingually deaf CI adults to perform speech-in-noise tasks from 0 to 20 dB SNR with a 4 dB step size. Simultaneously, their pupillary responses and self-reported subjective effort were recorded. To characterize top-down and bottom-up individual variabilities, a spectro-temporal modulation task and a set of cognitive abilities were measured. Clinical word recognition in quiet and Quality of Life (QoL) were also collected. Results showed that at a group level, an inverted-U shape psychometric curve between task difficulty (SNR) and peak pupil dilation (PPD) was not observed. Individual shape of the psychometric curve was significantly associated with some individual factors: CI users with higher clinical word and speech-in-noise recognition showed a quadratic decrease of PPD over increasing SNRs; CI users with better non-verbal intelligence and lower QoL showed smaller average PPD. To summarize, individual differences in CI users had a significant impact on the psychometric relation between pupillary response and task difficulty, hence affecting the interpretation of pupillary response as listening effort (or engagement) at different task difficulty levels. Future research and clinical applications should further characterize the possible effects of individual factors (such as motivation or engagement) in modulating CI users' occurrence of 'tipping point' on their psychometric functions, and develop an individualized method for reliably quantifying listening effort using pupillometry.

Massive production of fibroin nano-fibrous biomaterial by turbulent co-flow.

Among the different polymers (proteins, polysaccharides, etc.) that make up natural fibers, fibroin is a protein produced by silk spinning animals, which have developed an optimized system for the conversion of a highly concentrated solution of this protein into high-performance solid fibers. This protein undergoes a self-assembly process in the silk glands that result from chemical gradients and by the application of mechanical stresses during the last step of the process. In the quest for a process that could mimic natural spinning at massive scales, we have discovered that turbulence offers a novel and promising solution: a turbulent liquid jet can be formed by a chemically green and simple coagulating liquid (a diluted solution of acetic acid in etanol) co-flowing with a concentrated solution of fibroin in water by the use of a Flow Blurring nebulizer. In this system, (a) the co-flowing coagulant liquid extracts water from the original protein solution and, simultaneously, (b) the self-assembled proteins are subjected to mechanical actions, including splitting and stretching. Given the non-negligible produced content with the size and appearance of natural silk, the stochastic distribution of those effects in our process should contain the range of natural ones found in animals. The resulting easily functionalizable and tunable one-step material is 100% biocompatible, and our method a perfect candidate to large-scale, low-cost, green and sustainable processing of fibroin for fibres and textiles.

A Delayed Diagnosis of Autism Spectrum Disorder in the Setting of Complex Attention Deficit Hyperactivity Disorder.

Autism spectrum disorder (ASD) presents a diagnostic challenge due to its highly heterogeneous nature. The most common clinical manifestations include difficulty with social interaction and the presence of repetitive sensory-motor behaviors. Females are more likely to be misdiagnosed or have a delayed diagnosis compared to males. Other factors that contribute to delayed diagnosis include low socioeconomic status and belonging to an ethnic minority. In pediatrics, the goal of ASD screening is to diagnose ASD earlier, with timely referral to early intervention services, so that better long-term neurodevelopmental outcomes can be achieved. Moreover, attention deficit hyperactivity disorder (ADHD) is the most common comorbidity in patients with ASD. While the Diagnostic and Statistical Manual of Mental Disorders fourth edition (DSM-4) prohibited a co-diagnosis of autism and ADHD, the DSM-5 has modified exclusion criteria to allow such. This case describes a minority adolescent male patient who presented initially with complex ADHD, who upon extensive evaluation, was ultimately diagnosed with co-existing autism. This patient's diagnosis of ASD at the age of 14 in the setting of a pre-existing complex ADHD diagnosis demonstrates how symptoms of inattention or hyperactivity may convolute underlying or newly emerging social interaction difficulties. We highlight how children who are diagnosed with ADHD should be screened or evaluated for autism in the right clinical setting, such as evident persistence of social interaction impairment despite ADHD treatment.

Delayed Diagnosis of Osteogenesis Imperfecta: A Differential Diagnosis Guided by Competing Ocular Findings and a Lack of Family History.

Osteogenesis imperfecta (OI) is an inherited connective tissue disorder with variable clinical manifestations involving many structures and organ systems, leading to characteristic presentations such as low bone mineral density (BMD), vertebral compression fractures, hearing loss, and blue sclerae. Even within the same family, individuals with the same inherited genotype may have differential presentations due to variable expressivity. Early diagnosis of OI in the pediatric population may allow for earlier treatment and interprofessional interventions. This case describes a minority female infant who initially presented with bilateral complexion-associated melanosis (CAM) inclusions in her eyes. The appearance of her inclusions was reminiscent of the blue sclera seen in OI; however, there was no clinical suspicion for OI on birth, developmental, and family histories. Her growth and development were unremarkable at all well-child checks until her three-year well-child check. It was then discovered that she suffered multiple long bone fractures due to low trauma, vertebral compression fractures, and kyphoscoliosis. Due to the occurrence of these fragility fractures, she was given a clinical diagnosis of osteoporosis with pending genetic testing for osteogenesis imperfecta. It was later discovered that there was, in fact, an extensive history of recurrent childhood fractures in the patient's brother, mother, and numerous maternal relatives. Our case demonstrates the greater need for certified medical interpretation services to obtain clear past medical and family history, especially in the face of language barriers and low health literacy, in conjunction with clinical findings, i.e., CAM, to guide the differential diagnosis and subsequent management appropriately.

Case of Treatment-Resistant Aggression in the Context of a Medically Underserved Community.

Aggression tends to decrease as a child matures and develops conflict resolution skills. However, aggression can persist if children are exposed to consistent negative stimuli, such as poor parenting and adverse childhood experiences (ACEs). Furthermore, aggression is commonplace in numerous psychiatric disorders, such as attention deficit hyperactivity disorder (ADHD) and oppositional defiant disorder. These negative stimuli and comorbid conditions could ultimately stunt a child's development during pivotal moments, leading to worsening aggressive behaviors, such as criminal activity. Behavioral interventions are imperative for individuals with these comorbid conditions and experiences. Our patient is an 11-year-old male with a pertinent past medical history of ADHD and disruptive mood dysregulation disorder (DMDD) on multiple psychotropic medications, who presented to the emergency department for the evaluation of homicidal ideation and suicidality. This also occurred with worsening aggressive behavior, demonstrated by his killing of family pets and subsequent threats to kill his family. The patient has had multiple emergency department visits for similar threats and has been admitted to numerous inpatient psychiatric facilities. Currently, the patient is being treated at an out-of-state inpatient psychiatric facility. Our patient's aggression most likely stems from his comorbid ADHD and DMDD, complicated by other factors, such as low socioeconomic status, limited access to mental health services, and living in a medically underserved community. Factors such as increasing primary care provider comfort in managing these conditions, especially in underserved communities where there are already shortages of mental health providers, could help address this issue. Furthermore, it is imperative to screen for other contributing factors, such as ACEs. This case also highlights the need for genetic testing as a part of the medical workup in psychiatric cases that display psychotropic medication resistance. However, genetic testing is something that is not readily available in our state and is not covered by Medicaid. Early treatment of mental health conditions can prevent social difficulties later in life. With aggression, providing appropriate interventions is key to preventing an individual from engaging in harmful activities. It is important to screen for ACEs in order to address well-known aggravating factors. Underserved populations also face a myriad of challenges that prevent them from accessing healthcare services. There are numerous problems contributing to this disparity, ranging from lack of adequate mental health services to lack of access. Accordingly, it is imperative that primary care physicians and providers practicing in underserved areas receive the training necessary to recognize and treat mental health conditions. Furthermore, physicians should be able to focus on psychosocial stressors that contribute to these mental health conditions and provide the resources necessary to address these factors.

A Case of Ophthalmoplegia, Hypotonia, and Developmental Delay in the Setting of Corpus Callosum Hypoplasia.

Anomalies of the corpus callosum, including complete agenesis, partial agenesis, and hypoplasia, are some of the most common brain malformations. Corpus callosum abnormalities are potentially syndromic, many of which have identifiable genetic etiologies. Patients affected with either syndromic or non-syndromic corpus callosum anomalies may also have associated ophthalmologic abnormalities. Some of the syndromes with corpus callosum malformations that also involve ophthalmologic findings include Aicardi syndrome, Mowat-Wilson syndrome, and Xia-Gibbs syndrome. This case report describes a patient with hypoplasia and possible dysgenesis of the corpus callosum noted on magnetic resonance imaging (MRI) who had several ophthalmologic findings, including ophthalmoplegia, strabismus, and nystagmus, associated with microcephaly, dysmorphic facial features, global developmental delay, hypotonia, and cryptorchidism. While several previously identified syndromes share similar clinical features with this patient, these findings may also represent an unidentified genetic syndrome, and the patient remains under evaluation for a genetic diagnosis. This report explores the differential for ophthalmologic abnormalities in the setting of corpus callosum hypoplasia.

Drenaje percutáneo de absceso hepático amibiano guiado por medio de ultrasonido. Resultados preliminares / Percutaneous drainage of amebic hepatic abscess by guided ultrasound. Preliminary results

El absceso hepático amibiano (AHA) es la más frecuente complicación extraintestinal de la amibiasis. A través del tiempo, su tratamiento ha sufrido algunos cambios, actualmente es a base de antiamibianos y en algunos casos el drenaje percutáneo. El objetivo de este trabajo es presentar nuestra experiencia en el tratamiento mediante el drenaje percutáneo, guiado por ultrasonido en pacientes con AHA. Se Incluyeron en este trabajo 170 pacientes que ingresaron al Servicio de Gastroenterología del Hospital General de Zona No 1 del Instituto Mexicano del Seguro Social, durante un periodo de ocho años (1990-1997), quienes reunieron de los siguientes criterios de inclusión: falla terapéutica clínica, AHA mayor a ocho centímetros por ultrasonido, de material netamente líquido, riesgo de ruptura, incapacidad prolongada sin datos de toxico-infección, ruta de drenaje accesible, disponibilidad de quirófano ante el riesgo de complicación, pruebas de coagulación normales. Dichos criterios se proponen a la comunidad médica. Se utilizó la técnica de Seldinger modificada.En 131 pacientes se realizó una sola punción, puesto que tenían absceso único, en 39 pacientes se requirió de una segunda evacuación por presentar dos abscesos, y en cuatro casos se requirió de una tercera evacuación, puesto que existía la presencia de tres abscesos o más y sólo en un caso se requirió procedimiento quirúrgico urgente por ruptura de absceso residual a pleural; sufrieron complicaciones solamente cinco pacientes, incluyéndose este último, los otros cuatro tuvieron resolución espontánea de sus complicaciones. Los pacientes fueron egresados a las 24 h ulteriores al procedimiento y ningún paciente requirió rehospitalización, por lo que se considera que es un procedimiento que en manos expertas de radiólogos intervencionistas, tiene cada vez menor morbilidad y mortalidad. Se pretende llevar este trabajo a 10 años