Gait disorders in patients with instrumented neuromuscular scoliosis / Distúrbios da marcha em pacientes com escoliose neuromuscular instrumentada / Disturbios de la marcha en pacientes con escoliosis neuromuscular instrumentada

ABSTRACT Introduction: The effect of spinal fusion on gait in patients with neuromuscular scoliosis continues to be a controversial issue, especially in patients where the spinal fusion extends to the pelvis. Objective: To evaluate the effect of spinal instrumentation in these patients. Methods: We evaluated 34 patients in a retrospective study. The mean age at surgery was 14±3 years and only ambulatory patients who presented neuromuscular scoliosis and non-progressing neurogenic pathology were included. The patients were surgically treated by posterior spinal fusion with or without extension to the pelvis. Preoperative (PRE) and postoperative (POP) Rx were measured. Ambulatory potential was clinically examined in all the patients, and 10 patients were assessed by full-gait analysis. Results: The minimum POP follow-up was 2 years (2006-2016). Nine patients were instrumented to the pelvis when the obliquity was greater than 15°; the remaining patients were treated using the same fusion-level criteria as those applied for idiopathic scoliosis. All patients maintained their gait, with improvements in coronal and sagittal balance, transfers and sitting skills, physical appearance, and in some cases, gait speed. Conclusions: Spinal instrumentation in ambulatory patients with neuromuscular scoliosis, including procedures with extension to the pelvis, provides adequate correction and preserves ambulatory function. Level of evidence III; Retrospective case control study.

RESUMO Introdução: O impacto da fusão de coluna vertebral sobre a marcha de pacientes com escoliose neuromuscular continua sendo uma questão controversa, especialmente, em pacientes nos quais a fusão espinhal se estende até a pelve. Objetivo: Avaliar o efeito da instrumentação espinhal nesses pacientes. Métodos: Avaliamos 34 pacientes em estudo retrospectivo, com média de idade de 14±3 anos à cirurgia; somente pacientes deambulatórios com escoliose neuromuscular e patologia neurogênica não progressiva foram incluídos. Os pacientes foram tratados cirurgicamente com fusão posterior da coluna com ou sem extensão até a pelve. Foram feitas radiografias pré-operatórias (PRE) e pós-operatórias (POP). O potencial deambulatório foi clinicamente examinado em todos os pacientes e 10 pacientes foram avaliados com análise completa em laboratório de marcha. Resultados: O acompanhamento mínimo do POP foi de 2 anos (2006-2016). Em nove pacientes foi realizada a instrumentação até a pelve quando a obliquidade era maior que 15°; os demais pacientes foram tratados pelos mesmos critérios de nível de fusão aplicados à escoliose idiopática. Todos os pacientes mantiveram a marcha, com melhoras do balanço coronal e sagital, e transferências e capacidade para sentar, aparência física e, em alguns casos, na velocidade da marcha. Conclusões: A instrumentação da coluna vertebral em pacientes deambulatórios com escoliose neuromuscular, incluindo procedimentos com extensão até a pelve, proporciona correção adequada e preserva a função deambulatória. Nível de evidência III; Estudo retrospectivo de caso-controle.

RESUMEN Introducción: El impacto de la fusión de columna vertebral sobre la marcha de pacientes con escoliosis neuromuscular continúa siendo una cuestión controversia, especialmente, en pacientes en los que la fusión espinal se extiende hasta la pelvis. Objetivo: Evaluar el efecto de la instrumentación espinal en esos pacientes. Métodos: Evaluamos 34 pacientes en estudio retrospectivo, con promedio de edad de 14±3 años en el momento de la cirugía; fueron incluidos solamente pacientes ambulatorios con escoliosis neuromuscular y patología neurogénica no progresiva. Los pacientes fueron tratados quirúrgicamente con fusión posterior de la columna con o sin extensión hasta la pelvis. Fueron hechas radiografías preoperatorias (PRE) y postoperatorias (POP). El potencial ambulatorio fue clínicamente examinado en todos los pacientes y 10 pacientes fueron evaluados con análisis completo en laboratorio de marcha. Resultados: El acompañamiento mínimo del POP fue de 10 años (2006-2016). En nueve pacientes fue realizada la instrumentación hasta la pelvis cuando la oblicuidad era mayor que 15°; los demás pacientes fueron tratados por los mismos criterios de nivel de fusión aplicados a la escoliosis idiopática. Todos los pacientes mantuvieron la marcha, con mejoras del balance coronal y sagital, y transferencias y capacidad para sentarse, apariencia física y, en algunos casos, en la velocidad de la marcha. Conclusiones: La instrumentación de la columna vertebral en pacientes ambulatorios con escoliosis neuromuscular, incluyendo procedimientos con extensión hasta la pelvis, proporciona corrección adecuada y preserva la función ambulatoria. Nivel de evidencia III; Estudio retrospectivo de caso-controle.

Factors affecting willingness to practice medicine in underserved areas: a survey of Argentine medical students.

INTRODUCTION: Previous research has explored the effect of motivations, incentives and working conditions on willingness to accept jobs in rural and remote areas. These studies demonstrated that difficult working conditions, low job satisfaction and remuneration, and poor security, predisposed new medical graduates to select cities instead of rural districts. Since Argentina has a critical shortage of health staff in rural and low-income marginal suburban settings, and limited qualitative and quantitative local research has been done to address this issue, the present study was developed to assess the factors associated with the willingness of medical students to work in low-resource underprivileged areas of the country after graduation. METHODS: A cross-sectional descriptive design was used with data collected from a self-administered questionnaire and using quantitative analysis methods. A total of 400 eligible second-year medical students were invited to participate in a survey focused on sociodemographic characteristics, incentives and working conditions expected in deprived areas, extrinsic and intrinsic motivations, university medical education and government promotion policies. RESULTS: Twenty-one per cent of medical students showed a strong willingness to work in a deprived area, 57.3% manifested weak willingness and 21.5% unwillingness to work in a low-resource setting. Being female, of older age, not having a university-trained professional parent, previous exposure or service in a poor area, choice of pediatrics as a specialty and strong altruistic motivations were highly associated with the willingness to practice medicine in rural or underprivileged areas. Only 21.5% of respondents considered that medical schools encourage the practice of medicine in poor deprived regions. Likewise, only 6.2% of students considered that national public health authorities suitably stimulate physician distribution in poorer districts. CONCLUSIONS: One-third of students expressed high altruistic motivations and should therefore be encouraged during their careers. Better remuneration and the assurance of a position at an urban hospital in the future may tip the choice in favor of underprivileged regions. Since most respondents said that neither government nor medical schools sufficiently encourage the practice of medicine in poor deprived regions, government policy-makers should recommend changes in resource allocation to better promote official proposals and opportunities to work.

Factores asociados con el éxito académico de los estudiantes de medicina de la Universidad de Buenos Aires

El objetivo fue identificar los factores asociados al éxito académico de los estudiantes de medicina distinguidos con diploma de honor por la Universidad de Buenos Aires. En 2011 se aplicó un cuestionario a 142 graduados con esta distinción en el 2006 que incluyó 59 preguntas sobre aspectos sociodemográficos, condiciones de vida e integración social, motivación para el estudio, capacidad de aprendizaje y estado de salud durante la carrera. En comparación con los demás alumnos, los exitosos habitaban más frecuentemente en la ciudad, provenían de escuelas medias privadas o universitarias, tenían menor necesidad de trabajar para financiarse, casi todos eran solteros y sin hijos, una proporción mayor vivía lejos de su familia, tenían más progenitores profesionales y eran financiados por ellos; nunca consideraron la salida laboral para elegir la carrera, para ellos era importante alcanzar el éxito y éste dependía principalmente del esfuerzo propio; solían manejar la ansiedad, eran sociables aunque independientes y preferían la experiencia concreta a la conceptualización abstracta para adquirir información. Con el actual sistema de ingreso, estos resultados sirven para cuantificar los mecanismos latentes de autoselección durante la carrera o en un régimen restrictivo, para seleccionar los candidatos a alcanzar el éxito académico. El análisis de los factores demográficos indica algún grado de inequidad para los estudiantes menos favorecidos socialmente. Quizás, un sistema de ingreso basado solo en las capacidades intelectuales, ayudaría a individualizar y apoyar a los mejores candidatos, independientemente de su contexto social.

The aim of this study was to identify common factors relating to the academic success of medical students who were distinguished with honors at the Buenos Aires University. In 2011, 142 graduates were surveyed; the questionnaire included 59 questions on their sociodemographic environment, living conditions and social integration, motivation to study, learning capacity and health quality during their career. Compared to other students, these distinguished students more often lived in the city, far from their families; had been educated at private or universitary high schools, their economic needs were financed by their parents, who were on the whole professionals. Most of them were single and childless. The possibility of future employment oportunities (work) did not influence their choice of a medical career, academic success was important to them and they believed that success depended largely on personal effort; they knew how to handle anxiety, were sociable but independent and preferred solid experience to abstract conceptuality in order to obtain information. Our conclusion, within the current system of candidate selection, these results serve to calculate the covert self-selection mechanisms during the career, or in a more restrictive regime, to select those likely to reach academic success due to their privileged ambience. The analysis of demographic factors indicates some degree of inequality for socially disadvantaged students. Perhaps, a selection system based only on intellectual abilities would help identify and support the best candidates regardless of their social context.

[Factors associated with academic success of medical students at Buenos Aires University]. / Factores asociados con el éxito académico de los estudiantes de medicina de la Universidad de Buenos Aires.

The aim of this study was to identify common factors relating to the academic success of medical students who were distinguished with honors at the Buenos Aires University. In 2011, 142 graduates were surveyed; the questionnaire included 59 questions on their sociodemographic environment, living conditions and social integration, motivation to study, learning capacity and health quality during their career. Compared to other students, these distinguished students more often lived in the city, far from their families; had been educated at private or universitary high schools, their economic needs were financed by their parents, who were on the whole professionals. Most of them were single and childless. The possibility of future employment oportunities (work) did not influence their choice of a medical career, academic success was important to them and they believed that success depended largely on personal effort; they knew how to handle anxiety, were sociable but independent and preferred solid experience to abstract conceptuality in order to obtain information. Our conclusion, within the current system of candidate selection, these results serve to calculate the covert self-selection mechanisms during the career, or in a more restrictive regime, to select those likely to reach academic success due to their privileged ambience. The analysis of demographic factors indicates some degree of inequality for socially disadvantaged students. Perhaps, a selection system based only on intellectual abilities would help identify and support the best candidates regardless of their social context.

Factores asociados con el éxito académico de los estudiantes de medicina de la Universidad de Buenos Aires. / [Factors associated with academic success of medical students at Buenos Aires University].

The aim of this study was to identify common factors relating to the academic success of medical students who were distinguished with honors at the Buenos Aires University. In 2011, 142 graduates were surveyed; the questionnaire included 59 questions on their sociodemographic environment, living conditions and social integration, motivation to study, learning capacity and health quality during their career. Compared to other students, these distinguished students more often lived in the city, far from their families; had been educated at private or universitary high schools, their economic needs were financed by their parents, who were on the whole professionals. Most of them were single and childless. The possibility of future employment oportunities (work) did not influence their choice of a medical career, academic success was important to them and they believed that success depended largely on personal effort; they knew how to handle anxiety, were sociable but independent and preferred solid experience to abstract conceptuality in order to obtain information. Our conclusion, within the current system of candidate selection, these results serve to calculate the covert self-selection mechanisms during the career, or in a more restrictive regime, to select those likely to reach academic success due to their privileged ambience. The analysis of demographic factors indicates some degree of inequality for socially disadvantaged students. Perhaps, a selection system based only on intellectual abilities would help identify and support the best candidates regardless of their social context.

Interocepción y corteza insular: convergencia multimodal y surgimiento de la conciencia corporal / Interoception and insular cortex: multimodal convergence and the emergence of body awareness

La interocepción como censado del estado homeostático y visceral, ha sido recientemente postulada como requisito para la conciencia de estados emocionales corporales (Craig, 2009). Vías parasimpáticas y espinotalámicas que codifican esta información corporal tienen relevo en la corteza insular. Simultáneamente, han sido descriptas otras funciones insulares implicadas en procesos conscientes, como la intencionalidad, la toma de decisiones, la conciencia sensorio-motora, la percepción temporal, reconocer la imagen visual de uno mismo o percibir confiables a otros individuos (Craig, 2009; Ibanez, Gleichgerrcht, & Manes, 2010). Esta evidencia, sumada a resultados de estudios de lesión y neuroimágenes funcionales, sugiere que la corteza insular anterior (IA) sería la encargada de integrar señales multimodales cognitivas, emocionales y sociales para dirigir las conductas motivacionales que entrañan la supervivencia del individuo. En esta revisión analizamos el cúmulo de evidencia que involucran a la interocepción y al procesamiento insular integrativo en el surgimiento de estados emocionales conscientes, a través de estudios de lesiones y de técnicas de conectividad funcional en resonancia magnética funcional (RMF).

Recent research have suggested that interoception, defined as the sensing of homeostatic and visceral state, is a prerequisite for the emerging of conscious body feelings (Craig, 2009). Parasympathetic and spinothalamic pathways coding such information from the body have their final station in insular cortex neurons. At the same time, several other cognitive functions related to awareness, have been associated with insular activation such as intentionality, decision making, sensory motor consciousness, time perception, recognition of self´s image, or trust on someone else (Craig, 2009; Ibanez et al., 2010). Lesion studies and functional neuroimaging research is in line with this evidence, suggesting that anterior insular cortex would be engaged in integrate multimodal cognitive, emotional and social information in order to modulate motivational behavior leading to the survival of the individual. In this review, we analyze last research works on interoception and integrative insular processing through lesion studies and functional connectivity in functional magnetic resonance imaging (FC-fMRI).

Fiebre en el posoperatorio de cirugias ortopedicas con multiples abordajes en la poblacion neuropediatrica / The relevance of fever after multi-level surgery in cerebral palsy and myelomeningocele

Introduccion: El proposito de este estudio es conocer nuestro indice de fiebre en el posoperatorio de cirugias neuroortopedicas electivas con abordajes multiples; identificar las complicaciones asociadas con la fiebre y las implicancias de los registros febriles en el tratamiento de nuestros pacientes; y sugerir una guia de conducta en estos casos. Materiales y metodos: Evaluamos en forma retrospectiva 50 cirugias ortopedicas pediatricas con multiples abordajes realizadas de manera electiva en una poblacion neuropediatrica en nuestro centro. Los pacientes (29 varones y 21 niñas) tenian una edad media de 9 años y 2 meses, dentro de un rango de 16 años y 3 meses y 12 meses. Todos los pacientes presentaban patologia neurologica de base; la mas frecuente fue la encefalopatia secuelar no progresiva (36/50) y el mielomeningocele (14/50).En cada una de las cirugias se evaluo: tiempo quirurgico, tipo de anestesia, cantidad de abordajes, transfusiones, registros termicos intraoperatorios y registros termicos posoperatorios; se considero registro febril aquel mayor de 38º C. Se consideraron el tiempo de internacion, los estudios complementarios solicitados y las complicaciones. Resultados: Veintiuno de los 50 pacientes presentaron fiebre en el posoperatorio, es decir un 42 por ciento. Los pacientes con registros febriles presentaron una duracion promedio de 169, con un rango de 120 a 310 minutos. El grupo de pacientes sin registros febriles tuvo de promedio 108 minutos con un rango de 60 a 220 minutos. De los 14 procedimientos en pacientes con mielomeningocele 10 presentaron fiebre en el posoperatorio y 4, no. Esto indica que un 71,4 por ciento de los pacientes con mielomeningocele tuvieron registros febriles en el posoperatorio inmediato. Dos pacientes con fiebre presentaron examenes de laboratorio con eritrosedimentacion elevada (70 y 80) en la primera hora y globulos blancos tambien elevados (> 10 000). En estos pacientes se realizaron multicultivos por la falta de...(AU)

Fiebre en el posoperatorio de cirugias ortopedicas con multiples abordajes en la poblacion neuropediatrica / The relevance of fever after multi-level surgery in cerebral palsy and myelomeningocele

Introduccion: El proposito de este estudio es conocer nuestro indice de fiebre en el posoperatorio de cirugias neuroortopedicas electivas con abordajes multiples; identificar las complicaciones asociadas con la fiebre y las implicancias de los registros febriles en el tratamiento de nuestros pacientes; y sugerir una guia de conducta en estos casos. Materiales y metodos: Evaluamos en forma retrospectiva 50 cirugias ortopedicas pediatricas con multiples abordajes realizadas de manera electiva en una poblacion neuropediatrica en nuestro centro. Los pacientes (29 varones y 21 niñas) tenian una edad media de 9 años y 2 meses, dentro de un rango de 16 años y 3 meses y 12 meses. Todos los pacientes presentaban patologia neurologica de base; la mas frecuente fue la encefalopatia secuelar no progresiva (36/50) y el mielomeningocele (14/50).En cada una de las cirugias se evaluo: tiempo quirurgico, tipo de anestesia, cantidad de abordajes, transfusiones, registros termicos intraoperatorios y registros termicos posoperatorios; se considero registro febril aquel mayor de 38º C. Se consideraron el tiempo de internacion, los estudios complementarios solicitados y las complicaciones. Resultados: Veintiuno de los 50 pacientes presentaron fiebre en el posoperatorio, es decir un 42 por ciento. Los pacientes con registros febriles presentaron una duracion promedio de 169, con un rango de 120 a 310 minutos. El grupo de pacientes sin registros febriles tuvo de promedio 108 minutos con un rango de 60 a 220 minutos. De los 14 procedimientos en pacientes con mielomeningocele 10 presentaron fiebre en el posoperatorio y 4, no. Esto indica que un 71,4 por ciento de los pacientes con mielomeningocele tuvieron registros febriles en el posoperatorio inmediato. Dos pacientes con fiebre presentaron examenes de laboratorio con eritrosedimentacion elevada (70 y 80) en la primera hora y globulos blancos tambien elevados (> 10 000). En estos pacientes se realizaron multicultivos por la falta de...(AU)

Fiebre en el posoperatorio de cirugias ortopedicas con multiples abordajes en la poblacion neuropediatrica / The relevance of fever after multi-level surgery in cerebral palsy and myelomeningocele

Introduccion: El proposito de este estudio es conocer nuestro indice de fiebre en el posoperatorio de cirugias neuroortopedicas electivas con abordajes multiples; identificar las complicaciones asociadas con la fiebre y las implicancias de los registros febriles en el tratamiento de nuestros pacientes; y sugerir una guia de conducta en estos casos. Materiales y metodos: Evaluamos en forma retrospectiva 50 cirugias ortopedicas pediatricas con multiples abordajes realizadas de manera electiva en una poblacion neuropediatrica en nuestro centro. Los pacientes (29 varones y 21 niñas) tenian una edad media de 9 años y 2 meses, dentro de un rango de 16 años y 3 meses y 12 meses. Todos los pacientes presentaban patologia neurologica de base; la mas frecuente fue la encefalopatia secuelar no progresiva (36/50) y el mielomeningocele (14/50).En cada una de las cirugias se evaluo: tiempo quirurgico, tipo de anestesia, cantidad de abordajes, transfusiones, registros termicos intraoperatorios y registros termicos posoperatorios; se considero registro febril aquel mayor de 38° C. Se consideraron el tiempo de internacion, los estudios complementarios solicitados y las complicaciones. Resultados: Veintiuno de los 50 pacientes presentaron fiebre en el posoperatorio, es decir un 42 por ciento. Los pacientes con registros febriles presentaron una duracion promedio de 169, con un rango de 120 a 310 minutos. El grupo de pacientes sin registros febriles tuvo de promedio 108 minutos con un rango de 60 a 220 minutos. De los 14 procedimientos en pacientes con mielomeningocele 10 presentaron fiebre en el posoperatorio y 4, no. Esto indica que un 71,4 por ciento de los pacientes con mielomeningocele tuvieron registros febriles en el posoperatorio inmediato. Dos pacientes con fiebre presentaron examenes de laboratorio con eritrosedimentacion elevada (70 y 80) en la primera hora y globulos blancos tambien elevados (> 10 000). En estos pacientes se realizaron multicultivos por la falta de...