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El modelo de Estado federal, posee múltiples diferencias sustanciales que le distinguen de otros modelos de Estado tradicionales, principalmente porque posee una estructura dual basada en la división del poder político, con la finalidad de dotar de mayor soberanía a los Estados que lo conforman, especialmente en lo que respecta al sistema electoral y su exclusividad legislativa. En este contexto, se destaca la cláusula de comercio, que, en su defecto, sí limita la autonomía de dichos Estados, en cuanto a las relaciones mercantiles, porque las somete a un control federal. Por lo cual, el objetivo del presente trabajo fue analizar la estructura dual del federalismo, especialmente con respecto de la cláusula de comercio, para poder determinar que la autonomía de los Estados, se ve supeditada a un control federal. La metodología que se empleó fue: Método deductivo, alcance descriptivo, a través de un enfoque cualitativo por ser de tipo post-positivista, por la interpretación hermenéutica de los documentos examinados. Se concluye que, la “commerce clause”, es un elemento caracterizador del federalismo, no obstante, constituye una limitación a la autonomía de los Estados Federados, puesto que somete las relaciones mercantiles a un control federal, por tal motivo, restringe el principio de soberanía.

Understanding adipocyte development, also known as adipogenesis, is crit- ical for improving metabolic health. Additionally, adipose tissue depot, sex, age, body-mass index, Type 2 diabetes status, and cell size are known to play important roles in adipogenesis. Here, two classes of unsupervised learning methods were used to investigate which of these phenotypes were most strongly associated with differences in omics data between human adipocytes. Data consisted of two omics data types, including RNA- Sequencing (RNA-Seq) and Adipocyte Profiling (AP), as well as nine pa- tient phenotypes: day, depot, sex, age, body-mass index, Type 2 diabetes status, mean cell area, cell area variance, and % small cells. Data was clustered with a systematic pipeline using either single-view learning or multi-view learning methods, where single-view learning was performed using Principal Component Analysis (PCA) and multi-view learning was performed using either Multi-Omics Factor Analysis (MOFA+) or Mul- tiple Canonical Correlation Analysis (MCCA). Chi-square permutation tests were used to test for association between K-Means clusters and phe- notype labels and an extra layer of FDR-Correction was performed to account for multiple testing across all clustering analyses. Day (RNA-Seq PCA P-Value = 0.0092; AP PCA P-Value = 0.4224; MOFA+ P-Value = 0.0078; MCCA P-Value = 0.0092) and depot (RNA-Seq PCA P-Value = 0.0352; AP PCA P-Value = 0.0736; MOFA+ P-Value = 0.0450; MCCA P-Value = 0.0092) were identified as the primary drivers of clustering. However, none of the other phenotypes drove clustering, potentially due to unbalanced clusters or reduced statistical power from stratification. This multi-omics analysis of adipogenesis demonstrates the power of unsuper- vised clustering methods for the generation of robust biological insights that are consistent with the current literature surrounding day and depot. Nonetheless, since neither single-view nor multi-view learning methods de- tected associations for any of the other phenotypes, the inclusion of more samples and more omics is preferred for future studies.

Vasopressin receptor-mediated vasoconstriction is considered to be involved in the pathogenesis of organ failure in acute-on-chronic liver failure (ACLF). We studied the association between six single nucleotide polymorphisms (SNPs) of the vasopressin 1a receptor gene and the development of organ failure in 826 patients admitted for acute decompensation of liver cirrhosis (n=641) or ACLF (n=185). No associations were found for SNPs with the presence of circulatory or renal failure. A C>T mutation in SNP rs7308855 and a T>A mutation in SNP rs7298346 showed an association with the presence of coagulation failure in the entire population (n=61, P=0.024 and 0.060, respectively) and in the subgroup of patients with ACLF (n=44, P=0.081 and 0.056, respectively). Genetic variation in the vasopressin 1a receptor was found not to be associated with circulatory or renal failure, but with the presence of coagulation failure in patients with acute decompensation of liver cirrhosis and ACLF.

Palatal fistula after the repair of cleft palate appears in 7.7-35% of patients. We present two cases of palatal fistula, detailing a multi-layer repair with an interpositional collagen graft.Patient 1: girl with a cleft palate operated using a Furlow technique. A reintervention was performed due to a Pittsburgh type III fistula. Patient 2: male with cleft palate operated using a Furlow technique. A reintervention was performed due to a type V fistula.We used a multilayer repair with a local rotational flap and the interposition of a collagen matrix between the nasal and oral layers. The suture was reinforced with a fibrin hemostatic adhesive. No recurrence of the fistula after 2 years.The three-layer closure is simple, safe, effective and avoids refistulizations. Interpositional grafts of a resorbable collagen membrane provide a "scaffold" for tissue growth, revascularization and epithelialization of the mucosa.La fístula palatina tras la reparación del paladar fisurado aparece en un 7,7-35% de pacientes. Presentamos dos casos de fístula palatina, detallando la técnica de reparación multicapa con injerto interposicional de colágeno.Paciente 1: niña con fisura de paladar blando, operada mediante técnica de Furlow. Se programa reintervención por fístula secundaria tipo III de Pittsburgh. Paciente 2: varón con fisura de paladar blando, operado mediante técnica de Furlow. Se programa reintervención por fístula secundaria tipo V.Reparación multicapa mediante flap rotacional y matriz de colágeno entre las capas nasal y oral. Refuerzo con adhesivo hemostático de fibrina. Ausencia de recidiva tras 2 años de seguimiento.El cierre en tres capas es sencillo y efectivo a la hora de evitar refistulizaciones. Los injertos interposicionales de membrana reabsorbible de colágeno proporcionan un “andamio” para el crecimiento de los tejidos, revascularización y epitelialización de la mucosa.

Systemic inflammation (SI) is involved in the pathogenesis of acute decompensation (AD) and acute-on-chronic liver failure (ACLF) in cirrhosis. In other diseases, SI activates tryptophan (Trp) degradation through the kynurenine pathway (KP), giving rise to metabolites that contribute to multiorgan/system damage and immunosuppression. In the current study, we aimed to characterize the KP in patients with cirrhosis, in whom this pathway is poorly known. The serum levels of Trp, key KP metabolites (kynurenine and kynurenic and quinolinic acids), and cytokines (SI markers) were measured at enrollment in 40 healthy subjects, 39 patients with compensated cirrhosis, 342 with AD (no ACLF) and 180 with ACLF, and repeated in 258 patients during the 28-day follow-up. Urine KP metabolites were measured in 50 patients with ACLF. Serum KP activity was normal in compensated cirrhosis, increased in AD and further increased in ACLF, in parallel with SI; it was remarkably higher in ACLF with kidney failure than in ACLF without kidney failure in the absence of differences in urine KP activity and fractional excretion of KP metabolites. The short-term course of AD and ACLF (worsening, improvement, stable) correlated closely with follow-up changes in serum KP activity. Among patients with AD at enrollment, those with the highest baseline KP activity developed ACLF during follow-up. Among patients who had ACLF at enrollment, those with immune suppression and the highest KP activity, both at baseline, developed nosocomial infections during follow-up. Finally, higher baseline KP activity independently predicted mortality in patients with AD and ACLF. Conclusion: Features of KP activation appear in patients with AD, culminate in patients with ACLF, and may be involved in the pathogenesis of ACLF, clinical course, and mortality., info:eu-repo/semantics/published

Background & Aims: Antibiotic resistance has been increasingly reported in patients with decompensated cirrhosis in single-center studies. Prospective investigations reporting broad epidemiological data are scarce. We aimed to analyze epidemiological changes in bacterial infections in patients with decompensated cirrhosis. Methods: This was a prospective evaluation of 2 series of patients hospitalized with decompensated cirrhosis. The Canonic series included 1,146 patients from Northern, Southern and Western Europe in 2011. Data on epidemiology, clinical characteristics of bacterial infections, microbiology and empirical antibiotic schedules were assessed. A second series of 883 patients from Eastern, Southern and Western Europe was investigated between 2017–2018. Results: A total of 455 patients developed 520 infections (39.7%) in the first series, with spontaneous bacterial peritonitis, urinary tract infections and pneumonia the most frequent infections. Nosocomial episodes predominated in this series. Nearly half of the infections were culture-positive, of which 29.2% were caused by multidrug-resistant organisms (MDROs). MDR strains were more frequently isolated in Northern and Western Europe. Extended-spectrum beta-lactamase-producing Enterobacteriaceae were the most frequent MDROs isolated in this series, although prevalence and type differed markedly among countries and centers. Antibiotic resistance was associated with poor prognosis and failure of antibiotic strategies, based on third-generation cephalosporins or quinolones. Nosocomial infection (odds ratio [OR] 2.74; p < 0.001), intensive care unit admission (OR 2.09; p = 0.02), and recent hospitalization (OR 1.93; p = 0.04) were identified as independent predictors of MDR infection. The prevalence of MDROs in the second series (392 infections/284 patients) was 23%; 38% in culture-positive infections. A mild increase in the rate of carbapenem-resistant Enterobacteriaceae was observed in this series. Conclusions: MDR bacterial infections constitute a prevalent, growing and complex healthcare problem in patients with decompensated cirrhosis and acute-on-chronic liver failure across Europe, negatively impacting on prognosis. Strategies aimed at preventing the spread of antibiotic resistance in cirrhosis should be urgently evaluated. Lay summary: Infections caused by bacteria resistant to the main antibiotic families are prevalent in patients with cirrhosis. This study demonstrates that this healthcare problem is increasing and extends through all European regions. Infections caused by these difficult to treat bacteria resolve less frequently and often cause the death of the patient. The type of resistant bacteria varies markedly among different hospitals., SCOPUS: ar.j, info:eu-repo/semantics/published