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This ultrasound-guided erector spinae plane (ESP) nerve block model is designed to instruct emergency medicine (EM) attending and resident physicians. However, this innovation is appropriate for all levels of learners, including medical students, advanced practice clinicians (APCs), and clinicians in other medical specialties. The ESP nerve block is a relatively new regional anesthesia technique that involves injection of local anesthetic along the fascial plane below the erector spinae muscles.1-3 The ESP nerve block was first described in 2016 by Forero et al. to help manage severe thoracic neuropathic pain resulting from malunion of multiple rib fractures and metastatic disease of the ribs.1 The block has since emerged as a safe, feasible and effective analgesic intervention for various pathologies, including management of pain for acute rib fractures.2,3 However, barriers to implementation into routine practice in the emergency department (ED) exist due to gaps in knowledge about the block and a lack of training.4 We created a novel, inexpensive, and portable ultrasound-guided ESP nerve block model that can be used to facilitate training for EM physicians and residents. This innovation model is designed to facilitate hands-on training of the ultrasound-guided ESP nerve block using a practical, realistic, and cost-effective ballistics gel model. By the end of this training session, learners should be able to: 1) identify relevant sonoanatomy on the created simulation model; 2) demonstrate proper in-plane technique; and 3) successfully replicate the procedure on a different target on the created training model. We created a cost-effective ESP nerve block model using a 3-D printed spine and ribcage suspended in ballistics gel that is compatible with ultrasound. The use of ballistics gelatin in the model closely simulates the viscosity and density of animal tissue, allows for ultrasound use, and is cost-efficient and more feasible than other organic models because it can be easily melted and re-used.5 At the time of this model's creation, the only previous approach to creating an ESP model was a porcine model that used meat cuts from the lower thoracic region and spine. However, the major limitation of this porcine model was its limited shelf life.6 The created ESP model was incorporated into a hands-on training module that took place one to two times per week over two months. Additional sessions were incorporated on a case-by-case basis. All participants were first given access to an educational ESP Nerve Block PowerPoint presentation to be reviewed prior to attending in-person sessions. The training sessions were promoted through weekly email reminders containing the dates and a link to an online sign-up sheet. Additionally, on training days, our project director actively sought to recruit available participants on-shift. Each training day, a one-to-two-hour window was made available for participants to attend. Each training session was conducted with a small group of four or fewer trainees beginning with a short didactic lecture presented by a lead instructor, either the Associate Research Director of Emergency Medicine or the Medical Director for Division of Pain Medicine, followed by live demonstration of the nerve block using the ESP model. Participants were then given the opportunity to practice on the ESP model. Sessions ended when all participants demonstrated proper and successful technique with the model, reported adequate confidence with the block, and all questions were addressed. Feedback on technique was provided throughout the training session by the lead instructor. Post-education surveys were distributed to all participants electronically to assess training impact. The survey collected data on the participants' title, prior experience performing ESP nerve blocks, competency of the teaching model, and their comfort with performing the block after the training. The Institutional Review Board (IRB) reviewed and deemed this project exempt from full board review. Thirty-four participants attended the in-person training sessions, consisting mainly of EM attending (16/34; 47%) and resident (13/34; 38%) physicians. Fourteen (14/34; 41%) participants returned completed surveys, of which 50% were residents (7/14; 50%) and 50% attending physicians (7/14; 50%). The majority (12/14; 86%) of respondents reported no prior experience in performing an ESP block with only 14% (2/14; 14%) reporting performing fewer than two ESP nerve blocks per year. All respondents (14/14; 100%) agreed or strongly agreed that the education session with the ESP model improved their confidence, knowledge, and skills to perform the block. All (14/14; 100%) agreed or strongly agreed that they felt confident in their ability to use ultrasound to identify landmarks on the model pertinent to performing the ESP block. All (14/14; 100%) reported that they felt that the material presented during these training sessions was relevant to their practice in the ED, within their scope of practice, and part of their job as an ED physician. All (14/14; 100%) reported they felt performing ESP blocks in the ED could positively impact patient outcomes and reported an increased likelihood of performing the ESP block in the ED following this training session. Lastly, respondents were asked to list any barriers that might inhibit them from performing the ESP block on shift, in addition to any strategies to facilitate ESP block use. Four participants (4/14; 29%) reported barriers to performing an ESP block including time constraints (50%) and patient mobility limitations (50%). Twelve participants (12/14; 86%) reported facilitators to performing ESP blocks, the most common of which being easier access to supplies and assistance with procedure setup (43%), followed by increased education sessions (21%). Our survey results indicate that our learners perceived an increase in knowledge, confidence, and skills in performing ultrasound-guided ESP blocks after using our innovative model as a hands-on teaching tool during a training session. A simple 30-minute training session with a novel ballistics gelatin ESP model can improve confidence, knowledge, and skills in performing this block in the ED, even amongst nerve block naive physicians. Additionally, by identifying barriers to the use of the ESP block in the ED, researchers can create strategies to mitigate these challenges to increase utilization of these procedures for appropriate patients in the ED. These strategies include but are not limited to addressing ways to mitigate time constraint issues, patient mobility limitations, access to supplies, assistance with procedure set up, and increasing education sessions to increase physician comfort with successful completion of the procedure. Erector spinae plane nerve block, ultrasound, regional anesthesia, rib fractures, ballistics gel model, hands-on training.

The early and precise identification of the different phenological stages of the bean (Phaseolus vulgaris L.) allows for the determination of critical and timely moments for the implementation of certain agricultural activities that contribute in a significant manner to the output and quality of the harvest, as well as the necessary actions to prevent and control possible damage caused by plagues and diseases. Overall, the standard procedure for phenological identification is conducted by the farmer. This can lead to the possibility of overlooking important findings during the phenological development of the plant, which could result in the appearance of plagues and diseases. In recent years, deep learning (DL) methods have been used to analyze crop behavior and minimize risk in agricultural decision making. One of the most used DL methods in image processing is the convolutional neural network (CNN) due to its high capacity for learning relevant features and recognizing objects in images. In this article, a transfer learning approach and a data augmentation method were applied. A station equipped with RGB cameras was used to gather data from images during the complete phenological cycle of the bean. The information gathered was used to create a set of data to evaluate the performance of each of the four proposed network models: AlexNet, VGG19, SqueezeNet, and GoogleNet. The metrics used were accuracy, precision, sensitivity, specificity, and F1-Score. The results of the best architecture obtained in the validation were those of GoogleNet, which obtained 96.71% accuracy, 96.81% precision, 95.77% sensitivity, 98.73% specificity, and 96.25% F1-Score.

Toxoplasma gondii  infection can trigger autoreactivity by different mechanisms. In the case of ocular toxoplasmosis, disruption of the blood-retinal barrier may cause exposure of confined retinal antigens such as recoverin. Besides, cross-reactivity can be induced by molecular mimicry of parasite antigens like HSP70, which shares 76% identity with the human ortholog. Autoreactivity can be a determining factor of clinical manifestations in the eye and in the central nervous system. We performed a prospective observational study to determine the presence of autoantibodies against recoverin and HSP70 by indirect ELISA in the serum of 65 patients with ocular, neuro-ophthalmic and congenital cerebral toxoplasmosis. We found systemic autoantibodies against recoverin and HSP70 in 33.8% and 15.6% of individuals, respectively. The presence of autoantibodies in cases of OT may be related to the severity of clinical manifestations, while in cases with CNS involvement they may have a protective role. Unexpectedly, anti-recoverin antibodies were found in patients with cerebral involvement, without ocular toxoplasmosis; therefore, we analyzed and proved cross-reactivity between recoverin and a brain antigen, hippocalcin, so the immunological phenomenon occurring in one immune-privileged organ (e.g. the central nervous system) could affect the environment of another (egg. the eye).

The classification of carbapenemases can help guide therapy. The present study evaluated the performance of the CPO detection test, included in the BD Phoenix™ NMIC-501 panel for the detection and classification of carbapenemases on the representative molecularly characterized strains collection from Mexico. Carbapenem non-susceptible isolates collected in Mexico were included. The clinical isolates (n = 484) comprised Klebsiella pneumoniae (n = 154), Escherichia coli (n = 150), and P. aeruginosa (n = 180). BD Phoenix CPO NMIC-504 and NMIC-501 panels were used for the identification of species, antimicrobial susceptibility tests, and detection of CPOs. For the detection of carbapenemase-encoding genes, E. coli and K. pneumoniae were evaluated using PCR assays for blaNDM-1, blaKPC, blaVIM, blaIMP, and blaOXA-48-like. For P. aeruginosa, blaVIM, blaIMP, and blaGES were detected using PCR. Regarding E. coli, the CPO panels had a sensitivity of 70% and specificity of 83.33% for the detection of a class B carbapenemase (blaNDM in the molecular test). Regarding K. pneumoniae, the panels had a sensitivity of 75% and specificity of 100% for the detection of a class A carbapenemase (blaKPC in the molecular test). The Phoenix NMIC-501 panels are reliable for detecting class B carbapenemases in E. coli. The carbapenemase classification in K. pneumoniae for class A carbapenemases has a high specificity and PPV; thus, a positive result is of high value.

We analyzed the antimicrobial resistance (AMR) data of 6519 clinical isolates of Escherichia coli (n = 3985), Klebsiella pneumoniae (n = 775), Acinetobacter baumannii (n = 163), Pseudomonas aeruginosa (n = 781), Enterococcus faecium (n = 124), and Staphylococcus aureus (n = 691) from 43 centers in Mexico. AMR assays were performed using commercial microdilution systems (37/43) and the disk diffusion susceptibility method (6/43). The presence of carbapenemase-encoding genes was assessed using PCR. Data from centers regarding site of care, patient age, and clinical specimen were collected. According to the site of care, the highest AMR was observed in E. coli, K. pneumoniae, and P. aeruginosa isolates from ICU patients. In contrast, in A. baumannii, higher AMR was observed in isolates from hospitalized non-ICU patients. According to age group, the highest AMR was observed in the ≥60 years age group for E. coli, E. faecium, and S. aureus, and in the 19–59 years age group for A. baumannii and P. aeruginosa. According to clinical specimen type, a higher AMR was observed in E. coli, K. pneumoniae, and P. aeruginosa isolates from blood specimens. The most frequently detected carbapenemase-encoding gene in E. coli was blaNDM (84%).

The classification of carbapenemases can help guide therapy. The present study evaluated the performance of the CPO detection test, included in the BD Phoenix[sup.™] NMIC-501 panel for the detection and classification of carbapenemases on the representative molecularly characterized strains collection from Mexico. Carbapenem non-susceptible isolates collected in Mexico were included. The clinical isolates (n = 484) comprised Klebsiella pneumoniae (n = 154), Escherichia coli (n = 150), and P. aeruginosa (n = 180). BD Phoenix CPO NMIC-504 and NMIC-501 panels were used for the identification of species, antimicrobial susceptibility tests, and detection of CPOs. For the detection of carbapenemase-encoding genes, E. coli and K. pneumoniae were evaluated using PCR assays for bla[sub.NDM-1], bla[sub.KPC], bla[sub.VIM], bla[sub.IMP], and bla[sub.OXA-48-like]. For P. aeruginosa, blaVIM, blaIMP, and blaGES were detected using PCR. Regarding E. coli, the CPO panels had a sensitivity of 70% and specificity of 83.33% for the detection of a class B carbapenemase (bla[sub.NDM] in the molecular test). Regarding K. pneumoniae, the panels had a sensitivity of 75% and specificity of 100% for the detection of a class A carbapenemase (bla[sub.KPC] in the molecular test). The Phoenix NMIC-501 panels are reliable for detecting class B carbapenemases in E. coli. The carbapenemase classification in K. pneumoniae for class A carbapenemases has a high specificity and PPV; thus, a positive result is of high value.

Background Fanconi syndrome and diabetes insipidus are rare adverse effects of ifosfamide. They usually present with high cumulative doses of this medication. They are mainly related to type II proximal renal tubular dysfunction. These complications typically present with severe polydipsia and polyuria accompanied by glycosuria, proteinuria, and some electrolyte abnormalities including hypokalemia, hypophosphataemia, and non-anion gap metabolic acidosis. Clinical case: A 15-year-old male with, a diagnosis of metastatic osteoblastic osteosarcoma in the right distal treated with ifosfamide three years prior to this hospitalization, was admitted to the emergency department complaining of 3 episodes of vomiting, 6 days history of increase volume of the right lower limb and fever. On admission, blood pressure of 80/50 mm Hg, heart rate of 110 beats / minute, respiratory rate of 30 breaths / minute, axillary temperature of 38.3 ° C. It was evident phlogosis at level of the proximal third of the right lower limb. CBC revealed pancytopenia (WBC 5 x10 9 L, Hb 6.8 g/dL, platelets 25×10 3 /mm 3) and ABG and CMP were compatible with mild metabolic acidosis normal AG (pH 7.285, K 1.9 meq / L, Na 156 meq / L, lactate: 0.9 meq / L, HCO3: 17 meq / L). A diagnosis of sepsis was made and the patient was started on meropenem 2g IV every 8 hours, vancomycin 1 g IV every 12 hours, filgastrim 120 ug/daily and one unit of packed RBC. Patient improved after 5 days over the course of his hospitalization. However, on the 18 th day after his hospital admission, he developed a new episode of polyuria, associated with hypocalcemia (7 mg/dL), hypokalemia (2 mEq/L), hypomagnesemia (0.95 mg/dL), hypophosphatemia (0.9 mg/dL) and metabolic acidosis (pH 7.2, bicarbonate 15 mEq/L). Urine analysis revealed glucosuria and proteinuria. Desmopressin test did not showed increase urinary osmolarity thus nephrogenic diabetes insipidus and Fanconi syndrome were diagnosed due to the multiple laboratory abnormalities and sign/symptoms. Patient received electrolyte replacement and ifosfamide was stopped from his chemotherapy regimen. After this, patient recovers and he was discharge at 25 th day of his admission. Conclusion : Ifosfamide causes tubular cell dysfunction leading to both nephrogenic diabetes insipidus and Fanconi syndrome. These complications might event present several years after receiving this chemotherapeutic agent. Full electrolyte repletion and hydration are the gold standard for management The present case report emphasizes the importance of the prevention of nephrotoxicity associated with ifosfamide, since its presentation could increase poor outcomes in patients receiving chemotherapy regimens that include ifosfamide. Presentation: No date and time listed