PACS and Photoshop assisted isosceles triangle osteotomy and Kirschner wire tension buckle fixation in the treatment of cubitus varus in children / 中国骨伤

OBJECTIVE@#To investigate the clinical efficacy of picture archiving and communication system (PACS) and Photoshop assisted isosceles triangle osteotomy and Kirschner wire fixation with tension band in the treatment of cubitus varus in children.@*METHODS@#The clinic data of 20 children with cubitus varus treated with isosceles triangle osteotomy of distal humerus and Kirschner wire fixation with tension band from October 2014 to October 2019, were retrospectively analyzed. There were 13 males and 7 females, aged from 3.2 to 13.5 years old, the median age was 6.65 years old. PACS system was applied for the osteotomy design preoperatively, simulating and measuring the side length of isosceles triangle osteotomy. Then, Photoshop system was used to simulate the preoperative and postoperative osteotomy graphics, which could guide precise osteotomy during operation.@*RESULTS@#All the 20 patients were followed up for 20 to 24 months, with a median of 22.5 months. At the last follow-up, the carrying angle of the affected limb was 5 ° to 13 °, with a median of 8.3 °. The clinical efficacy was evaluated according to the Flynn elbow function score:excellent in 16 cases, good in 2 cases, and fair in 2 cases.@*CONCLUSION@#The treatment of cubitus varus in children by isosceles triangle osteotomy and Kirschner wire fixation with tension band assisted by PACS and Photoshop system has shown good clinical outcome.

Application of LEARNS model based on Triangle stratified model on the management of out-patients with type 2 diabetes mellitus / 中国实用护理杂志

Objective:To analyze the effects of stratified follow-up intervention combined with LEARNS model on self-management, glucose metabolism, compliance and satisfaction in patients with type 2 diabetes mellitus (T2DM).Methods:This study was a quasi-experimental study. A total of 212 patients with T2DM who visited the DM nursing clinic of Beijing Tiantan Hospital, Capital Medical University from June 2020 to May 2021 were selected and divided into control group (102 cases) and intervention group (110 cases) according to the treatment time. All the patients received the conventional medical treatment and health education guidance for 6 months, at the same time, the intervention group received management of the triangle stratified model combined with LEARNS mode. The glucose metabolism, self-management behavior, satisfaction and compliance were compared before and after the intervention.Results:Before the intervention, the baseline data of the 2 groups had no significant difference(all P>0.05) and were comparable. Three and six months after the intervention, the HbA1c values of the intervention group were (6.18 ± 0.57)% and (6.40 ± 0.47)%, which were significant better than those in the control group, (6.74 ± 0.90)% and (6.99 ± 0.91)%, the differences were significant ( t=8.05 and 9.12, both P<0.01). Three and six months after the intervention, the SDASC values in the intervention group were (46.51 ± 5.80) and (44.41 ± 5.61), which were higher than those in the control group, (43.45 ± 4.20) and (42.08 ± 3.67), the difference were significant ( t=6.56 and 5.32, both P<0.01). Three and six months after the intervention, the compliance and patient satisfaction of intervention group were better than those in the control group ( χ2=5.52 and 7.26, t=7.02 and 15.75, all P<0.05). Conclusions:Triangle hierarchical management combined with LEARNS model can effectively improve the blood glucose levels of T2DM patients as well as their self-management levels, satisfaction and compliance, which can help nurses reasonably allocate follow-up time.

Effect of Triangle hierarchical management among community patients with hypertension / 预防医学

Objective@#To evaluate the effect of Triangle hierarchical management among community patients with hypertension, so as to provide insights into the improvements of standardized hypertension management.@*Methods@#Patients with newly diagnosed hypertension from 2 community health service centers in Qiantang District of Hangzhou City by the end of 2020 were randomly assigned to the conventional group and the Triangle group. Patients in the conventional group were given health management services according to the requirements of basic public health service standard for one year, while patients in the Triangle group were given Triangle hierarchical management. The blood pressure, self-management behaviors, treatment compliance, smoking, alcohol consumption and exercise were collected using the self-management behavior scale, treatment compliance scale and self-designed questionnaires, and were compared before and after intervention with analysis of covariance and generalized estimation equations.@*Results@#Totally 200 patients with hypertension were recruited, including 100 patients in the conventional group and 100 patients in the Triangle group. There were no significant differences between the two groups before implementation of interventions in terms of gender, age, educational level or occupation (P>0.05). The reduction in blood pressure, increase in the score of treatment, diet, exercise and living habitat management and the total score of self-management behaviors, increase in the score of adherence to medication regimens, daily living management behaviors, smoking and alcohol consumption preference and the total score of treatment compliance, and increase in the number of patients with normal standard of quitting smoking, quitting alcohol consumption, exercise and blood pressure were significantly higher in the Triangle group than in the conventional group after intervention (P<0.05). @*Conclusions @#Triangle hierarchical management may increase the treatment compliance, improve the self-management behavior and facilitate hypertension control among hypertensive patients, which may be popularized for health management among community patients with hypertension.

Guía de valoración pediátrica de urgencias en Cuba / Guide of pediatric emergency assessment in Cuba

La valoración pediátrica de urgencias tiene características especiales respecto al resto de la atención pediátrica. El diagnóstico final será una prioridad secundaria. Es una evaluación clínica, cuyo intento principal es la identificación de aspectos anatómicos y fisiológicos anormales, la estimación de la gravedad de la enfermedad o lesión y la determinación de la necesidad de tratamiento urgente. El objetivo de esta colaboración es brindar una sistemática clara, con una secuencia de valoraciones y acciones que sirvan de base para la toma de decisiones clínicas orientadas a la estabilización del paciente y a evitar situaciones que pueden amenazar la vida en poco tiempo. El triángulo de evaluación pediátrica, la secuencia ABCDE, una breve anamnesis y examen enfocado que identifique el motivo de consulta de mayor prioridad, signos de alarma que pueden cambiar la prioridad y las reevaluaciones frecuentes serán los pilares de la actuación médica. Con el propósito de respetar el derecho del niño al disfrute del más alto nivel posible de salud, de garantizar la calidad asistencial y la seguridad de los pacientes pediátricos con entidades agudas o traumatismos, el grupo nacional de pediatría desarrolló y aprobó la guía de valoración pediátrica de urgencias en Cuba. Mediante la aplicación de esta guía se puede optimizar el proceso de valoración pediátrica de urgencias de forma que los pacientes de este segmento de edad reciban el nivel de cuidados médicos más apropiado para su situación clínica(AU)

The pediatric emergency assessment has special characteristics with respect to the rest of pediatric care. The final diagnosis will be a secondary priority. It is a clinical evaluation, and the main purpose of it is the identification of abnormal anatomical and physiological aspects, the estimation of the severity of the disease or injury and the determination of the need for urgent treatment. The objective of this collaboration is to provide a clear system, with a sequence of assessments and actions that serve as a basis for clinical decision-making aimed at stabilizing the patient and avoiding life-threatening situations in a short time. The pediatric assessment triangle, the ABCDE sequence, a brief history and focused examination that identifies the highest priority reason for consultation, warning signs that may change priority and frequent re-evaluations will be the pillars of medical action. To respect the right of the child to have access to the highest possible level of health, to guarantee the quality of care and its safety in the face of acute conditions or trauma, the National Group of Pediatrics developed and approved the guide for pediatric emergency assessment in Cuba. Through its application, the pediatric emergency evaluation process can be optimized so that patients of this age segment receive the most appropriate level of medical care for their clinical situation(AU)

RECOGNIZING THE INDICATORS OF FRAUDS BY TRACING THE ELEMENTS OF FRAUD TRIANGLE AND ITS DETERRENCE

The present paper endeavors to throw light on the factors that stimulates an individual to commit fraud in the light of the fraud triangle theory. Based on the existing theories and literature, an attempt has been made to recognize the red-?ags of fraud risk related to an individual's behavioral approach. The paper further suggests that of the other elements, a check on the Opportunity vertex of the triangle can control the intensity of the fraud. It also highlights the applicability of SAS-99 and COSO framework for deterring fraud constituents from the system

Effect of local infiltration of ropivacaine in gallbladder triangle on agitation and postoperative pain in patients undergoing laparoscopic cholecystectomy / 中国医师杂志

Objective:To study the effect of local infiltration of ropivacaine in gallbladder triangle on agitation and postoperative pain in patients undergoing laparoscopic cholecystectomy (LC).Methods:108 patients with LC who met the requirements of this study treated in Yunnan Cancer Hospital from March 2018 to March 2021 were randomly divided into two groups, 54 cases in each group. Both groups received routine LC under general anesthesia. The observation group received ropivacaine for local infiltration in the gallbladder triangle, and the control group received the same amount of normal saline for local infiltration in the gallbladder triangle. The anesthesia indexes, agitation during awakening and postoperative pain were compared between the two groups.Results:There was no significant difference in extubation, anesthesia and recovery time between the observation group and the control group (all P>0.05); The scores of static and dynamic visual analogue scale (VAS) in the two groups reached the highest value at 6 h after operation, and then decreased gradually, with significant differences between the two groups ( F=15.28, 4.26, 11.06, 3.21, all P<0.05). The dynamic and static VAS scores of the observation group were lower than those of the control group at the time of awakening, 6 h, 12 h and 24 h after operation, with statistically significant difference (all P<0.05). Compared with the control group, the Riker sedation agitation score (SAS) and the incidence of agitation in the observation group were significantly lower (all P<0.05), and the effective times of analgesic pump pressing 24 hours after operation were significantly less ( P<0.05); There was no significant difference in SpO 2 level between the observation group and the control group ( P>0.05); The levels of heart rate (HR) and mean arterial pressure (MAP) in the two groups were significantly higher than those before anesthesia, and the rising degree in the observation group was significantly lower than that in the control group (all P<0.05); The levels of norepinephrine (NE), C-reactive protein (CRP) and cortisol in the two groups were significantly higher than those before anesthesia, and the rising degree in the observation group was significantly lower than that in the control group (all P<0.05). Conclusions:Local infiltration of gallbladder triangle with ropivacaine during LC can reduce the degree of postoperative pain, the use of PCIA pump and the occurrence of agitation during awakening, so as to maintain hemodynamic stability.

Incomplete petrosphenoidal foramen: morphological and morphometric analysis and the proposal of a classification study in Brazilian dry skulls / Foramen petrosfenoidal incompleto: análisis morfológico y morfométrico y propuesta de clasificación: estudio en cráneos secos brasileños

SUMMARY: The complete petrosphenoidal foramen, or canal, is an eventual and atavistic bony formation at the boundary between the posterior and middle cranial fossa, by occurrence of ossification of the superior petrosphenoidal ligament. This ligament ossification, which has important clinical and surgical significance, can be complete or incomplete, in variable degrees, and is associated with the passageway of neurovascular structures, such as the abducens nerve and the inferior petrosal sinus. This study, conducted with 175 dry skulls that belong to the University of São Paulo's collection (USP), São Paulo, Brazil, established criteria for a morphological classification of the incomplete petrosphenoid foramen in nine types. In addition, anatomical parameters were established for the morphometric determination of two diameters: the Oblique Diameter (ObDi) and the Maximum Transverse Diameter (MTD). Thus, of the 175 skulls, 146 (83.42 %) presented some of the incomplete forms of the petrosphenoid foramen, and 43 skulls (29.45 %), due to their conservation characteristics, were habilitated to the morphological study, in the classification and in the morphometry (the types I and II of our classification). The type II (incomplete foramen with bony projections of the petrosal tubercle, of the margin of the dorsum of the hypophyseal fossa or of the posterior clinoid process with a distance between them greater than 1mm) and type V (incomplete foramen with a bony projection only in one of the referential structures - posterior clinoid process) were the most common in this study (50 % of the 86 hemiskulls). Morphometry was attributed only to the types: I selar (incomplete foramen with bony projections from the petrosal tubercle and the margin of the dorsum of the hypophyseal fossa with a distance between them less than or equal to 1mm) and to the type II of this classification. The type I selar (9.3 % of the 43 skulls) resulted in an average of 3.25 mm of MTD and 4.63 mm, on average, of ObDi. The type II (25.58 % of the 43 skulls) showed, on average, 4.93 mm of MTD and 7.01 mm of ObDi.

RESUMEN: El foramen o canal petroesfenoidal completo es una formación ósea eventual y atávica en el límite entre las fosas craneal posterior y media, por osificación del ligamento petroesfenoidal superior. Esta osificación del ligamento, que tiene un importante significado clínico y quirúrgico, puede ser completa o incompleta, en grados variables, y está asociada al paso de estructuras neurovasculares, como el nervio abducente y el seno petroso inferior. Este estudio se realizó en 175 cráneos secos pertenecientes a la colección de la Universidad de São Paulo (USP), São Paulo, Brasil. Se establecieron criterios para una clasificación morfológica del foramen petrosfenoidal incompleto en nueve tipos. Además, se establecieron parámetros anatómicos para la determinación morfométrica de dos diámetros: el Diámetro Oblicuo (ObDi) y el Diámetro Transversal Máximo (MTD). Así, de los 175 cráneos, 146 (83,42 %) presentaron alguna de las formas incompletas del foramen petrosfenoidal, y 43 cráneos (29,45 %), por sus características de conservación, fueron habilitados para el estudio morfológico, en la clasificación y en la morfometría (los tipos I y II de nuestra clasificación). El Tipo II (foramen incompleto con proyecciones óseas del tubérculo petroso, del margen del dorso de la fosa hipofisaria o del proceso clinoides posterior con una distancia entre ellos mayor de 1 mm) y el Tipo V (foramen incompleto con proyección ósea solamente en una de las estructuras referenciales - proceso clinoides posterior) fueron los más comunes en este estudio (50 % de los 86 hemiscráneos). La morfometría se atribuyó únicamente al Tipo I selar (foramen incompleto con proyecciones óseas desde el tubérculo petroso y el margen del dorso de la fosa hipofisaria con una distancia entre ellos menor o igual a 1mm) y al Tipo II de esta clasificación. El Tipo I selar (9,3 % de los 43 cráneos) resultó en un promedio de 3,25 mm de MTD y 4,63 mm, en promedio, de ObDi. El Tipo II (25,58 % de los 43 cráneos) mostró, en promedio, 4,93 mm de MTD y 7,01 mm de ObDi.

Short-term outcome of Heidelberg triangle dissection in laparoscopic pancreaticoduodenectomy for pancreatic cancer / 中华胰腺病杂志

Objective:To investigate the short-term outcome of Heidelberg triangle dissection in laparoscopic pancreaticoduodenectomy (LPD) for pancreatic cancer.Methods:The clinical data of 84 patients with pancreatic head cancer who underwent LPD from July 2015 to September 2020 in the Department of Hepatobiliary and Pancreatic Surgery of the Cangzhou Central Hospital were retrospectively analyzed. According to the scope of surgical dissection, the patients were divided into the control group ( n=45) and the Heidelberg group ( n=39). In the control group, routine lymph node dissection was performed, and in the Heidelberg group, all blood vessels, lymphatic tissue and nerve tissue in the Heidelberg triangle area were dissected on the basis of routine lymph node dissection. Operation-related indicators (operation duration, intraoperative blood loss, cases of patients with intraoperative blood transfusion, fasting time and hospitalization duration after operation), postoperative complications (pancreatic fistula, biliary fistula, lymphatic fistula, bleeding and delayed gastric emptying) and postoperative pathological parameters (surgical margin, degree of differentiation, tumor size, cases of nerve invasion, number of dissected lymph nodes, lymph node metastasis and TNM stage) were compared between the two groups. Results:Compared with the control group, the operation time of the Heidelberg group was longer [ (334.85±24.95)min vs (305.09±24.54)min], theincidence of lymphatic fistula was higher (15.4% vs 2.2%), the rate of >1 mm at surgical margin was higher (76.9% vs 53.3%), and the total number of lymph nodes dissection was more [ (11.31±2.46) vs (9.49±2.28)]. All the differences between the two groups were statistically significant ( P<0.05). However, there were no significant differences on the intraoperative blood loss, cases of patients with intraoperative blood transfusion, postoperative hospital stay and fasting time, incidence of pancreatic fistula and biliary fistula, bleeding, delayed gastric emptying, degree of differentiation, tumor size, cases of nerve invasion, lymph node metastasis and TNM stage between the two groups. Conclusions:LPD combined with Heidelberg triangle dissection for pancreatic cancer was feasible and safe, which can increase the R 0 resection rate, remove more lymph nodes, reduce the local recurrence of pancreatic cancer and improve the prognosis of patients.

Application of autogenous cartilage transplantation in correction of nasal soft-tissue triangle deformities aided by 3D technology / 中华医学美学美容杂志

Objective:To evaluate the curative effect of autogenous cartilage transplantation in the correction of nasal soft-tissue triangle deformities aided by 3D technology.Methods:From January 2016 to January 2018, 32 patients with nasal soft-tissue triangle deformities were collected, with 7 males and 25 females, aged from 18 to 32 years (mean 28.5±6.8 years). A part of the costal cartilage/nasal septum cartilage or auricular cartilage was cut as repair material, which was carved into strips, and used as nasal alar rim grafts to reconstruct the dome shape and correct the nasal soft triangle deformities. The costal cartilage or nasal septum cartilage was used to strengthen the support of the columella nasi and augmentation rhinoplasty was performed with prosthesis, and the fascia was placed on nose tip to relieve tension. The surgical results were evaluated by comparing the pre- and post-operative images; statistical analysis was conducted to compare the difference of alar cartilage angle along inside and outside implants before and after the fornix reconstruction, and the difference of maximum distance from the nostrils long shaft to the nose flange between pre- and post-operation, and so the effect of nasal soft triangular deformity correction was evaluated.Results:The alar cartilage angle of the 32 patients was (51.5±10.9)° before surgery, and decreased to (37.2±5.9)° after surgery; the difference was statistically significant ( P<0.05). The maximum distance from the nostrils long shaft to the nose flange was (3.3±0.6) mm before surgery, and it reduced to (1.9±0.7) mm after surgery; the difference was statistically significant ( P<0.05). The patients were followed up for 6 to 18 months, and the result showed that the curative effect was significant, with good appearance and natural feeling, and there were no serious complications, and the satisfactory rate was 87.5%. Conclusions:Autogenous cartilage is used to repair nasal soft-tissue triangle deformities aided by 3D technology; the nasal morphology is improved delicately, and the postoperative satisfaction of curative effect is high, which is an ideal surgical method.

Essential palatal tremor: a case report and literature review / 中华神经科杂志

Essential palatal tremor is relatively rare in clinical practice, which manifests involuntary and rhythmic contraction of soft-palate along with auditory click. The cause is unknown and there is no specific treatment at present. This article reports a female patient with essential palatine tremor, who presented with involuntarily beating of soft palate, disappeared during sleep, had sensory tricks, and gradually developed mental and psychological problems such as anxiety disorders. After treatment with integrated traditional Chinese and Western medicine, the symptoms improved. The clinical features of the case were analyzed, relevant literature was reviewed, and the possible etiology and characteristics of the disease were explored, so as to provide reference for clinical diagnosis and treatment.

Colangiografía intraoperatoria: curva de aprendizaje en una Residencia de Cirugía General / Intraoperative cholangiography: Learning curve in a General Surgery residency

RESUMEN Antecedentes: el uso de la colangiografía intraoperatoria dinámica (CIOd) durante la colecistectomía laparoscópica (Colelap) sigue siendo un tema en discusión. Objetivos: Este trabajo tiene como objetivo describir y evaluar la curva de aprendizaje y los hallazgos en la CIOd durante las colecistectomías laparoscópicas realizadas por residentes de Cirugía General, incluyéndola como herramienta para una colecistectomía segura, así como entrenamiento para el de sarrollo de habilidades y destrezas. Material y métodos: se incluyeron pacientes con indicación de colecistectomía laparoscópica pro gramada o de urgencia. En las cirugías se realizó tracción según Hunter, visión crítica de seguridad y CIOd sistemática, por un residente mayor y la CIOd por un residente inferior, tutorizado por cirujano de planta. Se evaluaron curva de aprendizaje, tiempos operatorios, relación del tiempo de CIOd con el tiempo de duración de la Colelap (CIO/CX), redisección del cístico y litiasis cística y coledociana. Resultados: se operaron 456 pacientes durante un año (2017-2018). Se observó que, independiente mente de quien realice la CIOd, los residentes pudieron mejorar su curva de aprendizaje, objetiván dose tiempos más cortos para la Colelap, CIOd y la relación CIO/CX. Los coeficientes de aprendizaje fueron mejores en cirugías más complejas en relación con el semestre. El 5,26% presentó litiasis cole dociana (n = 24); de estas, 66,7% tenían litiasis cística (n = 16) y 25% colecistitis (n = 6) asociadas. Todas se resolvieron por vía transcística. No hubo conversiones y se realizó CIOd en el 100%. Conclusión: la CIOd es un procedimiento ideal para ser practicado de manera sistemática durante la Residencia, porque da el entrenamiento necesario para el manejo de la vía transcística, permite evitar una lesión quirúrgica de vía biliar mayor y el diagnóstico de coledocolitiasis.

ABSTRACT Background: The use of dynamic intra-operative cholangiography (dIOC) during laparoscopic cholecystectomy (Lap Chole) remains a topic under discussion. Objectives: This study aims to describe and evaluate the learning curve and findings in the dIOC during laparoscopic cholecystectomies performed by Residents of General Surgery, including it as a tool for a safe cholecystectomy, as well as training for the development of skills and abilities. Material and methods: Patients with indication of scheduled or emergency laparoscopic cholecystectomy were included. In the surgeries, traction was performed according to Hunter, critical safety vision and systematic dIOC, by a senior Resident and the dIOC by a less trained resident, tutored by a staff surgeon. Learning curve, operative times, dIOC time relationship with Lap Chole duration time (IOC/LC), repeated cystic dissection, cystic lithiasis and choledocholithiasis were evaluated. Results: 456 patients were operated for one year (2017-2018). It was observed that regardless of who performs the dIOC, they were able to improve their learning curve, objectifying shorter times for Lap Chole, dIOC and the IOC/LC relationship. The learning coefficients were better in complex surgeries in relation to the semester. 5.26 % had choledocholithiasis (n = 24), of these, 66.7% had cystic lithiasis (n = 16) and 25% associated cholecystitis (n = 6). All were resolved trancystically. There were no conversions and dIOC was performed in 100% of cases. Conclusion: The dIOC is an ideal procedure to be practiced systematically during residency. Because it gives the necessary training for the management of the transcystic pathway, allows avoiding an upper bile duct injury and the diagnosis of choledocholithiasis.

Nervio occipital mayor: trayecto, relaciones anatómicas e implicancias clínicas de sus posibles sitios de atrapamiento / Great occipital nerve: course, anatomical relations and clinical implications of their potential entrapment sites

RESUMEN: El nervio occipital mayor (NOM) se forma del ramo dorsal del nervio espinal C2 y asciende entre la musculatura cervical posterior para inervar la piel del cuero cabelludo. Diversos autores han descrito su recorrido, sin embargo, es escasa la información referente a la relación que presenta este nervio con el músculo oblicuo inferior de la cabeza (OIC) y su trayecto intramuscular. El objetivo de este estudio fue determinar el recorrido y relaciones que el NOM estableció en el intervalo existente entre los músculos OIC y músculo trapecio (T). Para ello, se midieron las distancias verticales y horizontales a la altura de la protuberancia occipital externa y línea mediana, y se dividió al músculo OIC en tercios para observar variaciones del recorrido de este nervio. Junto con medir el diámetro del NOM, se midieron las distancias vertical y horizontal de este nervio a través de cinco puntos de referencia muscular y un punto de referencia vascular. Estos puntos musculares fueron: a) sobre el vientre del músculo OIC (punto 1); b) en la cara profunda del músculo semiespinoso de la cabeza (SEC) (punto 2); c) en la cara superficial del músculo SEC (punto 3); d) en la cara profunda del músculo T (punto 4); y e) en la cara superficial del músculo T (punto 5). A este se sumó el punto 6, en el cual se establecieron las distancias vertical y horizontal con la arteria occipital a la altura de la cara superficial del músculo T. Para ello se disecaron 18 cabezas (36 triángulos suboccipitales) de cadáveres adultos brasileños pertenecientes al laboratorio de Anatomía de la Universidade Federal de Alagoas (UFAL), Maceió, Brasil. Las distancias verticales y horizontales obtenidas respecto de los seis puntos fueron: 63,67 y 27,15 mm (punto 1); 53,89 y 21,44 mm (punto 2); 30,61 y 14,49 mm (punto 3); 20,39 y 22,8 mm (punto 4); 5,86 y 33,46 mm (punto 5); 5,99 y 35,56 mm (punto 6), respectivamente. En relación al músculo OIC, el NOM se ubicó en un 72,22 % de las muestras en el tercio medio de este músculo, 19,44% en su tercio lateral y un 8,33 % en su tercio medial. Todos estos hallazgos deben ser considerados al momento de diagnosticar correctamente posibles atrapamientos del NOM en la región cervical profunda, siendo además, una contribución para el éxito de procedimientos quirúrgicos de esta región.

SUMMARY: The great occipital nerve (GON) is formed from the dorsal branch of the C2 spinal nerve and ascends between the posterior cervical musculature to innervate the skin of the scalp. Various authors have described its course, however, there is little information regarding the relationship that this nerve presents with the obliquus capitis inferior (OCI) and its intramuscular path. The objective of this study was to determine the route and relationships that the GON established in the interval between the OCI muscles and the trapezius muscle (T). For this, the vertical and horizontal distances were measured at the height of the external occipital protuberance and median line, and the OCI muscle was divided into thirds to observe variations in the path of this nerve. Along with measuring the diameter of the GON, the vertical and horizontal distances of this nerve were measured through five muscle reference points and one vascular reference point. These muscle points were: a) on the belly of the OCI muscle (point 1); b) in the deep face of the semispinalis capitis muscle (SCM) (point 2); c) on the surface of the SCM (point 3); d) on the deep face of the T (point 4); and e) on the surface face of the T (point 5). To this was added point 6, in which the vertical and horizontal distances were established with the occipital artery at the height of the superficial face of the T. For this, 18 heads (36 suboccipital triangles) of Brazilian adult corpses belonging to the Anatomy laboratory of the Universidade Federal de Alagoas (UFAL), Maceió, Brazil, were dissected. The vertical and horizontal distances obtained with respect to the six points were: 63.67 and 27.15 mm (point 1); 53.89 and 21.44 mm (point 2); 30.61 and 14.49 mm (point 3); 20.39 and 22.8 mm (point 4); 5.86 and 33.46 mm (point 5); 5.99 and 35.56 mm (point 6), respectively. In relation to the OCI, the GON was located in 72.22 % of the samples in the middle third of this muscle, 19.44 % in its lateral third and 8.33 % in its medial third. All these findings should be considered when correctly diagnosing possible entrapments of GON in the deep cervical region, being a contribution to the success of surgical procedures in this region.

Abordaje mínimamente invasivo para hernias de disco extraforaminales: indicaciones, consideraciones quirúrgicas y resultados clínicos / Minimally Invasive Approach for Extraforaminal Herniated Discs: Indications, Surgical Considerations, and Clinical Outcomes

Introducción: Las hernias de disco extraforaminales representan entre el 0.3% y el 11.3% del total de las hernias de disco lumbares. Existen múltiples procedimientos quirúrgicos para el tratamiento de las mismas. Objetivo: Nuestro objetivo es presentar una serie de 5 casos de hernia de disco extraforaminal tratados mediante abordaje tubular mínimamente invasivo, describir la técnica quirúrgica utilizada y analizar la literatura pertinente. Pacientes y método: Cinco pacientes sin respuesta al tratamiento conservador con diagnóstico de hernia de disco extraforaminal, fueron sometidos a tratamiento quirúrgico mediante técnica tubular mínimamente invasiva durante el período de enero 2018-febrero 2019. Se analizaron datos demográficos e intraoperatorios. Los resultados clínicos fueron evaluados mediante la Escala Visual Analógica pre y postquirúrgico (EVA). Resultados: Cinco pacientes presentaron déficit neurológico y dolor lumbar que requirieron resolución quirúrgica. Todos los pacientes fueron dados de alta dentro de las 24 hs. postoperatorias. La escala de dolor disminuyó de forma estadísticamente significativa entre el momento pre y post quirúrgico (p=0.038). No se registraron fístulas ni infecciones. Conclusión: El abordaje tubular mínimamente invasivo fue una técnica efectiva para el tratamiento de hernias extraforaminales

ntroduction: Extraforaminal disc herniations represents 0.3-11.3% of every herniated lumbar discs. A variety of surgical procedures may be used for the treatment of this pathology. Objective: The aim of this study is to present 5 cases of extraforaminal herniated discs treated via a minimally invasive spine surgery using tubular retractors, to describe the surgical technique and to analyze the literature on this subject. Pacients and method: 5 patients who did not get better with conservative treatment were operated using minimally invasive tubular retractors between January 2018 and February 2019. Demographic variables and intraoperative data were analyzed. Clinical outcomes was evaluated using the Analog Visual Scale (VAS). Results: Five patients who presented neurological deficit and low back pain were operated. Every patients was discharged before 24 hours postoperative. VAS significantly decrease comparing pre and postoperative (p=0.038). No cerebrospinal fluid leaks or infections were recorded. Conclusion: The use of minimally invasive tubular retractors is an effective technique for treating extraforaminal herniated discs.

Mais uma vez, por que a guerra?: why war? / Again: ¿por qué la guerra? / Una vez más: pourquoi la guerre ? / Encore une fois

A partir da correspondência entre Einstein e Freud, publicada com o título "Por que a guerra?", e em especial da leitura de textos que estão na gênese da carta-resposta freudiana, neste trabalho sugerimos a hipótese de que o primeiro desafio de nosso psiquismo seja o de ir além de um princípio no ódio, que seria fundado na experiência de desamparo trazida pelo nascimento, e reproduzido em experiências futuras de castração. A capacidade de lidar com a falta, com a insatisfação dos próprios impulsos, será determinante na estruturação do psiquismo, na elaboração da castração e inscrição da interdição edípica, assim como no reconhecimento da alteridade e da lei. A recusa da realidade da castração poderá levar ao cenário de atuação do ódio, da intolerância às diferenças, do predomínio da pulsão de morte, tão presente nos dias atuais. Sob o eco da angústia de Freud, concluímos com o convite de ouvir o adoecimento de nossa sociedade e, quem sabe, através do fortalecimento da pulsão de vida e de seu potencial integrador, criar alternativas ao labirinto de ódio e morte a que nossa destrutividade nos levou.

From the correspondence between Einstein and Freud, published under the title "Why War?" (Einstein and Freud, 1933), this paper suggests the hypothesis that our psyche's first challenge is to go beyond a principle in hatred, which would be based on the experience of helplessness brought up by birth, and reproduced in future experiences of castration. The capability for dealing with failure, with one's own impulses' dissatisfaction, will be decisive in structuring the psyche, in elaborating castration and inscription in oedipal interdiction, as well as in recognizing alterity and law. The refusal of castration reality can lead us to scenarios of hatred, intolerance of differences, and to the predominance of death drive so present today. I conclude, under the echo of Freud's anguish, by inviting us to pay attention to the sickening of our society and, perhaps, by strengthening the motor for life and its integrative potential, to create alternatives to the maze of hatred and death that our destructiveness has led us to.

A partir de la correspondencia entre Einstein y Freud, publicada con el título "[Por qué la guerra?" (Freud, 1933 [1932], en especial de la lectura de textos que están en la génesis de la carta-respuesta freudiana, este trabajo sugiere la hipótesis de que el primer desafío de nuestro psiquismo sea el de ir más allá de un principio en el odio, que sería fundado en la experiencia de desamparo traída por el nacimiento, y reproducido en experiencias futuras de castración. La capacidad de lidiar con la falta, con la insatisfacción de los propios impulsos, será determinante en la estructuración del psiquismo, en la elaboración de la castración e inscripción en la interdicción edípica, en el reconocimiento de la alteridad y de la ley. El rechazo de la realidad de la castración puede llevarnos al escenario de actuación del odio, de la intolerancia a las diferencias, del predominio de la pulsión de muerte, tan presente en los días actuales. Concluyo, bajo el eco de la angustia de Freud, con la invitación para que podamos oír la enfermedad de nuestra sociedad y, quizás, a través del fortalecimiento de la pulsión de vida y de su potencial integrador, crear alternativas al laberinto de odio y muerte a que nuestra destructividad nos llevó.

À l'appui de la correspondance entre Einstein et Freud, publiée sous le titre « Pourquoi la Guerre ? ¼ (Freud, 1933), notamment de la lecture de textes faisant partie de la genèse de la lettre réponse freudienne, cet article suggère l'hypothèse que le premier défi de notre psychisme soit celui d'aller au-delà d'un principe de haine, qui serait fondé sur l'expérience de délaissement apportée par la naissance et reproduite dans des expériences futures de castration. La capacité de faire face au manque, au mécontentement de ses propres impulsions, sera déterminante lors de la structuration de la psyché, de l'élaboration de la castration et de son inscription dans l'interdiction œdipienne, ainsi que lors de la reconnaissance de l'altérité et de la loi. Le refus de la réalité de la castration pourra nous conduire à une situation d'action de la haine, de l'intolérance face aux différences, de la prédominance de la pulsion de mort, si présent de nos jours. Je conclus, sous l'écho de l'angoisse de Freud, par une invitation à entendre les maladies de notre société et, peut-être, au moyen d'un renforcement de la pulsion de vie et de son potentiel d'intégration, à créer des alternatives au labyrinthe de haine et de mort où notre destructivité nous a conduits.

Hallazgos y propuesta de sistematización de las variaciones quirúrgicamente importantes de la arteria cística en un estudio in vivo en 2000 colecistectomías laparoscópicas ambulatorias / Findings and proposal for systematization of surgically important variations of the cystic artery based on an in vivo study of 2000 outpatient laparoscopic cholecystectomies

Realizar un estudio anatómico in vivo con la especial y pequeña disección quirúrgica durante una colecistectomía laparoscópica sobre las variaciones de la arteria cística. Estudio prospectivo de 38 meses, en 2000 pacientes consecutivos sometidos a colecistectomía laparoscópica programada, sin signos de inflamación aguda, ni alteración que impida disección y correcta evaluación del triángulo hepatocístico. Se disecó quirúrgicamente identificándose la arteria cística y posible duplicación, eran clínicamente importantes aquellas con diámetro mayor a 1,5 mm, requerían maniobra hemostática. Se anotaron los hallazgos en planilla especial a los fines del presente estudio. En 1831 casos había arteria única en medio del triángulo hepatocístico. Hubo 169 variaciones (8,45 %). En 97 casos: doble vascularización, con una arteria en situación normal y otra ubicada lateralmente al triangulo hepatocístico. En 44 pacientes había una arteria única lateralmente al conducto cístico que no lo cruzaba nunca. En 22 casos existía una arteria cruzando el colédoco y el cístico entrando en el triángulo. En 6 oportunidades una doble arteria, una en el triángulo hepatocístico y otra lateralmente que no cruzaba el cístico ni colédoco. En una oportunidad se observó una sola arteria importante que salía directamente de la placa cística entre segmento 4 y 5, y en otro caso solo pequeñas arterias proveniente de la placa cística. Podemos dividirlas en arterias únicas o dobles, en base exclusiva a la necesidad de maniobra hemostática. Podemos decir que las variaciones estarán presentes en aproximadamente 1/12 casos y necesitará una maniobra hemostática especial en 1/20 casos.

This is an anatomical study with the special and small dissection of a laparoscopic cholecystectomy on the surgically important variations of the cystic artery. A prospective, 19-month study was conducted in 2000, including consecutive patients undergoing programmed laparoscopic cholecystectomy, without signs of acute inflammation, or alteration, that would prevent dissection and correct evaluation of the cystohepatic triangle. It was surgically dissected, identifying the main cystic artery and its possible collateral arteries. Those with a diameter greater than 1.5 mm being considered as clinically important, requiring haemostatic maneuver (clipping and / or electrocoagulation). The findings were recorded on a special form for the purposes of this study. The classic, single-artery arrangement in the middle of the cystohepatic triangle was found in 1831 cases. The variations found were 169 (8.45 %). In 97 cases there was double vascularization, with one artery in normal position and another outside the cystic duct. In 44 patients, a single artery that did not cross the cystic was observed. In 22 cases an artery outside the cystic but crossing it before the duct. In 6 cases a double artery, one in the cystohepatic triangle and another outside the triangle, did not cross the cystic or the bile duct. In one instance, a single major artery was seen emerging directly from the cystic plaque between segments four and five. These can be divided into single or double arteries, based exclusively on the need for hemostatic maneuver. Knowledge of anatomical variations of the cystic artery is important for the surgeon. The variation presents in 1 of 12 cases, and requires a special hemostatic maneuver in 1 of 20 cases.

Systematic review of triangle versus inverted triangle-configurated cannulated screws in the treatment of femoral neck fractures / 中国组织工程研究

BACKGROUND: The use of three cannuiated screws is the preferred method for the treatment of femoral neck fractures for many years. However, some clinical studies have explored the clinical efficacy of triangular and Inverted triangular hollow screw Internal fixation In the treatment of femoral neck fracture, but the conclusions are not consistent. OBJECTIVE: To systematically review the efficacy of triangle and inverted triangle-configurated cannuiated screws in the treatment of femoral neck fractures. METHODS: The PubMed, Cochrane Library, EMbase, CNKI and WanFang Database were searched up to May 2018, for studies concerning the efficacy of three cannuiated screws fixation for femoral neck fractures. Two reviewers independently screened literature according to the inclusion and exclusion criteria, extracted data and assessed the methodological quality of included studies. The meta-analysis and trial sequential analysis were performed by using RevMan 5.3 software and TSA 0.9 respectively. RESULTS AND CONCLUSION: (1) A total of 8 cohort studies involving 1 150 patients were included. (2) The results of meta-analysis showed that compared with the inverted triangle group, the triangle group was inferior in operation time [MD=12.30, 95%C/(4.83,19.77), P < 0.01] and blood loss during the operation [MD=12.44, 95%C/(6.56, 18.32), P < 0.01]. However, there were no statistical differences between the two groups in femoral head osteonecrosis rate [0/?=0.66, 95%C/(0.34,1.29), P=0.22], nonunion rate [OR=1.37, 95%C/(0.86, 2.18), P=0.18] and the Harris scores in the final follow-up [OR=1.29, 95%C/(0.58, 2.26), P=0.53]. (3) Current evidence shows that inverted triangle group is superior to triangle group in shorting operation time and reducing blood loss. Nevertheless, there was no significant difference in femoral head osteonecrosis rate, nonunion rate, and the Harris scores < 70 in the final follow up. Because the inclusion of the study is mainly cohort study, and there is a large bias, so the above conclusions need to be verified by more multi-center randomized controlled trials.

A study on the role of paediatric assessment triangle, clinical scoring and serum lactate in the management of septic shock in children

Background: There is dearth of studies in India on the management of paediatric septic shock. So it is prudent to do a study on paediatric septic shock management. The objective of the study is to determine the correlation between Paediatric Assessment Triangle and serum lactate levels., to determine the role Paediatric Assessment Triangle in predicting mortality in septic shock and to the determine the role of elevated lactate levels in predicting mortality in septic shock.Methods: Descriptive study of 100 children from 31 days to 12 years of age who are admitted with septic shock in a tertiary care hospital are assessed with paediatric assessment triangle and clinical score and serum lactate was tested along with other standard tests and the children are managed as per the standard protocols. Outcome is analysed.Results: In this study, septic shock children with total clinical score >22 are having statistically significant low levels of diastolic blood pressure and low mean arterial pressure. There was a significant difference in median serum lactate levels between the survivors (28.08 mg/dl) and non-survivors (40.92 mg/dl).Conclusions: Paediatric assessment triangle and clinical scoring based on it more than 22 and serum lactate levels of more than 2mmol/L or 18mg/dl predict the mortality.

Scrub typhus: as it stands today

Scrub typhus is one of the three most common causes of prolonged fever in Southeast Asia and Pacific affecting almost 1 million people annually worldwide out of 1 billion exposed. Scrub typhus is a rickettsial infection caused by Orientia Tsutsugamushi transmitted through bite of Chiggers (larval stage of trombiculid mite). It is an acute febrile illness which generally causes non-specific symptoms and signs. The clinical manifestations of this disease range from sub-clinical disease to organ failure and death. Deaths are attributable to late presentation, delayed diagnosis, and drug resistance. Scrub typhus, though endemic in India; yet is under reported. It should be considered as an important differential diagnosis in a febrile patient with thrombocytopenia, deranged liver or renal functions, and B/L chest opacities. Relapse is not uncommon. Presumptive treatment with Doxycycline can be a suitable option in febrile patients from Typhus pockets. Alert physician should keep an eye on deviation from usual presentation to changing spectrum of the disease. Early diagnosis and appropriate treatment is rewarding and prevents morbidity and mortality.

Migrantes centroamericanos en tránsito por México ¿Primacía de los Derechos Humanos o de los capitales? / Central American Migrants in Transit Through Mexico. Primacy of Human Rights or That of Capitals?

Resumen Este artículo describe las condiciones violatorias de Derechos Humanos que hacen parte de los riesgos a los que están expuestos los migrantes pertenecientes al Triángulo Norte Centroamericano (Guatemala, El Salvador y Honduras), en su tránsito por México. Plantea que, frente al sueño de llegar a Estados Unidos, a pesar de la voz oficial del Estado, México más que intentar responder a la crisis humanitaria de los migrantes haciendo prevalecer los Derechos Humanos, opta por allanarse a los criterios de la política internacional norteamericana.

Abstract This article describes the violating conditions of Human Rights, which are part of the risks to which migrants belonging to the Central American Northern Triangle (Guatemala, El Salvador, and Honduras) are exposed, in transit through Mexico. It raises that, against the dream of reaching the United States, despite the voice official of the State, Mexico rather than attempting to respond to the humanitarian crisis of migrants, by making prevail Human Rights, opt for agreeing with the criteria of the American international politics.

Relationship Of Great Cardiac Vein In The Triangle Of Brocq And Mouchet- A Corrosion Cast Study

Background: The triangle of Brocq and Mouchet is an arteriovenous triangle between the anterior interventricularartery, circumflex artery and the great cardiac vein. The vascular triangle has been classified into 4 types viz.closed, superiorly opened, inferiorly opened and completely opened or absent. Polyurethane foam is a newmaterial used in corrosion casting. It is economical, easy to carry out and does not require special apparatus.Context and purpose of the study:a) To study the relationship of the Great cardiac vein (GCV) in the triangle of Brocq and Mouchet in human heartsusing PU foam for corrosion cast.b) To study the relationship of GCV in relation to the arteries forming the triangle.Results: The triangle was present in 98% of the hearts. Relationship of GCV in triangle of Brocq and Mouchet:Inferiorly open type of Triangle was the most common (87.5%). Next common type was, closed type (6.7%). Inrelation to GCV relation with the arteries in the triangle, it was to the left of AIA in 87.51% and crosses circumflexartery, either superficially or deep.The GCV crossing anterior interventricular artery was found in few specimens. It crossed the artery superficiallyor deeply. The intertwining type of variation was observed in few casts, and could not be placed under anyclassification as suggested by previous authors.Conclusion: The topography of the Great cardiac vein and its variations are significant in relation to the arteriesin the region. It is relevant in interventional cardiology, radiology, and catheter-based procedures.