Numerical values and impact of hypertension in Spain.

In Spain, 33% of adults aged 30 to 79 years (10 million) were hypertensive in 2019. Among them, 68% were diagnosed, 57% received drug therapy, and effective therapeutic coverage (control) reached 33%. Both diagnosis and control show geographical and social disparities. Approximately 46 000 cardiovascular deaths per year are attributable to hypertension. In recent decades, the control of hypertension has increased, due to improvements in lifestyle measures and increased use of polytherapy, coinciding with a reduction in stroke mortality. There are several modifiable determinants of the lack of hypertension control: a) white-coat phenomenon affects 22% to 33% of treated individuals, partly due to the limited availability of ambulatory blood pressure monitoring (ABPM) (49%) and self-measured BP (SMBP) (78%); b) inadequate patient adherence to medication and healthy lifestyles (weight loss, the most effective measure, is the least used, ≈40%); and c) insufficient use of polytherapy (≈55%). The remaining challenges include: a) technological aspects, such as measuring BP with more accurate techniques (ABPM, SMBP) and using cardiovascular-risk estimation tools (eg, SCORE); b) clinical challenges, such as reducing therapeutic inertia (≈59%), involving patients in their own management (medication adherence, ≈62%) and effectively implementing clinical guidelines); and c) public health challenges, such as reducing the burden of obesity (≈24%), monitoring progress with updated surveys, and setting national BP control targets.

Tratamiento quirúrgico de las neoplasias en la glándula parótida / Surgical treatment of the neoplasmsof the parotid gland

Objetivo: Caracterizar a pacientes con diagnóstico de neoplasias en glándula parótida, según el procedimiento quirúrgico efectuado, la técnica de identificación del nervio facial, y la relación de los hallazgos patológicos definitivos con los estudios de muestreo histológico preoperatorio. Métodos: Estudio multidisciplinario, multiinstitucional, descriptivo, cuantitativo y retrospectivo de 26 pacientes con diagnóstico de neoplasias en glándula parótida entre el año 2018 al 2023. Se dividieron de acuerdo a la histología en benignas y malignas. Las distintas frecuencias fueron expresadas en número y porcentaje. Se calculó la sensibilidad y especificidad de la punción con aguja fina como prueba de muestreo histológico. Resultados: Categoría benigna: 16 pacientes (61,5% %). El resto de la serie, diez pacientes, de la categoría de tumores malignos (38,5%). La lobectomía superficial parotídea fue el procedimiento más frecuente en las neoplasias benignas (75%) y malignas (60%). La técnica anterógrada de identificación del nervio facial fue la más común. Entre 25% a 30% de parálisis temporales en ambos grupos. La sensibilidad y especificidad de la punción con aguja fina para el diagnóstico de neoplasias benignas fue de 92,3% y 50%, el porcentaje de falsos negativos de 5,8%. Conclusión: La lobectomía superficial de la glándula parótida y la técnica anterógrada representaron el procedimiento quirúrgico y la técnica de identificación del nervio facial más frecuentemente realizado en ambas categorías. La baja especificidad de la punción con aguja fina y el porcentaje de falsos negativos representaron algunas de las dificultades a afrontar para decidir la extensión del tratamiento quirúrgico(AU)

Objective: To evaluate the surgical procedure, technique identification of nerve facial and correlate the pathological findings withthe preoperative histological sampling studies, in patients with neoplasms parotid underwent surgery. Methods: Study multi-institutiona, multi-disciplinary, descriptive y quantitative of 26 patients with neoplasm parotid between the years 2018 to 2023. We divided in two categories benign and malignant. The frequency was expressed in number and percentage. It was calculated the sensibility and specificity of the fine needle puncture. Results: Category benign: 16 patients (61,5% %). Malignant, ten patients (38,5%). The lobectomy superficial was the surgical procedure more frequent in the neoplasm benign (75%) and malignant (60%). The anterograde technique of identification of nerve facial was the more common. Between 25% and 30% presents facial palsytemporal. The sensibility and specificity of the fine needle puncture were 92,3% y 50%, the percentage of false negatives was 5,8%. Conclusion: In this study the lobectomy superficial and anterograde technique were the surgical procedure and technique of identification of nerve facial more frequent in both categories. The low specificity of fine needle puncture and the percentage of false negatives were some of the difficulties to affront in the decision of the surgery exten(AU)

Two new species of terrestrial frogs of the Pristimantisgladiator complex (Anura, Strabomantidae) from the Ecuadorian Andes, with insights on their biogeography and skull morphology.

The explosive diversity of rainfrogs (Pristimantis spp) reaches its highest levels in the mountains of the Tropical Andes, with remarkable cryptic species mainly in unexplored areas of Ecuador. Based on phylogenetics, morphometric traits, skull osteology and bioacoustics, we describe two new species of Pristimantis, previously confused with Pristimantisgladiator, that belong to the subgenus Trachyphrynus traditionally known as the Pristimantismyersi species group. The two new taxa are closely related, but have allopatric distributions. We discuss the importance of the Quijos and Pastaza River valleys in the diversification along Amazonian slopes of the Ecuadorian Andes.

First insights in terrestrial mammals monitoring in the Candelaria and Machay Reserves in the Ecuadorian Tropical Andes.

Habitat disturbance leads to biodiversity decline and modifications in the landscape structure and composition, affecting both dispersal movements and ecological processes at different temporal and spatial scales. The Ecuadorian Tropical Andes harbour suitable habitats for the distribution of a wide variety of species; however, there is a lack of studies focused on mammal diversity and its association with the habitat attributes in the central-eastern slopes. Here, we reported the diversity of terrestrial mammals recorded between 2019 and 2021 in a camera-trap monitoring study in the Candelaria and Machay reserves in the upper basin of the Pastaza River, Ecuador. We performed site-occupancy probability analysis to assess the influence of spatial variables in the species' occurrence and also, based on natural marks, we reported preliminary findings in Andean bear individual identification. We detected 22 species of terrestrial mammals. Alpha diversity was similar between reserves with slightly higher species richness in Machay. Evenness indices showed unequal species distribution, with the Andean bear and domestic dogs exhibiting greater dominance. In addition, species composition was dissimilar between reserves, where the species turnover mostly explained the beta diversity. We observed that Andean bear and puma detections increased according to the natural vegetation cover. Conversely, domestic dogs were frequently detected in cells with an increasing proportion of pastures and crops. Additionally, we identified 26 Andean bears and six individuals recaptured during our study. Our results caution about the disturbance derived from human activities since we recorded unprecedented detections of domestic dogs in wild habitats. Nonetheless, it highlights the importance of private conservation areas (e.g. Candelaria, Machay and others) for supporting the occurrence and dispersal of terrestrial mammal species between larger areas in the upper basin of the Pastaza River.

A spectacular new species of Hyloscirtus (Anura: Hylidae) from the Cordillera de Los Llanganates in the eastern Andes of Ecuador.

We have discovered a spectacular new species of frog in the genus Hyloscirtus, belonging to the H. larinopygion species group. The adult female is characterized by a mostly black body with large bright red spots on the dorsal and ventral surface, extremities, and toe pads. The adult male is unknown. Small juveniles are characterized by a yellow body with variable black markings on the flanks; while one larger juvenile displayed irregular orange or yellow marks on a black background color, with light orange or yellow toe pads. Additional distinctive external morphological features such as cloacal ornamentation are described, and some osteological details are imaged and analyzed. The performed phylogeny places the new species as the sister to a clade consisting of ten taxa, all of which are part of the H. larinopygion group. We use genetic distances to fit the new species into a published time-calibrated phylogeny of this group; our analysis based on the published chronology suggests that the divergence of the new species from its known congeners pre-dates the Quaternary period. The new species is currently only known only from Cerro Mayordomo, in Fundación EcoMinga´s Machay Reserve, at 2,900 m in the eastern Andes of Tungurahua province, Ecuador, near the southern edge of Los Llanganates National Park, but its real distribution may be larger.

Estado de la información médica y el consentimiento del paciente en cirugía ortopédica y traumatología en el Hospital Universitario de Burgos (periodo 2017-2018) / Status of medical information and patient consent in orthopedic surgery and traumatology at the University Hospital of Burgos (period 2017-2018)

Introducción: El principio de autonomía es la base del concepto de consentimiento informado. El consentimiento informado es un derecho del paciente que consiste en que este, previamente a que se efectúe la intervención médica en su cuerpo, debe expresar su conformidad que debe ir precedida de la debida información que le permite decidir según sus intereses. En este trabajo, nuestro objetivo fue conocer la situación de la información médica y del consentimiento informado del paciente en el Servicio de Traumatología y Cirugía Ortopédica del Hospital Universitario de Burgos.Material y métodosSe elaboró y distribuyó un cuestionario anónimo entre 647 pacientes de cirugía ortopédica y traumatología del Hospital Universitario de Burgos. Posteriormente, se realizó un estudio cuantitativo observacional descriptivo de corte transversal. Se estudió la asociación de las variables sociodemográficas con las respuestas a los ítems del cuestionario.ResultadosSolo el 28,9% de los pacientes conoce que la información es un derecho, pero la mayoría (97,3%) manifestaron la necesidad de recibir información sobre riesgos y complicaciones del tratamiento y consideran que la información no aumenta el miedo o ansiedad (63,4%). La mayoría afirmaron que fueron informados sobre la actuación asistencial (98,1%), comprendiendo las explicaciones recibidas (98,0%). El tiempo utilizado fue suficiente (73,7%). En general, la información recibida fue calificada como suficiente (89,8%).ConclusionesLos pacientes, en su mayoría, se sintieron informados y consideraron que el tiempo que el facultativo había tenido para ello era suficiente. (AU)

Introduction: The principle of autonomy is the basis of the informed consent concept. Informed consent is a patient´s right consisting in prior to the medical intervention being carried out on his body, he must express his agreement that it must be preceded by the proper information that allows him to decide according to his interests. In this work, our objective was to know the status of medical information and informed consent of the patient in the Traumatology and Orthopedic Surgery Service of the University Hospital of Burgos.Material and methodsAn anonymous questionnaire was prepared and distributed among 647 orthopedic surgery and trauma patients at the University Hospital of Burgos. Subsequently, a descriptive, cross-sectional, observational quantitative study was carried out. The association of sociodemographic variables with the responses to the questionnaire items was studied.ResultsOnly 28.9% of the patients know that information is a right, but the majority (97.3%) expressed the need to receive information on risks and complications of the treatment and consider that the information does not increase fear or anxiety (63.4%). The majority stated that they were informed about the care performance (98.1%), understanding the explanations received (98.0%). The time used was sufficient (73.7%). In general, the information received was rated as sufficient (89.8%).ConclusionsMost of the patients felt informed and considered that the time that the doctor had had for this was sufficient. (AU)

Conducta selectiva en trauma penetrante de cuello / Selective management in penetrating neck trauma

Objetivo: evaluar la incidencia de hallazgosquirúrgicos positivos en pacientes con diagnóstico de traumapenetrante de cuello de dos instituciones hospitalariascapitalinas, sometidos a exploración quirúrgica inmediatao conducta selectiva. Métodos: en un estudio descriptivo,cuantitativo y transversal, se evaluaron 22 heridos condiagnóstico de lesiones penetrantes de cuello entre años 2017y 2021. Se dividieron en dos grupos de acuerdo al tipo deconducta aplicada. Las distintas frecuencias fueron expresadas ennúmero y porcentaje. Resultados: Grupo A, ocho heridos (36,4%), siete ingresaron con signos duros sometidos a exploraciónquirúrgica inmediata, el 87,5 % presentó hallazgos positivos ala cervicotomía; dos fueron incluidos en un esquema de cirugíade control de daños. Grupo B, catorce lesionados con signosblandos admitidos para conducta selectiva mediante observaciónfrecuente y realización de diversos estudios paraclínicos (63,6%),tres requirieron intervención operatoria por la presencia deenfisema subcutáneo expansivo después de las primeras 48 horas;se identificó una lesión esofágica, que se reparó con cierreprimario y rotación de colgajo muscular. Conclusión: En elpresente estudio, la incorporación de la conducta selectiva enel manejo multidisciplinario del trauma penetrante de cuellopermitió incrementar el número de exploraciones positivas yreducir las negativas. Nuevas estrategias como la cirugía decontrol de daños y la zona cero han sido incluidas en algunasheridas vasculares o lesiones extensas(AU)

Objective: To evaluate the incidence of positiveexplorations in patients with penetrating neck trauma oftwo capitals hospitals underwent to immediate surgicalexploration or selective management. Method: Studydescriptive, quantitative and transversal of twenty-two patientswith penetrating neck trauma since years 2017 to 2021. Distribute in two groups in the basis of the management.Different frequency express in frequency and percentages.Results: Group A, eight injured, 36.4 %. Seven with hardsigns, underwent immediate surgical exploration of the neck.the 87.5 % had positive explorations. Two were included in ascheme of surgery damaged control. Evidenced injuries extentsand for high velocity projectile. Group B, fourteen wounded,63.6 %. three required surgical intervention for the presence ofpersistent emphysema. One occult esophagical injury, repairedwith suture and muscular rotation. Conclusion: In the present study the selective management of penetrating neck traumapermit increase the number of positive explorations and reducethe negatives. this alternative was viable and secures(AU)

PITS: An Intelligent Transportation System in pandemic times.

The control of the pandemic caused by SARS-CoV-2 is a challenge for governments all around the globe. To manage this situation, countries have adopted a bundle of measures, including restrictions to population mobility. As a consequence, drivers face with the problem of obtaining fast routes to reach their destinations. In this context, some recent works combine Intelligent Transportation Systems (ITS) with big data processing technologies taking the traffic information into account. However, there are no proposals able to gather the COVID-19 health information, assist in the decision-making process, and compute fast routes in an all-in-one solution. In this paper, we propose a Pandemic Intelligent Transportation System (PITS) based on Complex Event Processing (CEP), Fuzzy Logic (FL) and Colored Petri Nets (CPN). CEP is used to process the COVID-19 health indicators and FL to provide recommendations about city areas that should not be crossed. CPNs are then used to create map models of health areas with the mobility restriction information and obtain fast routes for drivers to reach their destinations. The application of PITS to Madrid region (Spain) demonstrates that this system provides support for authorities in the decision-making process about mobility restrictions and obtain fast routes for drivers. PITS is a versatile proposal which can easily be adapted to other scenarios in order to tackle different emergency situations.

Strong differentiation between amphibian communities on two adjacent mountains in the Upper Rio Pastaza watershed of Ecuador, with descriptions of two new species of terrestrial frogs.

We present the results of herpetological surveys in two adjacent mountains where the EcoMinga Foundation protects the cloud forest in the Upper Rio Pastaza watershed, in the Llanganates Sangay Ecological Corridor in Ecuador. A rapid assessment of the amphibian communities of the study sites reveals a diverse and heterogeneous composition, dominated by terrestrial frogs from the genus Pristimantis. We also identify a cryptic diversity with a significant number of candidate new species. We describe two new species of terrestrial frogs of the genus Pristimantis. Pristimantismaryanneae sp. nov. is characterised by not having tympanum externally visible and having 2-3 subconical tubercles in the upper eyelid; and Pristimantisburtoniorum sp. nov. is characterised by the presence of red colouration in hidden surfaces of the hind-limbs, tubercles on the upper eyelid, interorbital tubercle and a row of rounded tubercles along the snout to the tip and a pale red venter with dark brown mottled pattern. Our samples from the two Reserves do not share species between them, so the proportion of shared species seems to be relatively low. In addition, we highlight the importance of updating the knowledge of amphibians that are restricted to this important conservation region and comment about the threats and composition of the amphibian communities on the eastern slopes of the Upper Rio Pastaza watershed.

Safety and Efficacy of Botulinum Toxin in the Treatment of Self-Biting Behavior in Lesch-Nyhan Disease.

BACKGROUND: Lesch-Nyhan disease (LND) is a disease of purine metabolism linked to chromosome X due to the absence or near-absence of enzyme hypoxanthine-guanine phosphoribosyltransferase. Patients with LND have a compulsive autoaggressive behavior that consists of self-mutilation by biting. METHODS: The objective of this study was to explore the safety and efficacy of botulinum toxin (BoNT) injected into the masticatory muscles and biceps brachii to reduce self-mutilation in patients with LND. We retrospectively analyzed six patients with LND who were treated with BoNT to prevent automutilatory behavior. RESULTS: The patient ages when started on treatment with BoNT were 4, 4.5, 6.6, 7.9, 13.9, and 32.3 years. Patients received a mean number of injections of 20, ranging from 3 to 29, over a period that ranged from 1.5 to 7.1 years. The maximum total dose of Botox was 21.3 units/kg mean and the maximum total dose of Dysport was 37.5 units/kg mean. A total of 119 injections were performed. Of these 113 (95%) were partially or completely effective. Only three of 119 injections (2.5%) produced adverse effects. CONCLUSIONS: Botulinum toxin is useful and safe for the treatment of self-biting behavior in patients with LND.

Detecting security attacks in cyber-physical systems: a comparison of Mule and WSO2 intelligent IoT architectures.

The Internet of Things (IoT) paradigm keeps growing, and many different IoT devices, such as smartphones and smart appliances, are extensively used in smart industries and smart cities. The benefits of this paradigm are obvious, but these IoT environments have brought with them new challenges, such as detecting and combating cybersecurity attacks against cyber-physical systems. This paper addresses the real-time detection of security attacks in these IoT systems through the combined used of Machine Learning (ML) techniques and Complex Event Processing (CEP). In this regard, in the past we proposed an intelligent architecture that integrates ML with CEP, and which permits the definition of event patterns for the real-time detection of not only specific IoT security attacks, but also novel attacks that have not previously been defined. Our current concern, and the main objective of this paper, is to ensure that the architecture is not necessarily linked to specific vendor technologies and that it can be implemented with other vendor technologies while maintaining its correct functionality. We also set out to evaluate and compare the performance and benefits of alternative implementations. This is why the proposed architecture has been implemented by using technologies from different vendors: firstly, the Mule Enterprise Service Bus (ESB) together with the Esper CEP engine; and secondly, the WSO2 ESB with the Siddhi CEP engine. Both implementations have been tested in terms of performance and stress, and they are compared and discussed in this paper. The results obtained demonstrate that both implementations are suitable and effective, but also that there are notable differences between them: the Mule-based architecture is faster when the architecture makes use of two message broker topics and compares different types of events, while the WSO2-based one is faster when there is a single topic and one event type, and the system has a heavy workload.

A new and very spiny lizard (Gymnophthalmidae: Echinosaura) from the Andes in northwestern Ecuador.

We describe a new species of Neotropical spiny-lizard of the genus Echinosaura from the Imbabura and Carchi Provinces on the western slopes of the Andes in northwestern Ecuador. The new species mostly resembles E. horrida. However, it can be distinguished from all congeners by having keeled enlarged dorsal scales forming a paired vertebral row, two paravertebral series of short oblique rows of projecting scales, and a pair of spine-like scales on temporal and nuchal regions. We also provide a detailed description of the osteology of the skull and pectoral girdle of the new species and present a phylogenetic hypothesis for Echinosaura based on three mitochondrial genes (12S, 16S, ND4) and one nuclear gene (c-mos).

Decentralizing Cell-Free RNA Sensing With the Use of Low-Cost Cell Extracts.

Cell-free gene expression systems have emerged as a promising platform for field-deployed biosensing and diagnostics. When combined with programmable toehold switch-based RNA sensors, these systems can be used to detect arbitrary RNAs and freeze-dried for room temperature transport to the point-of-need. These sensors, however, have been mainly implemented using reconstituted PURE cell-free protein expression systems that are difficult to source in the Global South due to their high commercial cost and cold-chain shipping requirements. Based on preliminary demonstrations of toehold sensors working on lysates, we describe the fast prototyping of RNA toehold switch-based sensors that can be produced locally and reduce the cost of sensors by two orders of magnitude. We demonstrate that these in-house cell lysates provide sensor performance comparable to commercial PURE cell-free systems. We further optimize these lysates with a CRISPRi strategy to enhance the stability of linear DNAs by knocking-down genes responsible for linear DNA degradation. This enables the direct use of PCR products for fast screening of new designs. As a proof-of-concept, we develop novel toehold sensors for the plant pathogen Potato Virus Y (PVY), which dramatically reduces the yield of this important staple crop. The local implementation of low-cost cell-free toehold sensors could enable biosensing capacity at the regional level and lead to more decentralized models for global surveillance of infectious disease.

A new Andean treefrog (Amphibia: Hyloscirtus bogotensis group) from Ecuador: an example of community involvement for conservation.

We provide several lines of evidence to delimit a new species of Hyloscirtus and define its phylogenetic position inside the Hyloscirtus bogotensis group. The new species is the sister taxon to Hyloscirtus mashpi and is related to a clade formed by H. alytolylax and a putative new species from the province of El Oro in, southwestern Ecuador. Hyloscirtus conscientia sp. nov. is described from the montane forests of the Mira River basin in the extreme northwestern Ecuador. The new species is characterized as follows: tympanic annulus conspicuous, tip of snout in dorsal view subacuminate, middorsal stripe formed by melanophores larger and less dense, dorsal skin with individual iridophores forming dots, scarcely distributed across dorsum. Our study also highlights the importance of the Mira River Valley as a biogeographic barrier; suggesting research efforts north and south of the valley are likely to reveal additional endemic cryptic diversity. Finally, our partnership with Reserva: The Youth Land Trust, Rainforest Trust and EcoMinga Foundation has produced a novel and meaningful way to connect young people with biodiversity discovery and habitat conservation.

Sala de emergencias Bagdad. La evolución en la cirugía de control de daños / Baghdad ER. The evolution of damage control surgery

Las características de las heridas producidas en los atentados terroristas en varias ciudades del mundo y en los combates de las operaciones militares en Afganistán e Irak, han determinado un nuevo tipo de manejo de las lesiones por parte del personal medico involucrado. La categorización de las hemorragias, el nuevo esquema de atención prehospitalaria MARCH y la incorporación de la resucitación balanceada a la cirugía de control de daños, en un hospital de soporte en combate en Bagdad, representan parte del cambio. La retroalimentación entre la experiencia civil y militar ha permitido el progreso del tratamiento de los traumatismos. Los hospitales venezolanos han desarrollado su propia experiencia en el desarrollo de la cirugía de control de daños. Un nuevo tipo de ingresos en las emergencias capitalinas y la covid 19 señalan los nuevos desafíos a los que se enfrentan los cirujanos venezolanos(AU)

The large number of casualties produced as a result of terrorist attacks and the wars in Afghanistan and Iraq, stimulated the medical community to rethink the management of trauma. The categorization of the haemorrhages, the new mnemonic MARCH and the incorporation the balanced resuscitation in the damage control surgery, in a combat support hospital in Baghdad, represent a change. The feedback between the civil and military permitted the progress in the treatment of the injuries. The venezuelans hospitals development their experience in the damage control surgery. A new kind of injuries in the capital and the covid 19 indicate the news challenges for the surgeons(AU)

Red List assessment of amphibian species of Ecuador: A multidimensional approach for their conservation.

Ecuador is one of the most biodiverse countries in the world, but faces severe pressures and threats to its natural ecosystems. Numerous species have declined and require to be objectively evaluated and quantified, as a step towards the development of conservation strategies. Herein, we present an updated National Red List Assessment for amphibian species of Ecuador, with one of the most detailed and complete coverages for any Ecuadorian taxonomic group to date. Based on standardized methodologies that integrate taxonomic work, spatial analyses, and ecological niche modeling, we assessed the extinction risk and identified the main threats for all Ecuadorian native amphibians (635 species), using the IUCN Red List Categories and Criteria. Our evaluation reveals that 57% (363 species) are categorized as Threatened, 12% (78 species) as Near Threatened, 4% (26 species) as Data Deficient, and 27% (168 species) as Least Concern. Our assessment almost doubles the number of threatened species in comparison with previous evaluations. In addition to habitat loss, the expansion of the agricultural/cattle raising frontier and other anthropogenic threats (roads, human settlements, and mining/oil activities) amplify the incidence of other pressures as relevant predictors of ecological integrity. Potential synergic effects with climate change and emergent diseases (apparently responsible for the sudden declines), had particular importance amongst the threats sustained by Ecuadorian amphibians. Most threatened species are distributed in montane forests and paramo habitats of the Andes, with nearly 10% of them occurring outside the National System of Protected Areas of the Ecuadorian government. Based on our results, we recommend the following actions: (i) An increase of the National System of Protected Areas to include threatened species. (ii) Supporting the ex/in-situ conservation programs to protect species considered like Critically Endangered and Endangered. (iii) Focalizing research efforts towards the description of new species, as well as species currently categorized as Data Deficient (DD) that may turn out to be threatened. The implementation of the described actions is challenging, but urgent, given the current conservation crisis faced by amphibians.

Trauma urbano moderno en Caracas / Modern urban trauma in Caracas

A principios del nuevo milenio surgió el concepto del "Trauma urbano moderno", sustentando en la experiencia de varios conflagraciones en zonas densamente pobladas. Fue definido como un conflicto violento, cerrado, con heridas destructivas y de difícil acceso para su evacuación. Su manejo incluyo el cuestionamiento de viejos dogmas y la incorporación de nuevas estrategias. El motín del reten "La Planta", el incremento en las detonaciones por granadas fragmentarias y los graves enfrentamientos entre bandas delictivas o contra cuerpos de seguridad, en diversas zonas de Caracas indican el establecimiento de una modalidad mas agresiva de violencia. Los cirujanos capitalinos se enfrentan con más frecuencia a lesiones severas y múltiples. El personal medico requiere la adecuada comprensión y preparación para afrontar este nuevo tipo de heridas. La reciente enfermedad Covid 19 representa un desafió agregado en el abordaje de los pacientes con traumatismos(AU)

The experience in many combats in densely populated urban areas, determined the new concept of "Modern urban warfare" in the beginning of the new millennium. This definition is a warfare violent, close-quarter, with destructive injuries and the delayed of evacuation. New innovations were incorporate. The revolt in the "La Planta" prison, the increase of grenades explosions and engagement between criminal organized, in many zones of Caracas, illustrated this new definition. The venezuelans surgeons attended many severe and multiple injuries. The surgical personal need understand this new kind of injuries. The new disease Covid 19 represents a challenge in the attention of these patients(AU)