Measurement of Ultra-High-Energy Diffuse Gamma-Ray Emission of the Galactic Plane from 10 TeV to 1 PeV with LHAASO-KM2A.

The diffuse Galactic γ-ray emission, mainly produced via interactions between cosmic rays and the interstellar medium and/or radiation field, is a very important probe of the distribution, propagation, and interaction of cosmic rays in the Milky Way. In this Letter, we report the measurements of diffuse γ rays from the Galactic plane between 10 TeV and 1 PeV energies, with the square kilometer array of the Large High Altitude Air Shower Observatory (LHAASO). Diffuse emissions from the inner (15°10 TeV). The energy spectrum in the inner Galaxy regions can be described by a power-law function with an index of -2.99±0.04, which is different from the curved spectrum as expected from hadronic interactions between locally measured cosmic rays and the line-of-sight integrated gas content. Furthermore, the measured flux is higher by a factor of ∼3 than the prediction. A similar spectrum with an index of -2.99±0.07 is found in the outer Galaxy region, and the absolute flux for 10≲E≲60 TeV is again higher than the prediction for hadronic cosmic ray interactions. The latitude distributions of the diffuse emission are consistent with the gas distribution, while the longitude distributions show clear deviation from the gas distribution. The LHAASO measurements imply that either additional emission sources exist or cosmic ray intensities have spatial variations.

A tera-electron volt afterglow from a narrow jet in an extremely bright gamma-ray burst.

Some gamma-ray bursts (GRBs) have a tera-electron volt (TeV) afterglow, but the early onset of this has not been observed. We report observations with the Large High Altitude Air Shower Observatory (LHAASO) of the bright GRB 221009A, which serendipitously occurred within the instrument's field of view. More than 64,000 photons >0.2 TeV were detected within the first 3000 seconds. The TeV flux began several minutes after the GRB trigger and then rose to a peak ~10 seconds later. This was followed by a decay phase, which became more rapid ~650 seconds after the peak. We interpret the emission using a model of a relativistic jet with half-opening angle of ~0.8°. This is consistent with the core of a structured jet and could explain the high isotropic energy of this GRB.

Drug Permeability - Best Practices for Biopharmaceutics Classification System (BCS)-Based Biowaivers: A workshop Summary Report.

The workshop "Drug Permeability - Best Practices for Biopharmaceutics Classification System (BCS) Based Biowaivers" was held virtually on December 6, 2021, organized by the University of Maryland Center of Excellence in Regulatory Science and Innovation (M-CERSI), and the Food and Drug Administration (FDA). The workshop focused on the industrial, academic, and regulatory experiences in generating and evaluating permeability data, with the aim to further facilitate implementation of the BCS and efficient development of high-quality drug products globally. As the first international permeability workshop since the BCS based biowaivers was finalized as the ICH M9 guideline, the workshop included lectures, panel discussions, and breakout sessions. Lecture and panel discussion topics covered case studies at IND, NDA, and ANDA stages, typical deficiencies relating to permeability assessment supporting BCS biowaiver, types of evidence that are available to demonstrate high permeability, method suitability of a permeability assay, impact of excipients, importance of global acceptance of permeability methods, opportunities to expand the use of biowaivers (e.g. non-Caco-2 cell lines, totality-of-evidence approach to demonstrate high permeability) and future of permeability testing. Breakout sessions focused on 1) in vitro and in silico intestinal permeability methods; 2) potential excipient effects on permeability and; 3) use of label and literature data to designate permeability class.

Center of mass-based posturography for free living environment applications.

BACKGROUND: Postural assessment is crucial as risk of falling is a major health problem for the elderly. The most widely used devices are force and balance plates, while center of pressure is the most studied parameter as measure of neuromuscular imbalances of the body sway. In out-of-laboratory conditions, where the use of plates is unattainable, the center of mass can serve as an alternative. This work proposes a center of mass-based posturographic measurement for free living applications. METHODS: Ten healthy and ten Parkinson's disease individuals (age = 26.1 ± 1.5, 70.4 ± 6.2 years, body mass index = 21.7 ± 2.2, 27.6 ± 2.8 kg/m2, respectively) participated in the study. A stereophotogrammetric system and a force plate were used to acquire the center of pressure and the 5th lumbar vertebra displacements during the Romberg test. The center of mass was estimated using anthropometric measures. Posturographic parameters were extracted from center of pressure, center of mass and 5th lumbar vertebra trajectories. Normalized root mean squared difference was used as metric to compare the trajectories; Spearman's correlation coefficient was computed among the posturographic parameters. FINDINGS: Low values of the metric indicated a good agreement between 5th lumbar vertebra trajectory and both center of pressure and center of mass trajectories. Statistically significant correlations were found among the postural variables. INTERPRETATION: A method to perform posturography tracking the movement of the 5th lumbar vertebra as an approximation of center of mass has been presented and validated. The method requires the solely kinematic tracking of one anatomical landmark with no need of plates for free living applications.

Temporal judgments of actions following unilateral brain damage.

Sense of time is a complex construct, and its neural correlates remain to date in most part unknown. To complicate the frame, physical attributes of the stimulus, such as its intensity or movement, influence temporal perception. Although previous studies have shown that time perception can be compromised after a brain lesion, the evidence on the role of the left and right hemispheres are meager. In two experiments, the study explores the ability of temporal estimation of multi-second actions and non-biological movements in 33 patients suffering from unilateral brain lesion. Furthermore, the modulatory role of induced embodiment processes is investigated. The results reveal a joint contribution of the two hemispheres depending not only on different durations but also on the presence of actions. Indeed, the left hemisphere damaged patients find it difficult to estimate 4500 ms or longer durations, while the right hemisphere damaged patients fail in 3000 ms durations. Furthermore, the former fail when a biological action is shown, while the latter fail in non-biological movement. Embodiment processes have a modulatory effect only after right hemisphere lesions. Among neuropsychological variables, only spatial neglect influences estimation of non-biological movement.

Quantitative assessment of training effects using EksoGT® exoskeleton in Parkinson's disease patients: A randomized single blind clinical trial.

Background: Gait alterations are among the most disabling motor-symptoms associated with Parkinson's Disease (PD): reduced stride length, stride velocity and lower limb joint range of motion are hallmarks of parkinsonian gait. Research focusing on optimal functional rehabilitation methods has been directed towards powered lower-limb exoskeletons which combines the advantages delivered from the grounded robotic devices with the ability to train the patient in a real-world environment. As gait involves both central (CNS) and peripheral nervous systems (PNS), targeted rehabilitation must restore not only mechanics but also neurophysiological gait patterns. Methods: Two cohorts of subjects will be enrolled and equally distributed between one group (n = 25) who will undergo a functional kinematic therapy, and one group (n = 25) who will undergo an overground wearable-exoskeleton training. Participants are evaluated at three time points: before the therapy (T0), after the therapy (T1), 4-weeks after T1 (T2). Comprehensive gait analysis and surface electromyography will be combined into neuromusculoskeletal modelling to determine modifications at the PNS level. Functional magnetic resonance imaging coupled with electroencephalography will be used to determine modifications at the CNS level. Conclusion: The findings of the proposed trial will likely give substantial solutions for the management of gait and postural disorders in PD where valid interventions are lacking. The coupling of movement evaluation, which assesses neuromuscular and biomechanical features, with neurological data, will better define the impact of the therapy on the relationship between PD motor alterations and brain activity. This will provide an active treatment that is personalized and shared to large populations.

Different perspectives in understanding muscle functions in Parkinson's disease through surface electromyography: Exploring multiple activation patterns.

Gait disorders are one of the cardinal features of Parkinson's Disease (PD) and might be affected by a modified pattern of motor unit activation. This work explores how PD affects the lower limb muscle control and how muscle activity contributes to gait impairment. Using clinical gait analysis data, the onset and the offset of the surface electromyographic (sEMG) signal of four lower limb muscles were determined in 18 people with PD and compared with 10 heathy controls. Different motor patterns were identified in both the populations through a statistical detector algorithm and described in terms of linear envelope, local maxima activation magnitude and occurrence, co-contractions, and bursts duration. Statistical analysis was performed using statistical parametric mapping for the sEMG envelope and linear mixed effects models for the sEMG parameters. An equivalent number of sEMG patterns was detected in PD with respect to controls. Significant differences were highlighted between the two cohorts within the same activation modality. Plantarflexors muscles activation was delayed on time and had different durations and activations peaks, while Biceps Femoris revealed a higher local maximum. These results suggested that functional tibiotarsus joint reeducation coupled with postural rehabilitation might be beneficial for people with PD.

Exploring Lorentz Invariance Violation from Ultrahigh-Energy γ Rays Observed by LHAASO.

Recently, the LHAASO Collaboration published the detection of 12 ultrahigh-energy γ-ray sources above 100 TeV, with the highest energy photon reaching 1.4 PeV. The first detection of PeV γ rays from astrophysical sources may provide a very sensitive probe of the effect of the Lorentz invariance violation (LIV), which results in decay of high-energy γ rays in the superluminal scenario and hence a sharp cutoff of the energy spectrum. Two highest energy sources are studied in this work. No signature of the existence of the LIV is found in their energy spectra, and the lower limits on the LIV energy scale are derived. Our results show that the first-order LIV energy scale should be higher than about 10^{5} times the Planck scale M_{Pl} and that the second-order LIV scale is >10^{-3}M_{Pl}. Both limits improve by at least one order of magnitude the previous results.

Constraints on Heavy Decaying Dark Matter from 570 Days of LHAASO Observations.

The kilometer square array (KM2A) of the large high altitude air shower observatory (LHAASO) aims at surveying the northern γ-ray sky at energies above 10 TeV with unprecedented sensitivity. γ-ray observations have long been one of the most powerful tools for dark matter searches, as, e.g., high-energy γ rays could be produced by the decays of heavy dark matter particles. In this Letter, we present the first dark matter analysis with LHAASO-KM2A, using the first 340 days of data from 1/2-KM2A and 230 days of data from 3/4-KM2A. Several regions of interest are used to search for a signal and account for the residual cosmic-ray background after γ/hadron separation. We find no excess of dark matter signals, and thus place some of the strongest γ-ray constraints on the lifetime of heavy dark matter particles with mass between 10^{5} and 10^{9} GeV. Our results with LHAASO are robust, and have important implications for dark matter interpretations of the diffuse astrophysical high-energy neutrino emission.

Peta-electron volt gamma-ray emission from the Crab Nebula.

The Crab Nebula is a bright source of gamma rays powered by the Crab Pulsar's rotational energy through the formation and termination of a relativistic electron-positron wind. We report the detection of gamma rays from this source with energies from 5 × 10-4 to 1.1 peta-electron volts with a spectrum showing gradual steepening over three energy decades. The ultrahigh-energy photons imply the presence of a peta-electron volt electron accelerator (a pevatron) in the nebula, with an acceleration rate exceeding 15% of the theoretical limit. We constrain the pevatron's size between 0.025 and 0.1 parsecs and the magnetic field to ≈110 microgauss. The production rate of peta-electron volt electrons, 2.5 × 1036 ergs per second, constitutes 0.5% of the pulsar spin-down luminosity, although we cannot exclude a contribution of peta-electron volt protons to the production of the highest-energy gamma rays.

Extended Very-High-Energy Gamma-Ray Emission Surrounding PSR J0622+3749 Observed by LHAASO-KM2A.

We report the discovery of an extended very-high-energy (VHE) gamma-ray source around the location of the middle-aged (207.8 kyr) pulsar PSR J0622+3749 with the Large High-Altitude Air Shower Observatory (LHAASO). The source is detected with a significance of 8.2σ for E>25 TeV assuming a Gaussian template. The best-fit location is (right ascension, declination) =(95.47°±0.11°,37.92°±0.09°), and the extension is 0.40°±0.07°. The energy spectrum can be described by a power-law spectrum with an index of -2.92±0.17_{stat}±0.02_{sys}. No clear extended multiwavelength counterpart of the LHAASO source has been found from the radio to sub-TeV bands. The LHAASO observations are consistent with the scenario that VHE electrons escaped from the pulsar, diffused in the interstellar medium, and scattered the interstellar radiation field. If interpreted as the pulsar halo scenario, the diffusion coefficient, inferred for electrons with median energies of ∼160 TeV, is consistent with those obtained from the extended halos around Geminga and Monogem and much smaller than that derived from cosmic ray secondaries. The LHAASO discovery of this source thus likely enriches the class of so-called pulsar halos and confirms that high-energy particles generally diffuse very slowly in the disturbed medium around pulsars.

Ultrahigh-energy photons up to 1.4 petaelectronvolts from 12 γ-ray Galactic sources.

The extension of the cosmic-ray spectrum beyond 1 petaelectronvolt (PeV; 1015 electronvolts) indicates the existence of the so-called PeVatrons-cosmic-ray factories that accelerate particles to PeV energies. We need to locate and identify such objects to find the origin of Galactic cosmic rays1. The principal signature of both electron and proton PeVatrons is ultrahigh-energy (exceeding 100 TeV) γ radiation. Evidence of the presence of a proton PeVatron has been found in the Galactic Centre, according to the detection of a hard-spectrum radiation extending to 0.04 PeV (ref. 2). Although γ-rays with energies slightly higher than 0.1 PeV have been reported from a few objects in the Galactic plane3-6, unbiased identification and in-depth exploration of PeVatrons requires detection of γ-rays with energies well above 0.1 PeV. Here we report the detection of more than 530 photons at energies above 100 teraelectronvolts and up to 1.4 PeV from 12 ultrahigh-energy γ-ray sources with a statistical significance greater than seven standard deviations. Despite having several potential counterparts in their proximity, including pulsar wind nebulae, supernova remnants and star-forming regions, the PeVatrons responsible for the ultrahigh-energy γ-rays have not yet been firmly localized and identified (except for the Crab Nebula), leaving open the origin of these extreme accelerators.

Muscular activation changes in lower limbs after underwater gait training in Parkinson's disease: A surface emg pilot study.

BACKGROUND: Under water gait training (UT) has been proposed as an innovative rehabilitative strategy for the treatment of axial disorders in Parkinson Disease (PD) patients, in particular for balance and gait impairment. However, the basis for the improvement is unclear. RESEARCH QUESTION: The aim of this study was to evaluate improvements in the muscular activation in the lower limbs in a cohort of PD patients after UT. METHODS: Ten PD participants in the "off" state and 10 controls (mean ± standard deviation of age and BMI were respectively: 71 ± 6 years, 28 ± 3 kg/m2; 65.5 ± 7 years, 28 ± 3 kg/m2) were enrolled in the study. After signing informed consent, they walked barefoot at their preferred speed on a 10 m walkway, before and after UT. The electrical activity of four muscles were collected bilaterally by means of a surface electromyography system (sEMG), two force plates and a motion capture system. All signals were synchronized in time with the gait cycle. The sEMG activity of Rectus Femoris (RF), Tibialis Anterior (TA), Biceps Femoris (BF) and Gastrocnemius Lateralis (GL) were acquired. The average from each signal was used to extract the peak of the Envelope (PoE) and its occurrence with respect to the gait cycle (PoPE%). Time and space parameters were determined. RESULTS: Our results showed that UT in PD patients improved the muscle's recruitment pattern towards normal. The PD patients POPE% was comparable with the one of the controls (TA: 20-35 %, 75-80 % of gait cycle; GL: 0-15 %, 25-45 %, 85-100 % of gait cycle) after UT on each muscle with the exception of BF. The muscle co-activation plots failed to show improvement in line with the muscle activation. SIGNIFICANCE: These results suggest that the muscle activation improvement with UT in PD participants might be due to a reorganisation at the executive rather than at the command level.

Mycobacteriosis in patients with breast implants: a case review from the Ivo Pitanguy Institute / Micobacteriose em implantes mamários: revisão da casuística do Instituto Ivo Pitanguy

INTRODUCTION: Reports of infections caused by rapidly growing mycobacteria during plastic surgery have increased in recent years despite improvements in techniques of asepsis/antisepsis and antibiotic prophylaxis. Infections occurring after the insertion of breast implants are a cause of patient morbidity and a significant problem for the surgeon. METHODS: Breast implant surgery cases complicated by mycobacterial infections at the Infirmary ward 38th of the Santa Casa da Misericórdia, Rio de Janeiro were retrospectively reviewed. A description of the current guidelines for the prevention and treatment of mycobacteriosis is included. Laboratory confirmed and clinically suspected cases were included in this study. RESULTS: Of 483 augmentation mammaplasty cases, 3 patients developed mycobacterial infections in the last 3 years. In 2 patients, there was a suspicion of infection that was not confirmed by laboratory data. CONCLUSIONS: Prophylaxis is fundamental for reducing the incidence of mycobacteriosis during plastic surgery procedures. However, the identification, diagnosis, and treatment of mycobacterial diseases are important to minimize the morbidity of this type of infection.

INTRODUÇÃO: Nos últimos anos, foram crescentes os registros de infecções por micobactéria de crescimento rápido em cirurgia plástica, mesmo com a melhoria dos métodos de assepsia/ antissepsia e da antibioticoprofilaxia. A infecção após inclusão de implantes mamários causa grande morbidade às pacientes e transtorno ao cirurgião. MÉTODO: Estudo retrospectivo dos casos de infecção por micobactéria de crescimento rápido da 38ª Enfermaria da Santa Casa da Misericórdia do Rio de Janeiro, após inclusão de implantes mamários, em que são apresentadas propostas de prevenção e tratamento da micobacteriose. Foram incluídos os casos confirmados laboratorialmente e os clinicamente suspeitos. RESULTADOS: Até o presente momento foram confirmados 3 casos de infecção por micobactéria, num total de 483 mamaplastia de aumento no decorrer de 3 anos. Em 2 pacientes, houve suspeita de infecção, porém sem confirmação laboratorial. CONCLUSÕES: A profilaxia é o pilar fundamental para a redução do impacto da micobacteriose em procedimentos de cirurgia plástica. Entretanto, saber identificar, diagnosticar e tratar corretamente a micobacteriose é de suma importância para minimizar a morbidade da paciente.

Assessment of vertical scar migration after classical abdominoplasty followed by lower abdominal flap fixation / Avaliação da migração vertical da cicatriz pós-abdominoplastia clássica com fixação do retalho abdominal inferior

BACKGROUND: In plastic surgery, the postoperative scar is a frequent concern. It is very important for the surgeon to understand the natural evolution of the scar. The abdominoplasty scar has a natural tendency to move upwards over time. In this study, the extent of natural vertical scar migration after abdominoplasty was calculated and the effect of fixing the lower abdominal flap to prevent this rise was assessed. METHODS: This prospective and randomized study was conducted at the 38th Nursing service of Santa Casa de Misericórdia do Rio de Janeiro, during 2010, and included 20 female patients with an indication for abdominoplasty. The patients were randomly divided into two groups, A and B. Classical abdominoplasty was performed in group A patients, according to the technique recommended by Prof. Ivo Pitanguy. Patients in group B also underwent lower abdominal flap fixation by suturing of Scarpa's fascia and the rectus abdominis muscle aponeurosis. At both two weeks and six months after surgery, the distance of vertical scar movement was measured in 16 patients after application of exclusion criteria. The average vertical migration and the mean difference between the groups were calculated. RESULTS: The average difference between the groups in vertical migration throughout the scar was 0.4 cm, with a mean overall migration of 1.06 cm and 0.68 cm in groups A (control group) and B (cases with fixation), respectively. CONCLUSIONS: The scar formed after abdominoplasty undergoes vertical migration over time; this migration is decreased when the lower abdominal flap is fixed. The surgeon should be aware of scar migration for better planning of the incision location.

INTRODUÇÃO: Na cirurgia plástica, uma constante preocupação é a cicatriz pós-operatória. É muito importante para o cirurgião conhecer a evolução natural da cicatriz. A cicatriz de abdominoplastia tem a tendência natural de subir com o passar do tempo. Neste estudo, calculou-se a migração vertical natural da cicatriz pós-abdominoplastia, avaliando o efeito da fixação do retalho abdominal inferior na prevenção dessa ascensão. MÉTODO: Estudo prospectivo e randomizado, realizado na 38ª Enfermaria da Santa Casa de Misericórdia do Rio de Janeiro durante o ano de 2010, incluindo 20 pacientes do sexo feminino com indicação de abdominoplastia, divididas em dois grupos, A e B, aleatoriamente. Nas pacientes do grupo A, foi realizada abdominoplastia clássica, segundo técnica preconizada pelo Prof. Ivo Pitanguy, e no grupo B foi incluída a fixação do retalho abdominal inferior por meio de sutura interessando a fáscia de Scarpa e a aponeurose do músculo reto abdominal. Duas semanas e seis meses após a cirurgia, foi medida a distância vertical em 16 pacientes, após aplicação dos critérios de exclusão, calculando-se a média de migração vertical e a diferença média entre os dois grupos. RESULTADOS: A diferença média de migração vertical ao longo de toda a cicatriz foi de 0,4 cm, sendo a média geral de migração nos grupo A (controle) e B (casos com fixação) de 1,06 cm e 0,68 cm, respectivamente. CONCLUSÕES: A cicatriz pós-abdominoplastia sofre migração vertical ao longo do tempo, sendo menor quando o retalho inferior é fixado. O cirurgião deve estar ciente da migração sofrida pela cicatriz para melhor planejamento da posição de sua incisão.

Correção das retrações palpebrais secundárias à blefaroplastia / Management of lower eyelid malposition following blepharoplasty

A retração palpebral nos seus diversos graus é uma complicação temida, mas frequentemente observada no pós-operatório da blefaroplastia inferior. Pode se apresentar desde uma discreta esclera aparente até um grave e sintomático ectrópio. Objetivo: Sistematizar o tratamento das retrações palpebrais secundárias à blefaroplastia nos seus diversos graus. Métodos: Três grupos foram divididos pela gravidade e tipo de retração palpebral, que orientaria o tratamento a ser recebido. No grupo 1, foram incluídas as retrações palpebrais confinadas ao canto lateral. Este grupo foi tratado com cantoplastia. No grupo 2, foram incluídas as alterações de canto lateral e terço medial da pálpebra causadas por deficiência da lamela média, anterior ou uma combinação entre as duas, mas que não causavam eversão da margem palpebral. Este grupo foi submetido a cantoplastia com retalho de tarso, perfuração lateral da órbita e liberação das retrações da lamela. No grupo 3, foram incluídos pacientes com evidente retração de lamela média, anterior ou uma combinação entre as duas, causando ectrópio franco. Esses pacientes foram submetidos à cantoplastia com retalho de tarso, liberação das retrações da lamela média e enxerto de mucosa de palato duro como espaçador (spacer graft). Resultados: A abordagem sugerida efetivamente corrigiu o mau posicionamento palpebral inferior e melhorou a sintomatologia nos três grupos propostos. Conclusão: O correto diagnóstico das causas da retração palpebral permite a escolha do tratamento adequado. Mais importante que o tratamento, no entanto, é a profilaxia deste tipo de complicação, que só é alcançada após entendimento amplo da anatomia periorbitária e avaliação meticulosa pré-operatória da função tarso ligamentar e outros parâmetros envolvidos.

Lower eyelid malposition is one of the most common complications following lower eyelid blepharoplasty. This may take the form of a mild scleral show with the round eye syndrome or may progress to frank ectropion in some patients. Objective: This study intended to systematically approach inferior lid malposition based on the severity and ethiopatogeny of each case. Methods: Inferior lid retraction was divided in 3 groups based on severity and ethiopatogeny that would guide the treatment. Group 1 had inferior displacement of the lid only on the canthal/ lateral aspect. Canthoplasty was performed in this group; Group 2 included retraction confined to the medial and lateral aspect of the lower eye lid with involvement of medial and/or anterior lamella but with no ectropion. Drill hole canthoplasty with tarsal strip and release of posterior lamellar scaring. Group 3 included patients with 2 or more lamella involved and ectropion. In this group, a Drill hole canthoplasty with tarsal strip, release of posterior lamellar scaring and hard plate mucosa spacer graft was performed. Results: The used approach effectively corrected the inferior lid malposition with release of the referred symptoms. Conclusion: Appropriate surgery, which is determined on the basis of the preoperative evaluation, has allowed for the correction of these previously difficult-to-treat lower eyelid malposition with minimal complications. Despite successful correction a pre operative evaluation is paramount to avoid complications in the lower eyelid surgery.

Peeling de gel de ácido tioglicólico 10%: opção segura e eficiente na pigmentação infraorbicular constitucional / 10% thioglycolic acid gel peels: a safe and efficient option in the treatment of constitutional infraorbital hyperpigmentation

Introdução: A hipercromia infraorbicular constitucional é dermatose comum, de difícil tratamento. Objetivo: Avaliar a melhoria clínica da pigmentação infraorbicular constitucional com cinco peelings seriados de ácido tioglicólico a 10% em gel. Métodos: 10 voluntárias do sexo feminino, entre 24 e 50 anos de idade, realizaram cinco sessões quinzenais de peeling de ácido tioglicólico 10% gel. Na primeira sessão, o produto foi deixado por dois minutos, acrescentando-se três minutos a cada uma das sessões subsequentes, tendo na última sido deixado por 15 minutos; 15 dias após a última sessão, foi aplicada escala de satisfação clínica, de 0 (ausência de melhora) a 10 (melhora total), tanto às pacientes quanto ao médico aplicador e a um médico avaliador-cego. Resultados: A média da satisfação clínica apontada pelas pacientes foi 7,8; a do médico aplicador, 7,6; e a do médico avaliador-cego, 6,8, sem diferenças estatísticas entre eles (p=0,065). Conclusão: Os peelings seriados de ácido tioglicólico 10% em gel são alternativa segura, eficiente e barata para a abordagem da pigmentação infraorbicular constitucional.

Introduction: Constitutional infraorbital hyperchromia (commonly called under-eye circles) is a common dermatosis that is difficult to treat. Objective:To evaluate the clinical improvement of constitutional infraorbital pigmentation resulting from the application of a series of five 10% thioglycolic acid gel peeling sessions. Methods: Patients were administered five successive 10% thioglycolic acid gel peel sessions, in 15- day intervals. In the first session, the product was left on for two minutes, with three minutes added in each subsequent session, culminating with 15 minutes of contact in the last session. Fifteen days after the last session, a satisfaction scale ranging from 0 (lack of improvement) to 10 (total improvement) was administered to the patients, to the dermatologist investigating the peelings, and to a blindevaluator medical doctor (a dermatologist that had not had taken part in the treatment sessions). Results: Study subjects (n=10) were females aged 24-50.The average clinical satisfaction presented by the patients, the investigator, and the blind-evaluator were 7.8, 7.6 and 6.8, respectively, with no statistically significant differences among them (p=0.065). Conclusion: The serial application of 10% thioglycolic acid gel peels is a safe, efficient, and costeffective treatment for constitutional infraorbital pigmentation.

Whole-body diffusion-weighted magnetic resonance imaging in the staging of oncological patients: comparison with positron emission tomography computed tomography (PET-CT) in a pilot study.

PURPOSE: The aim of this pilot study was to compare positron emission tomography computed tomography (PET-CT) and whole-body DWIBS in staging oncological patients to determine the staging accuracy of whole-body DWIBS. MATERIALS AND METHODS: We initiated a prospective, blinded investigation on 29 patients affected by oncological diseases (n=14) or lymphoma (n=15), who underwent fluorodeoxyglucose (FDG)-based PET-CT and whole-body DWIBS for restaging purposes. Magnetic resonance (MR) imaging was conducted with a multistack (n=4) DWIBS pulse sequence. Images were read independently by two experienced radiologists and one nuclear physician. Statistical analysis assessed interobserver agreement and diagnostic accuracy. RESULTS: Whole-body DWIBS had a room occupation time of 20 min. Mean postprocessing time was 15 min (range 10-17 min). Mean reading time was 20 min for reader 1 (range 15-25 min) and 18 min for reader 2 (range 13-22 min). Interobserver agreement was almost perfect (=0.93). Reader 1 had a sensitivity of 89.07%, a specificity of 98.5%, and an accuracy of 97.65%, with a positive predictive value (PPV) of 85.48% and a negative predictive value (NPV) of 98.91%. Reader 2 had a sensitivity of 87.39%, a specificity of 98.39% and a diagnostic accuracy of 97.8%, with a PPV of 88.13% and a NPV of 98.75%. CONCLUSIONS: The whole-body DWIBS protocol provided a fast whole-body examination with high specificity and NPV. One major bias of the study was the inclusion of patients with diffuse disease and advanced disease stage and the heterogeneity of the neoplastic diseases included.

Virtual MR arthroscopy of the shoulder: image gallery with arthroscopic correlation of major pathologies in shoulder instability.

BACKGROUND: The purpose of this study was to compare virtual MR arthroscopic reconstructions with arthroscopic images in patients affected by shoulder joint instability. MR arthrography (MR-AR) of the shoulder is now a well-assessed technique, based on the injection of a contrast medium solution, which fills the articular space and finds its way between the rotator cuff (RC) and the glenohumeral ligaments. In patients with glenolabral pathology, we used an additional sequence that provided virtual arthroscopy (VA) post-processed views, which completed the MR evaluation of shoulder pathology. MATERIALS AND METHODS: We enrolled 36 patients, from whom MR arthrographic sequence data (SE T1w and GRE T1 FAT SAT) were obtained using a GE 0.5 T Signa--before any surgical or arthroscopic planned treatment; the protocol included a supplemental 3D, spoiled GE T1w positioned in the coronal plane. Dedicated software loaded on a work-station was used to elaborate VAs. Two radiologists evaluated, on a semiquantitative scale, the visibility of the principal anatomic structures, and then, in consensus, the pathology emerging from the VA images. RESULTS: These images were reconstructed in all patients, except one. The visualization of all anatomical structures was acceptable. VA and MR arthrographic images were fairly concordant with intraoperative findings. CONCLUSIONS: Although in our pilot study the VA findings did not change the surgical planning, the results showed concordance with the surgical or arthroscopic images.

Getting the data right: information accuracy in pediatric emergency medicine.

OBJECTIVES: (1) To identify the extent to which information provided by parents in the pediatric emergency department (ED) can drive the assessment and categorization of data on allergies to medications, and (2) to identify errors related to the capture and documentation of allergy data at specific process level steps during ED care. METHODS: An observational study was conducted in a pediatric ED, combining direct observation at triage, a structured verbal interview with parents to ascertain a full allergy history related to medications, and chart abstraction. A comparative standard for the allergy history was established using parents' interview responses and existing guidelines for allergy. Errors associated with ED information management of allergy data were evaluated at five steps: (1) triage assessment, (2) treating physician's discussion with parent, (3) treating nurse's discussion with parent, (4) use of an allergy bracelet, and (5) documentation of allergy history on medication order sheets. RESULTS: 256 parent-child dyads were observed at triage; 211/256 parents (82.4%) completed the structured verbal interview that served as the basis for the comparative standard (CS). Parents reported a total of 59 medications as possible allergies; 56 (94.9%) were categorized as allergy or not based on the CS. Twenty eight of 48 patient cases were true allergies by guideline based assessment. Sensitivity of triage for detecting true medication allergy was 74.1% (95% confidence interval (CI) 53.7 to 88.9). Specificity of triage personnel for correctly determining that no allergy existed was 93.2% (95% CI 88.5 to 96.5). Physician and nursing care had performance gaps related to medication allergy in 10-25% of cases. CONCLUSIONS: There are significant gaps in the quality of information management regarding medication allergies in the pediatric ED.