Heridas por proyectil de arma de fuego. Atipicidad en orificios de entrada y el fenómeno de ''cola de cometa": Reporte de caso / Gunshot wounds. Atypicality in entry holes and the "comet tail" phenomenon: Case report

El análisis de los orificios de entrada por proyectil de arma de fuego en una autopsia médico legal representa un importante papel en la determinación de la forma y causa de muerte en casos relacionados con armas de fuego. Su valoración puede proporcionar información valiosa sobre las características del arma utilizada, la distancia entre el arma de fuego y la víctima, entre otros factores que contribuyen a la investigación. El fenómeno de ''cola de cometa" observado en ciertos orificios de entrada es poco frecuente y conocido. Por lo anterior, el objetivo de este artículo es investigar las características y mecanismos de producción de los orificios de entrada con este fenómeno, proporcionando información sobre su formación, las posibles implicaciones y consideraciones médico legales a tomar en cuenta para su diagnóstico de esta causa de muerte. Se presenta un reporte de caso que destaca la descripción del fenómeno de ''cola de cometa" en una investigación forense de la vida real, proporcionando información valiosa sobre su utilidad y potencial para mejorar la precisión del análisis de heridas de bala. Se realizó revisión de artículos científicos, sobre orificios de entrada en heridas por proyectil de arma de fuego con el fenómeno de ''cola de cometa".

The analysis of firearm projectile entry holes in a medicolegal autopsy plays an important role in determining the manner and cause of death in cases involving firearms. The assessment can provide valuable information about the characteristics of the weapon used, the distance between the firearm and the victim, among other factors that contribute to the investigation. The ''comet tail" phenomenon observed in certain entry holes is rare and well known. Therefore, the objective of this article is to investigate the characteristics and mechanisms of production of the entrance orifices with this phenomenon, providing information about their formation, the possible implications, and medical-legal considerations to be taken into account for the diagnosis of this cause of death. A case report is presented highlighting the description of the ''comet tail" phenomenon in a real-life forensic investigation, providing valuable insight into its utility and potential to improve the accuracy of gunshot wound analysis. A review of scientific articles was carried out on entry holes in gunshot wounds with the "comet tail" phenomenon.

Heridas atípicas producidas por proyectil de arma de fuego Reporte de caso / Atypical wounds caused by firearm projectile Case report

Resumen Las heridas por proyectil de arma de fuego se definen como los efectos que producen sobre el organismo los disparos realizados con armas cargadas de proyectiles o diversos tipos de pólvora u otros explosivos. La valoración médico legal en estos casos, en personas vivas, se realiza en la Sección Clínica Médico Forense del Departamento de Medicina Legal del Organismo de Investigación Judicial, esta incluye la historia médico legal, el examen físico, el análisis de documentos médicos aportados, pericias conexas efectuadas y revisión de bibliografía, esto para tener todos los elementos de juicio que permitan realizar un análisis objetivo y basado en la evidencia científica, y así poder responder a las interrogantes de la Autoridad Judicial. El presente artículo abarca algunos de los aspectos principales a tomar en cuenta ante hallazgos atípicos de los orificios de entrada y salida de los proyectiles, mediante la presentación y abordaje de un caso clínico.

Abstract Firearm projectile injuries are defined as the effects produced on the body by shots fired with weapons loaded with projectiles or various types of gunpowder or other explosives. The legal medical assessment in these cases, in living persons, is carried out in the Forensic Medical Clinical Section of the Department of Legal Medicine of the Organismo de Investigación Judicial, this includes the legal medical history, physical examination, analysis of medical documents provided, expert carried out and bibliography review, this to have all the elements of judgment that allow an objective analysis based on scientific evidence, and thus be able to answer the questions of the Judicial Authority. This article covers some of the main aspects to be considered when faced with atypical findings of the entry and exit holes of the projectiles, through the presentation and approach of a clinical case. Ver bases de datos

Análisis del uso de mupirocina en la cura del orificio sano en diálisis peritoneal / Analysis of the use of mupirocin in the cure of the healthy orifice in peritoneal dialysis

Introducción: La infección del orificio de salida del catéter de diálisis peritoneal es una complicación importante en la diálisis peritoneal, que puede evolucionar hacia una tunelitis y/o infección peritoneal, lo que suele conllevar una retirada del mismo.Objetivo: Analizar el uso de mupirocina en la cura del orificio sano y su repercusión en la ratio de infecciones del orificio de salida y en el porcentaje de infecciones peritoneales dependientes de catéter.Material y Método: Estudio observacional retrospectivo, en una unidad de diálisis peritoneal provincial. Se incluyeron a todos los pacientes mayores de 18 años, que realizaron diálisis peritoneal en domicilio del 01/01/2019 hasta el 31/12/2021. Las variables analizadas, fueron: sexo , ratio de infección de orificio anual, gérmenes responsables, infecciones peritoneales dependientes de catéter y aparición de resistencias. Los datos se obtuvieron del registro anual de la unidad.Resultados: Tras la incorporación del uso de mupirocina 2 veces por semana en la cura del orificio de salida sano disminuyó la ratio de infección del orificio de salida, pasando de 0,47 episodio/paciente/año en 2019, a una ratio de 0,32 en 2020 y de 0,16 en 2021, disminuyendo el porcentaje de infecciones peritoneales dependientes de catéter de 38% en 2019, al 30% en 2020 y del 8% en 2021. No se han objetivado resistencias a antibióticos, ni otros efectos indeseados.Conclusiones: El uso de mupirocina en nuestra unidad parece ser eficaz en la reducción de las infecciones del orificio de salida, y de las infecciones peritoneales dependientes de catéter. (AU)

ntroduction: Outflow tract infection is an important compli-cation in peritoneal dialysis, mainly because it can progress to tunelitis and/or catheter-dependent peritoneal infection that often leads to catheter removal. Objective: To analyse the mupirocin application in the mana-gement of the healthy exit site and the impact on the infection rate and the percentage of catheter-dependent peritoneal in-fections.Material and Method: Retrospective observational study in a provincial peritoneal dialysis unit. Patients over 18 years of age who underwent peritoneal dialysis at home from 01/01/2019 to 31/12/2021 were included. Variables analysed were: sex, yearly orifice infection rate, responsible germs, catheter-dependent peritoneal infections and appearance of resistance. Data were obtained from the unit’s annual registry.342338Results:Twice-weekly mupirocin application in healthy peritoneal catheter exit site care has decreased the rate of exit site infections from 0.47 episode/patient/year in 2019 to 0.32 in 2020 and 0.16 in 2021, decreasing the percentage of catheter-dependent peritoneal infections from 38% in 2019 to 30% in 2020 and 8% in 2021. No resistance has been observed.Conclusions:Mupirocin application in our unit appears to be effective in reducing exit site infections and catheter-dependent peritoneal infections. (AU)

Suicidio mediante el uso de un arma de fuego, con presencia de doble Signo de Hoffmann: reporte de un caso / Firearm suicide with the presence of a double Hoffmann sign: case report

Resumen El presente artículo expone el caso de un suicidio de un masculino, el cual presentó dos orificios de entrada en la cabeza con características propias de un orificio de contacto, específicamente dos signos de boca de mina, también conocido como signo de Hoffmann.

Abstract This article presents the case of a suicide of a male, which presented two entry holes with characteristics of a contact hole in his head, two mine mouth signs, also known as Hoffman´s sign.

Análisis de las infecciones del orificio de salida del catéter peritoneal. Efectividad de un protocolo basado en la aplicación de mupirocina tópica diaria / Analysis of peritoneal catheter exit-site infections. Effectiveness of a protocol based on daily topical mupirocin application

Objetivos: Analizar las infecciones del orificio de salida del catéter peritoneal, identificando los principales factores relacionados con las mismas; asimismo se ha comparado la efectividad de un protocolo basado en la utilización diaria de mupirocina tópica en la cura del orificio de salida frente a la utilización suero salino.Material y Método:Estudio observacional, retrospectivo. Recogimos variables demográficas, clínicas, la etiología y evolución de los episodios de infección del orificio en un periodo de 2 años. Utilizamos un protocolo de profilaxis con suero fisiológico y con mupirocina crema al 2%.Resultados:Estudiamos 75 pacientes, edad media 60,3±13,9 años, 66,7% varones, mediana de tiempo en diálisis peritoneal 24,3 meses (rango intercuartílico 11-48,7). La incidencia de infección del orificio de salida fue del 26,7%, el 77% fueron originadas por microorganismos de piel y mucosas. La infección del orificio de salida se relacionó con el estado portador nasal de Staphylococcus aureus (p=0,048) y la extrusión del dacron externo (p=0,004). De los 4 pacientes que presentaron una peritonitis secundaria a la infección del orificio de salida, 3 fueron trasferidos a hemodiálisis (p=0,025). Con el protocolo de antibioterapia tópica diaria se redujo un 68% la tasa de infecciones.Conclusiones:La exteriorización del anillo externo del catéter peritoneal es un factor predisponente de infecciones. La aplicación diaria de mupirocina es una estrategia efectiva para reducir la incidencia de infección del orificio y peritonitis. La erradicación de portadores nasales de Staphylococcus aureus puede contribuir a reducir la pérdida del catéter y la transferencia a hemodiálisis. (AU)

Objectives: To analyze the characteristics of catheter related exit-site infections, identifying the main related factors. Likewise, the effectiveness of a protocol based on the daily use of topical mupirocin in the exit site prophylaxis strategy has been compared with the use of saline solution.Material and Method: Observational retrospective study. Demographic and clinical variables, the etiology and evolution of the episodes of infection of the orifice in a period of 2 years were collected. A prophylaxis protocol with saline solution and 2% mupirocin cream was used.Results:We recruited 75 patients, mean age 60.3±13.9 years, 66.7% male, median time on peritoneal dialysis 24.3 months (interquartile range 11-48.7). The incidence of exit site infection was 26.7%, 77% were produced by skin and mucous microorganisms. The exit site infection was associated to Staphylococcus aureus nasal carriage (p=0.048) and the superficial cuff extrusion (p=0.004). 4 of the patients who presented peritonitis secondary to exit site infection, 3 were switch to hemodialysis (p=0.025). Daily topical antibiotic therapy protocol reduced the exit site infection rate by 68%.Conclusions:The superficial cuff externalization is a predisposing factor for infections. Daily application of mupirocin is an effective strategy in reducing the incidence of exit site infections and peritonitis. The eradication of nasal carriers of Staphylococcus aureus can help reduce catheter loss and transfer to hemodialysis. (AU)

Natural orifice specimen extraction versus transabdominal extraction in laparoscopic right hemicolectomy.

INTRODUCCIÓN: La extracción de muestras de orificio natural (NOSE) para resecciones colorrectales, que mejoran aún más las ventajas de la cirugía mínimamente invasiva, se utilizan cada vez con mayor frecuencia. En este estudio, nuestro objetivo fue comparar los métodos de extracción de muestras de nariz y transabdominales en casos de resecciones de colon derecho totalmente laparoscópicas. MÉTODOS: Se incluyeron datos de 52 pacientes que se sometieron a cirugía laparoscópica de colon derecho entre 2013 y 2019. La extracción de muestras transabdominales se realizó en 35 pacientes, mientras que 17 pacientes fueron sometidos a NOSE. Se compararon datos demográficos, hallazgos operativos, resultados patológicos y datos de seguimiento. RESULTADOS: Las mujeres (94% frente a 28%, p = 0,0001), comórbidas (76% frente a 40%, p = 0,01) y antecedentes de cirugía abdominal previa (75% frente a 23%, p = 0,001) fueron más altas en el grupo NOSE . Todas las otras características preoperatorias de los grupos fueron comparables. La pérdida de sangre intraoperatoria, el tiempo de operación y las tasas de complicaciones fueron similares en ambos grupos. La escala VAS postoperatoria (2.8 ± 1.2 vs. 4.5 ± 2.4, p = 0.001) y los puntajes cosméticos fueron mejores en el grupo NOSE (10 vs. 7, p = 0.0001). Los resultados oncológicos fueron similares después de un seguimiento medio de 27.4 ± 20.5 (1-77) meses. CONCLUSIÓN: El método NOSE después de la resección laparoscópica del colon derecho fue un método más ventajoso en términos de cosméticos y dolor postoperatorio que la extracción de muestras transabdominales. INTRODUCTION: Natural orifice specimen extraction (NOSE) for colorectal resections, which further enhance the advantages of minimally invasive surgery, are being used increasingly more often. In this study, we aimed to compare NOSE and transabdominal specimen extraction methods in cases of totally laparoscopic right colon resections. METHODS: Data of 52 patients who underwent laparoscopic right colon surgery between 2013 and 2019 were included in the study. Transabdominal specimen removal was done in 35 patients, while 17 patients underwent NOSE. Demographic data, operative findings, pathological results, and follow-up data were compared. RESULTS: Female (94% vs. 28%, p = 0.0001), co-morbid (76% vs. 40%, p = 0.01), and previous abdominal surgery history (75% vs. 23%, p = 0.001) were higher in the NOSE group. All the other pre-operative features of the groups were comparable. Intraoperative blood loss, operation time, and complication rates were similar in both groups. Post-operative visual analog scale (2.8 ± 1.2 vs. 4.5 ± 2.4, p = 0.001) and cosmetic scores were better in the NOSE group (10 vs. 7, p = 0.0001). Oncologic results were similar after a mean follow-up of 27.4 ± 20.5 (1-77) months. CONCLUSION: The NOSE method following laparoscopic right colon resection was a more advantageous method in terms of cosmetics and post-operative pain than transabdominal specimen extraction.

Complications of transoral endoscopic thyroidectomy vestibular approach (TOETVA) / Tireoidectomia endoscópica transoral por acesso vestibular (TOETVA) e complicações

ABSTRACT The thyroidectomy is the most frequently executed procedure in head and neck surgery. Since its first description by Kocher, the transverse cervical incision has been the main access to the thyroid site, as it provides broad exposure of the central neck compartment. Despite the meticulous suture of the incision, the development of a scar with variable dimensions is unavoidable and, hence, some patients might not agree to the approach, due to this consequence. The transoral endoscopic thyroidectomy vestibular access (TOETVA) gains importance as an alternative to the traditional surgery, since it avoids the formation of visible scars. The objective of this study is to develop a systematic review on the currently available literature to evaluate possible complications related to the TOETVA. The systematic review was based on the databases of Medline, Cochrane library, Embase and Scielo/Lilacs, resulting in the selection of six studies, which were compared in regard of the type of study duration of the study and identified complications. Our study showed that TOETVA is related to complications similar to the ones identified in the conventional approach, such as hematoma, seroma, recurrent laryngeal nerve injury, hypoparathyroidism, surgical site infection. The TOETVA was associated to a higher risk of thermic injury of the skin and mentual nerve paresthesia. Moreover, it was possible to conclude that TOETVA is a safe procedure for well selected patients, with favorable conditions and concerned about the aesthetic outcome. The risk of complications of the procedure should always be explained to those patients.

RESUMO A tireoidectomia é o procedimento cirúrgico mais frequentemente realizado na cirurgia de cabeça e pescoço. Desde sua descrição por Kocher, a incisão cervical transversa constitui o principal acesso à loja tireoideana e permite ampla exposição à região central do pescoço. Apesar do fechamento meticuloso da incisão, uma cicatriz de dimensões variáveis é inevitável, e certos pacientes podem discordar de tal abordagem. A tireoidectomia vestibular endoscópica transoral (TOETVA) ganha importância como alternativa à cirurgia tradicional, pois evita a formação de cicatrizes visíveis. O objetivo de estudo é realizar uma revisão sistemática da literatura das possíveis complicações da TOETVA. Foi realizada revisão sistemática da literatura nas bases de dados Medline, The Cochrane Library, Embase e SciElo/Lilacs, sendo selecionados seis artigos e tabulados os dados de tipo de estudo, período do estudo e complicações apresentadas. O estudo mostra que a TOETVA apresenta complicações semelhantes à técnica convencional, como hematoma, seroma, lesão de nervo laríngeo recorrente, hipoparatireoidismo, além de infecção de sítio cirúrgico, com maior risco de lesão térmica da pele e parestesia por lesão do nervo mentual. Em adição, foi possível concluir que a TOETVA é uma técnica segura para pacientes bem selecionados, com condições favoráveis e com especial preocupação com resultados estéticos, devendo sempre ser orientados sobre possíveis complicações.

Transanal specimen extraction following combined laparoscopic colectomy and liver resection.

A 47-year-old woman admitted with constipation and a sigmoid colon adenocarcinoma and liver metastasis was diagnosed. Synchronous laparoscopic anterior resection and liver metastasectomy were done and transanal specimen extractions were performed for both resection materials. No recurrence or procedure-related problem was found in the follow-up of the 14th months, and her esthetic score was determined as 9/10. Transanal specimen extraction can be a viable method for patients with left-sided colon cancer with liver metastasis. It avoids additional abdominal incision, and as far as we know, this is the first liver specimen removed through the anus.

Una mujer de 47 años ingresó con estreñimiento y fue diagnosticada de adenocarcinoma de colon sigmoide y metástasis hepáticas. Se realizaron resección anterior laparoscópica sincrónica y metastasectomía hepática, y se extrajeron muestras transanales de ambos materiales de resección. No se encontró ningún problema relacionado con la recidiva o el procedimiento en el seguimiento a los 14 meses, y su puntaje estético se determinó como 9/10. La extracción transanal de muestras puede ser un método viable para pacientes con cáncer de colon izquierdo con metástasis hepáticas. Esta técnica previene la incisión abdominal adicional. Hasta donde sabemos, esta es la primera muestra de hígado extraída a través del ano.

Does the use of dynamic surgical guidance assist accurate pedicle screw placement in patients with osteoporosis or osteopenia? / O uso do guia cirúrgico dinâmico auxilia a acurácia do posicionamento dos parafusos pediculares em pacientes com osteoporose ou osteopenia? / ¿el uso de guía quirúrgica dinámica ayuda a colocar con precisión los tornillos pediculares en pacientes con osteoporosis u osteopenia?

ABSTRACT Objective To compare the use of a dynamic surgical guide (PediGuard®) and pilot hole preparation, with the use of a probe and the aid of fluoroscopy in osteoporotic or osteopenic patients undergoing pedicular fixation of the thoracic or lumbar spine. Methods One hundred and eight patients were randomized. A pilot hole was prepared with the dynamic surgical guide (PediGuard®), or with a probe with the aid of fluoroscopy. A total of 657 vertebral pedicles (120 thoracic and 180 lumbar) were included in the study. The parameters used for the comparison were: accuracy of the pedicular screw, number of fluoroscopic shots, and change in intraoperative trajectory of the perforation after detecting pedicle wall rupture. Results In the group with use of the dynamic surgical guide, malpositioning of the pedicle screws was observed in 8 (2.6%) patients and intraoperative change of perforation trajectory in 12 (4%) patients, and there were 52 fluoroscopic shots. In the group without use of the dynamic surgical guide (PediGuard®), misplacement of the pedicle screws was observed in 33 (11%) patients and intraoperative change of perforation trajectory in 47 (13.2%) patients, and there were 136 fluoroscopic shots. Conclusion The use of the dynamic surgical guide (PediGuard®) in patients with osteoporosis or osteopenia enabled more accurate placement of pedicular screws, with less change in the intraoperative course of the perforation and less intraoperative radiation. Level of Evidence II; Randomized clinical trial of lesser quality.

RESUMO Objetivo Comparar o uso de um guia cirúrgico dinâmico (PediGuard®) e o preparo de orifício piloto com uma sonda e o auxílio de fluoroscopia em pacientes com osteopenia ou osteoporose submetidos à fixação pedicular da coluna torácica ou lombar. Métodos Cento e oito pacientes foram randomizados. Um orifício piloto foi preparado com o guia cirúrgico dinâmico (PediGuard®) ou com uma sonda com auxílio de fluoroscopia. Foram incluídos no estudo 657 pedículos vertebrais (120 torácicos e 180 lombares). Os parâmetros usados para a comparação foram: acurácia da colocação do parafuso pedicular, número de disparos fluoroscópicos e mudança da trajetória intraoperatória da perfuração depois da detecção de ruptura da parede do pedículo. Resultados No grupo de pacientes em que se usou o guia cirúrgico dinâmico, observou-se mau posicionamento dos parafusos pediculares em oito (2,6%) pacientes e alteração da trajetória intraoperatória da perfuração em 12 (4%) pacientes, com 52 disparos fluoroscópicos. No grupo de pacientes em que o guia cirúrgico dinâmico (PediGuard®) não foi usado o mau posicionamento dos parafusos pediculares foi observado em 33 (11%) pacientes, a mudança intraoperatória da trajetória da perfuração foi vista em 47 (13,2%) pacientes, com 136 disparos fluoroscópicos. Conclusão O uso do guia cirúrgico dinâmico (PediGuard®) em pacientes com osteoporose ou osteopenia permitiu a colocação de parafusos pediculares com maior acurácia, com menor alteração da trajetória intraoperatória da perfuração e menor dose de radiação intraoperatória. Nível de Evidência II; Estudo clínico randomizado de menor qualidade.

RESUMEN Objetivo Comparar el uso de una guía quirúrgica dinámica (PediGuard®) y la preparación del orificio piloto con una sonda y la ayuda de fluoroscopia en pacientes con osteopenia u osteoporosis sometidos a fijación pedicular de la columna torácica o lumbar. Métodos Ciento ocho pacientes fueron asignados aleatoriamente. Se preparó un orificio piloto preparado con la guía quirúrgica dinámica (PediGuard®) o con una sonda con ayuda de fluoroscopia. Se incluyeron en el estudio 657 pedículos vertebrales (120 torácicos y 180 lumbares). Los parámetros utilizados para la comparación fueron: precisión de la colocación del tornillo pedicular, número de disparos del dispositivo de fluoroscopia y cambio en la trayectoria intraoperatoria de la perforación después de la detección de ruptura de la pared del pedículo. Resultados En el grupo de pacientes en el que se utilizó la guía quirúrgica dinámica, se observó mal posicionamiento de los tornillos pediculares en 8 (2,6%) pacientes y cambios de la trayectoria intraoperatoria de la perforación en 12 (4%) pacientes, con 52 disparos del aparato de fluoroscopia. En el grupo de pacientes en los que no se utilizó la guía quirúrgica dinámica (PediGuard®), se observó un mal posicionamiento de los tornillos pediculares en 33 (11%) pacientes, el cambio intraoperatorio de la trayectoria de perforación se observó en 47 (13,2%) pacientes, con 136 disparos fluoroscópicos. Conclusión El uso de la guía quirúrgica dinámica (PediGuard®) en pacientes con osteoporosis u osteopenia permitió la colocación de tornillos pediculares con mayor precisión, menos cambios en la trayectoria intraoperatoria de la perforación y dosis más baja de radiación intraoperatoria. Nivel de Evidencia II; Ensayo clínico aleatorizado de menor calidad.

First report of Artystone trysibia (Isopoda: Cymothoidae) in Caquetaia spectabilis (Cichliformes: Cichlidae) / Primeiro relato de Artystone trysibia (Isopoda: Cymothoidae) em Caquetaia spectabilis (Cichliformes: Cichlidae)

Abstract The present study provides the first record of an isopod parasite (Artystone trysibia) on Caquetaia spectabilis, a cichlid from the eastern Amazon collected in the State of Amapá, northern Brazil. In May 2018, specimens of C. spectabilis were collected in the lower Jari River, and 33.3% were parasitized by A. trysibia on the tegument tissue between pelvic fins. No hemorrhage or injury signals were observed in the tegument of the host. This study also expanded the distribution of A. trysibia to the eastern Amazon.

Resumo O presente estudo fornece o primeiro registro de um isópode parasito (Artystone trysibia) em Caquetaia spectabilis, um ciclídeo da Amazônia coletado no estado do Amapá, norte do Brasil. Em maio de 2018, espécimes de C. spectabilis foram coletados no baixo Rio Jari e 33,3% estavam parasitados por A. trysibia dentro do orifício tegumentar localizado na região ventral, entre as nadadeiras pélvicas de C. spectabilis. Nenhuma hemorragia ou lesões foram observadas no tegumento dos hospedeiros. Este estudo amplia a distribuição de A. trysibia para a Amazônia oriental.

Breaking paradigms in severe epistaxis: the importance of looking for the S-point / Quebrando paradigmas na epistaxe grave: a importância de procurar o S-point

Abstract Introduction: Since the introduction of nasal endoscopy into the field of Otorhinolaryngology, the treatment paradigm for cases of severe epistaxis has shifted toward early and precise identification of the bleeding site. Although severe epistaxis is usually considered to arise from posterior bleeding, an arterial vascular pedicle in the superior portion of the nasal septum, around the axilla projection of the middle turbinate, posterior to the septal body, frequently has been observed. That vascular pedicle was named the Stamm's S-point. Objective: The aim of this study was to describe the S-point and report cases of severe epistaxis originating from it. Methods: A retrospective case series study was conducted. Nine patients with spontaneous severe epistaxis, where the S-point was identified as the source of bleeding, were treated between March 2016 and March 2017. Results: Male predominance (77.8%) with age average of 59.3 years old were reported. Most cases presented comorbidities (88.9%) and were not taking acetylsalicylic acid (66.7%). A predominance of left sided involvement (55.6%) and anteroposterior bleeding being the principal initial presentation (77.8%) was seen. Six patients (66.7%) presented with hemoglobin levels below 10 g/dL, and four (44.4%) required blood transfusion. Cauterization of S-point was performed in all patients, with complete resolution of bleeding. No patient experienced recurrence of severe epistaxis. Conclusion: The Stamm's S-point, a novel source of spontaneous severe epistaxis, is reported, and its cauterization was effective and safe. Otolaryngologists must actively seek this site of bleeding in cases of severe epistaxis.

Resumo Introdução: Desde a introdução da endoscopia nasal no campo de otorrinolaringologia, o paradigma de tratamento para casos graves de epistaxe voltou-se para a identificação precoce e correta do local de sangramento. Embora a epistaxe grave seja geralmente considerada uma hemorragia posterior, um pedículo vascular arterial tem sido frequentemente observado na porção superior do septo nasal, ao redor da projeção da axila da concha média, posterior ao tubérculo septal. Esse pedículo vascular foi chamado de Stamm's S-point. Objetivo: Descrever o S-point e relatar casos graves de epistaxe que se originam nesse local. Método: Um estudo retrospectivo de série de casos foi conduzido. Nove pacientes com epistaxe grave espontânea, na qual o S-point foi identificado como a fonte do sangramento, foram tratados de março de 2016 a março de 2017. Resultados: Houve predominância do sexo masculino (77,8%) com média de 59,3 anos. A maioria dos casos apresentava comorbidades (88,9%), mas sem uso de ácido acetilsalicílico (66,7%). Observou-se predominância do lado esquerdo (55,6%) com sangramento anteroposterior como a principal apresentação inicial (77,8%). Seis pacientes (66,7%) apresentaram níveis de hemoglobina inferiores a 10 g/dL e quatro (44,4%) necessitaram de transfusão sanguínea. Cauterização do S-point foi feita em todos os pacientes, com resolução completa do sangramento. Nenhum paciente apresentou recorrência de epistaxe grave. Conclusão: O Stamm's S-point é relatado como uma nova região de origem de epistaxe grave espontânea e o tratamento feito com cauterização foi eficaz e seguro. Os otorrinolaringologistas devem buscar ativamente esse local de sangramento em casos de epistaxe grave.

Breaking paradigms in severe epistaxis: the importance of looking for the S-point.

INTRODUCTION: Since the introduction of nasal endoscopy into the field of Otorhinolaryngology, the treatment paradigm for cases of severe epistaxis has shifted toward early and precise identification of the bleeding site. Although severe epistaxis is usually considered to arise from posterior bleeding, an arterial vascular pedicle in the superior portion of the nasal septum, around the axilla projection of the middle turbinate, posterior to the septal body, frequently has been observed. That vascular pedicle was named the Stamm's S-point. OBJECTIVE: The aim of this study was to describe the S-point and report cases of severe epistaxis originating from it. METHODS: A retrospective case series study was conducted. Nine patients with spontaneous severe epistaxis, where the S-point was identified as the source of bleeding, were treated between March 2016 and March 2017. RESULTS: Male predominance (77.8%) with age average of 59.3 years old were reported. Most cases presented comorbidities (88.9%) and were not taking acetylsalicylic acid (66.7%). A predominance of left sided involvement (55.6%) and anteroposterior bleeding being the principal initial presentation (77.8%) was seen. Six patients (66.7%) presented with hemoglobin levels below 10g/dL, and four (44.4%) required blood transfusion. Cauterization of S-point was performed in all patients, with complete resolution of bleeding. No patient experienced recurrence of severe epistaxis. CONCLUSION: The Stamm's S-point, a novel source of spontaneous severe epistaxis, is reported, and its cauterization was effective and safe. Otolaryngologists must actively seek this site of bleeding in cases of severe epistaxis.

Incisivo central único de la línea media del maxilar, holoprosencefalia y estenosis congènita del orificio nasal anterior en un recién nacido prematuro: a propósito de un caso / Solitary median maxillary central incisor, holoprosencephaly and congenital nasal pyriform aperture stenosis in a premature infant: case report

El síndrome del incisivo central único de la línea media del maxilar es un trastorno raro que implica anomalías de la línea media, como holoprosencefalia, anomalías de las fosas nasales, fisura palatina, labio leporino, hipotelorismo, microcefalia y panhipopituitarismo. La estenosis congénita del orificio nasal anterior es una causa mortal de dificultad respiratoria neonatal debido al estrechamiento del orificio nasal anterior, y podría confundirse con la atresia de coanas. En este informe, presentamos el caso de un recién nacido con síndrome del incisivo central único de la línea media del maxilar acompañado de otras anomalías, tales como holoprosencefalia, estenosis del orificio nasal anterior, microcefalia y panhipopituitarismo. El cariotipado mostró una deleción heterocigota en el gen SIX3 en la región 2p21, que produjo una forma más grave de holoprosencefalia.

Solitary median maxillary central incisor syndrome is a rare disorder involving midline abnormalities such as holoprosencephaly, nasal cavity anomalies, cleft palate-lip, hypotelorism, microcephaly, and panhypopituitarism. Congenital nasal pyriform aperture stenosis is a lethal cause of neonatal respiratory distress due to narrowing of the pyriform aperture anteriorly and it can be confused with choanal atresia. In this report, we present a newborn infant with solitary median maxillary central incisor syndrome accompanied by other abnormalities including holoprosencephaly, nasal pyriform aperture stenosis, microcephaly and panhypopituitarism. Chromosomal analysis showed heterozygous SIX3 gene deletion at 2p21 region resulting in a more severe form of holoprosencephaly.

Retroperitoneal abscess after transanal minimally invasive surgery: case report and review of literature / Abscesso retroperitoneal após cirurgia de ressecção transanal minimamente invasiva: relato de caso clínico e revisão a literatura médica

ABSTRACT Abscesses are a rare complication of transanal minimally invasive surgery and transanal endoscopic micro surgery. Reported cases have been in the rectal and pre-sacral areas and have been managed with either antibiotics alone or in conjunction with laparotomy and diverting colostomy. We report a case of a large retroperitoneal abscess following a Transanal minimally invasive surgery full thickness rectal polyp excision. The patient was successfully managed conservatively with antibiotics and a percutaneous drain. Retroperitoneal infection should be included in a differential diagnosis following a Transanal minimally invasive surgery procedure as the presentation can be insidious and timely intervention is needed to prevent further morbidity.

RESUMO Os abscessos são uma complicação rara da cirurgia de ressecção transanal minimamente invasiva (TAMIS) e da micro cirurgia endoscópica transanal (TEMS). Os casos notificados foram nas áreas rectal e pré-sacral e foram administrados com antibióticos isoladamente ou em conjunto com laparotomia e desvio de colostomia. Relatamos um caso de grande abscesso retroperitoneal após uma excisão de pólipo retal de espessura total TAMIS. O paciente foi tratado com sucesso com a administração de antibióticos e drenagem percutânea. Para prevenir mais morbidade é necessária incluir a infecção retroperitoneal no diagnostico diferencial após um procedimento TAMIS onde a apresentação pode ser insidiosa e a intervenção atempada.

Radiological management of the exiting points of supraorbital region neurovascular bundles / Manejo radiológico de los puntos de salida de los haces neurovasculares de la región supraorbitaria

SUMMARY: A preoperative computed tomography scan is useful to determine neurovascular exit points from orbit to supraorbital region. Determining the structure of exiting points (absence or presence, if present, being in form of foramen or notch) is important to plan the surgical approach. The aim of the study was to provide the radiological data by multi-detector computed tomography for estimating exiting points of the neurovascular bundles of the supraorbital region whether through foramen or notch in living subjects related to side (right/left), sex and age. Computed tomography examinations of 214 (102 male and 112 female) adult patients, aged average 44.2 ± 14 years, were evaluated, retrospectively. Presence or absence, number and nature (foramen/notch) of exiting points of neurovascular bundles were noted in each side regarding sex and age groups. The distance of foramen/notch to the midline of the face was recorded. Single notch was seen on the right in 123 and in 134 on the left, single foramen was seen in 62 on the right and in 56 on the left side and double foramen was seen in 13 on the right and in 6 on the left. The absence was seen in 16 on the right and 18 on the left side. No significant difference was seen on frequency compared between the sexes and age groups. Foramen was seen in 58 sides unilaterally and in 39 sides bilaterally. Notch was unilateral in 75 sides and bilateral in 95 sides. It was shown that males had a wider distance between right side foramen and left side notch to midline. Age groups did not show a significant difference in terms of side. Absence and foramen presence made up about 30-40 % of cases. Notch was the most common form. Foramen/notch presence was statistically unaffected by the sex and age factors. In terms of surgery, preoperative assessment of orbital exit points with computed tomography is essential.

RESUMEN: Una tomografía computarizada preoperatoria es útil para determinar los puntos de salida neurovascular en la región supraorbitaria. Para la planificación del abordaje quirúrgico es importante determinar la estructura de los puntos de salida (ausencia o presencia en forma de foramen). El objetivo de este estudio fue proporcionar los datos radiológicos mediante tomografía computarizada de detectores múltiples, para estimar los puntos de salida de los haces neurovasculares de la región supraorbitaria, ya sea a través del foramen o incisura en sujetos vivos relacionados con lado (derecho/izquierdo), sexo y edad. Se evaluaron retrospectivamente los exámenes de tomografía computarizada de 214 adultos (102 hombres y 112 mujeres), edad 44,2 ± 14 años. Se observó, en cada lado, presencia o ausencia, número y naturaleza (foramen / incisura) de los puntos de salida de los haces neurovasculares en cuanto a sexo y grupos de edad. Se registró la distancia del foramen / incisura al plano mediano de la cara. Se observó un foramen a la derecha en 123 de las tomografìas y en 134 a la izquierda, se observó un foramen simple en 62 a la derecha y en 56 en el lado izquierdo y se visualizó forámenes doble en 13 tomografías a la derecha y en 6 a la izquierda. Se observó ausencia en 16 casos a la derecha y 18 casos a la izquierda. No existió diferencia significativa en la frecuencia comparada entre los sexos y los grupos etarios. El foramen se detectó en 58 lados unilateralmente y en 39 lados bilateralmente. Se demostró que los hombres tenían una distancia mayor entre el foramen del lado derecho y el foramen del lado izquierdo hasta el pno mediano. No se observó una diferencia significativa en los diferentes grupos etarios en términos de lado. La ausencia y la presencia de los forámenes constituían alrededor del 30-40 % de los casos. Los factores de sexo y edad no afectaron estadísticamente la presencia del foramen / incisura. En términos de cirugía, la evaluación preoperatoria de los puntos de salida orbitales con tomografía computarizada es esencial.

Efficacy of syringe-irrigation topical therapy and the influence of the middle turbinate in sinus penetration of solutions / Eficácia da terapia tópica de irrigação com seringa e a influência da concha média na penetração sinusal de soluções

Abstract Introduction: Topical therapies are the best postoperative treatment option for chronic rhinosinusitis, especially those with high volume and pressure, such as the squeeze bottles. However, they are not an available option in Brazil, where irrigation syringes are used. Objective: To investigate the efficacy of topical sinonasal therapy with syringe and the influence of the middle turbinate on this process Methods: Intervention study in training models (S.I.M.O.N.T.). After standard dissection, three interventions were performed (Nasal Spray 4 puffs, 60-mL syringe and 240-mL Squeeze Bottle) with normal and Sutured Middle Turbinate. Images of each sinus were captured after the interventions, totalizing 144 images. The images were classified by 10 evaluators according to the amount of residual volume from zero to 3, with zero and 1 being considered poor penetration and 2 and 3, good penetration. The 1440 evaluations were used in this study. Results: Considering all middle turbinate situations, the amount of good penetrations were 8.1% for Spray; 68.3% for Syringe, and 78.3% for Squeeze (p < 0.0001). Considering all types of interventions, the Normal Middle Turbinate group had 48.2% of good penetrations and the Sutured Middle Turbinate, 55% (p = 0.01). Considering only the Sutured Middle Turbinates, there was no difference between the interventions with Syringe and Squeeze (76.3% vs. 80.4%; p = 0.27). Conclusion: Topical therapy of irrigation with a 60-mL syringe was more effective than that with nasal spray. The status of the middle turbinate proved to be fundamental and influenced topical therapy. Irrigation with syringe was as effective as the squeeze bottle when the middle turbinate was sutured to the nasal septum.

Resumo Introdução: Terapias tópicas são a melhor opção de tratamento pós-operatório da rinossinusite crônica, principalmente com alto volume e pressão, como os squeeze bottles. Porém, não são opções disponíveis na realidade brasileira, na qual frequentemente são usados seringas para a irrigação. Objetivo: Averiguar a eficácia da terapia tópica nasossinusal com seringa e a influência da concha média nesse processo. Método: Estudo de intervenção em modelos de treinamento (S.I.M.O.N.T.). Após dissecção padronizada, três intervenções foram feitas (spray nasal 4 puffs, seringa de 60 mL e squeeze bottle de 240 mL) com a concha média normal e suturada. Foram capturadas imagens de cada seio após as intervenções, totalizando 144 imagens. As imagens foram classificadas por 10 avaliadores de acordo com a quantidade de volume residual de zero a 3, sendo zero e 1 considerados penetração ruim e 2 e 3, penetração boa. As 1.440 avaliações foram utilizadas neste estudo. Resultados: Considerando todas as situações de concha média, a quantidade de penetrações boas foi de 8,1% para spray; 68,3% para seringa e 78,3% para squeeze (p < 0,0001). Considerando todos os tipos de intervenção, a concha média normal obteve 48,2% de penetrações boas e a concha média suturada, 55% (p = 0,01). Considerando apenas concha média suturada, não houve diferença entre as intervenções seringa e squeeze (76,3% vs. 80,4%; p = 0,27). Conclusão: A terapia tópica de irrigação com seringa de 60 mL foi mais eficaz do que com spray nasal. O status da concha média mostrou-se fundamental e influenciou a terapia tópica. A irrigação com seringa foi tão eficaz quanto a com squeeze bottle quando a concha média foi suturada ao septo nasal.

Efficacy of syringe-irrigation topical therapy and the influence of the middle turbinate in sinus penetration of solutions.

INTRODUCTION: Topical therapies are the best postoperative treatment option for chronic rhinosinusitis, especially those with high volume and pressure, such as the squeeze bottles. However, they are not an available option in Brazil, where irrigation syringes are used. OBJECTIVE: To investigate the efficacy of topical sinonasal therapy with syringe and the influence of the middle turbinate on this process METHODS: Intervention study in training models (S.I.M.O.N.T.). After standard dissection, three interventions were performed (Nasal Spray 4 puffs, 60-mL syringe and 240-mL Squeeze Bottle) with normal and Sutured Middle Turbinate. Images of each sinus were captured after the interventions, totalizing 144 images. The images were classified by 10 evaluators according to the amount of residual volume from zero to 3, with zero and 1 being considered poor penetration and 2 and 3, good penetration. The 1440 evaluations were used in this study. RESULTS: Considering all middle turbinate situations, the amount of good penetrations were 8.1% for Spray; 68.3% for Syringe, and 78.3% for Squeeze (p<0.0001). Considering all types of interventions, the Normal Middle Turbinate group had 48.2% of good penetrations and the Sutured Middle Turbinate, 55% (p=0.01). Considering only the Sutured Middle Turbinates, there was no difference between the interventions with Syringe and Squeeze (76.3% vs. 80.4%; p=0.27). CONCLUSION: Topical therapy of irrigation with a 60-mL syringe was more effective than that with nasal spray. The status of the middle turbinate proved to be fundamental and influenced topical therapy. Irrigation with syringe was as effective as the squeeze bottle when the middle turbinate was sutured to the nasal septum.

Spatial and temporal distribution of cotton squares and small cotton bolls fallen on ground after damage by boll weevil and the efficiency of the equipment used to collect them / Distribuição espacial e temporal dos botões florais e pequenas maçãs de algodão caídas ao solo danificadas pelo bicudo e eficiência de equipamento para coletá-los

ABSTRACT: In this study, we determined the spatial and temporal distribution of fallen cotton squares and small cotton bolls fallen damaged by boll weevil and the efficiency and time interval of the equipment used to collect cotton samples. Spatial and temporal distribution of cotton squares and small cotton bolls fallen on the soil damaged by boll weevil among cotton rows was determined in an experimental design of randomized blocks in a factorial arrangement of 4x3, represented by soil surface tracks located at 1-11cm, 12-22cm, 23-33cm, and 34-44cm away from the planting row of cotton plants 70, 85, and 100 days of age. Efficiency and collection time interval of the cotton samples fallen on the soil infested by boll weevil by plastic rakes that were straight or fan-shaped, big broom, collector instrument model CNPA and aspirator of leaves ‘Trapp’ were determined in randomized block design with five treatments, 10 repetitions for each. Results demonstrated that the collection of cotton samples must be performed with greater attention to soil strips located below the cotton top projection and aspirator ‘Trapp’ of leaves was more appropriate for the operation as it used less time of collection with similar efficiency to other available equipment.

RESUMO: Neste estudo, determinou-se a distribuição espacial e temporal dos botões florais e pequenas maçãs de algodoeiros caídas ao solo danificadas pelo bicudo e a eficiência de equipamentos para coletá-las. A distribuição espacial e temporal dos botões florais e pequenas maçãs de algodoeiros caídas ao solo danificadas pelo bicudo entre as fileiras de algodão foram determinadas em delineamento experimental de blocos ao acaso em arranjo fatorial 4x3, representado por faixas de superfície de solo localizadas entre 1-11cm; 12-22cm; 23-33cm e 34-44cm de distância da fileira de plantio em algodoeiros com 70, 85 e 100 dias de idade. A eficiência de coleta dos botões florais e pequenas maçãs caídas ao solo danificado pelo bicudo pelos rastelos plásticos em leque e reto, vassourão, catador modelo CNPA e aspirador de folhas “Trapp” foi determinado em delineamento de blocos ao acaso com cinco tratamentos e 10 repetições. Os resultados demonstraram que a coleta dos botões florais e pequenas maçãs caídas ao solo devem ser realizadas com maior atenção nas faixas de solo localizada abaixo da projeção da copa do algodoeiro e que o aspirador “Trapp” se mostrou mais adequado para essa operação porque gastou menos tempo para coletar essas estruturas vegetais, embora tenha apresentado eficiência semelhante aos demais equipamentos.

Perspectiva actual de la cirugía endoscópica transluminal por orificios naturales (CETON)

La cirugía endoscópica transluminal por orificios naturales (CETON o NOTES por sus siglas en inglés) representa una alternativa en el abordaje quirúrgico, en combinación con los adelantos y experiencia obtenida de la cirugía convencional y endoscópica. Búsqueda bibliográfica en la base de datos PubMed, Medline del año 2000 al 2015 con análisis de las revisiones bibliográficas encontradas. La CETON proporciona la visión y abordaje por orificios naturales, ha optimizado los tiempos quirúrgicos además de reducir las complicaciones, mediante ésta técnica se pueden obtener mejores resultados cosméticos. Se han reportado pequeñas series de pacientes, pero no existe un estudio clínico o multicéntrico validado por medicina basada en evidencia. La CETON puede ayudar a perfeccionar las operaciones estándar, complementándose con la cirugía laparoscópica en lugar de sustituirla y de esta forma desarrollar herramientas para la resolución de diversas patologías que requieran un tratamiento quirúrgico. Esta opción en la cirugía actual se presenta segura y con resultados satisfactorios en los casos reportados. El desarrollo de esta nueva forma de abordaje para la realización de procedimientos quirúrgicos requiere de mayores estudios y el desarrollo de nueva tecnología que permita hacer estos procedimientos cada vez más accesibles y representen de manera práctica y sustentada una mejor opción de abordaje de la patología quirúrgica.

Natural orifice transluminal endoscopic surgery (NOTES) represents an alternative in surgical approach, combined with the progress and experience gained from conventional and endoscopic surgery. Bibliographic research in PubMed, Medline database from 2000 to 2015 and analysis of the literature reviews found. NOTES provides vision and natural orifice approach, it has optimized operating times as well as reduced complications and better cosmetic results. Small series of patients have been reported, but there is not a valid clinical multicenter study by evidence-based medicine. NOTES can help to improve the standard operations, complemented with laparoscopic surgery rather than replace it and thus develop tools for the resolution of various diseases that require surgical treatment. This option in current surgery is safe and presents satisfactory results in the reported cases. The development of this new approach of performing surgical procedures requires further study and development of new technology in order to increase the accessibility of these procedures and represent in a practical and sustained way, a better option to approach surgical pathology.

Transcanal endoscopic myringoplasty: a case series in a university center / Miringoplastia endoscópica transcanal: série de casos em um serviço universitário

ABSTRACT INTRODUCTION: Transcanal myringoplasty has the advantages of demanding lower operative time and minimal external incisions. It can be performed using the microscopic or endoscopic approach. In the last decade, the use of endoscopes in ear surgery has increased significantly. This technique may allow "around the corner" visualization of small recesses, through narrow spaces, without the aid of canalplasty in unfavorable ear canals. OBJECTIVE: To describe a case series of transcanal endoscopic myringoplasty performed in a university service. The characteristics, advantages, and disadvantages of this technique are also discussed. METHODS: A case series study, based on the chart review of patients submitted to transcanal endoscopic myringoplasty in the period from January of 2012 to October of 2014. RESULTS: Data from 22 patients were analyzed. Tympanic perforation closure three months after surgery was observed in 86.4% of all patients. There was statistically significant improvement in pure tone average thresholds after surgery (p < 0.001). CONCLUSION: Transcanal endoscopic myringoplasty is a feasible, safe, and effective procedure; it can be an alternative to microscopic surgery.

Resumo Introdução: A miringoplastia realizada por via transcanal possui como vantagens a maior rapidez do procedimento e menor incisão externa, podendo ser realizada com auxílio de microscópio ou endoscópio. Na última década tem sido observado um aumento do uso de endoscópios na cirurgia otológica. Essa técnica pode permitir melhor visibilização de espaços encobertos e estreitos, sem necessidade canaloplastia em meatos desfavoráveis. Objetivo: Descrever uma série de casos de miringoplastia endoscópica transcanal, em um serviço universitário, discutindo suas particularidades, vantagens e desvantagens. Método: Estudo de série de casos, baseado na revisão de prontuários dos pacientes submetidos a miringoplastia com uso exclusivo de endoscópio rígido, no período de Janeiro de 2012 a Outubro de 2014. Resultados: Foram analisados os dados de 22 pacientes. Na otoscopia pós-operatória, foi observado fechamento da perfuração timpânica em 86,4% dos pacientes, após 3 meses da intervenção. Para a amostra estudada, foi observada melhora funcional estatisticamente significante da média dos limiares tonais (PTA) após a cirurgia (p < 0,001). Conclusão: A miringoplastia endoscópica transcanal é um procedimento seguro, factível e efetivo, podendo ser realizado como alternativa à cirurgia microscópica.