A Sequential Multiple Assignment Randomized Trial (SMART) study of medication and CBT sequencing in the treatment of pediatric anxiety disorders.

BACKGROUND: Treatment of a child who has an anxiety disorder usually begins with the question of which treatment to start first, medication or psychotherapy. Both have strong empirical support, but few studies have compared their effectiveness head-to-head, and none has investigated what to do if the treatment tried first isn't working well-whether to optimize the treatment already begun or to add the other treatment. METHODS: This is a single-blind Sequential Multiple Assignment Randomized Trial (SMART) of 24 weeks duration with two levels of randomization, one in each of two 12-week stages. In Stage 1, children will be randomized to fluoxetine or Coping Cat Cognitive Behavioral Therapy (CBT). In Stage 2, remitters will continue maintenance-level therapy with the single-modality treatment received in Stage 1. Non-remitters during the first 12 weeks of treatment will be randomized to either [1] optimization of their Stage 1 treatment, or [2] optimization of Stage 1 treatment and addition of the other intervention. After the 24-week trial, we will follow participants during open, naturalistic treatment to assess the durability of study treatment effects. Patients, 8-17 years of age who are diagnosed with an anxiety disorder, will be recruited and treated within 9 large clinical sites throughout greater Los Angeles. They will be predominantly underserved, ethnic minorities. The primary outcome measure will be the self-report score on the 41-item youth SCARED (Screen for Child Anxiety Related Disorders). An intent-to-treat analysis will compare youth randomized to fluoxetine first versus those randomized to CBT first ("Main Effect 1"). Then, among Stage 1 non-remitters, we will compare non-remitters randomized to optimization of their Stage 1 monotherapy versus non-remitters randomized to combination treatment ("Main Effect 2"). The interaction of these main effects will assess whether one of the 4 treatment sequences (CBT➔CBT; CBT➔med; med➔med; med➔CBT) in non-remitters is significantly better or worse than predicted from main effects alone. DISCUSSION: Findings from this SMART study will identify treatment sequences that optimize outcomes in ethnically diverse pediatric patients from underserved low- and middle-income households who have anxiety disorders. TRIAL REGISTRATION: This protocol, version 1.0, was registered in ClinicalTrials.gov on February 17, 2021 with Identifier: NCT04760275 .

An Abscopal Effect on Lung Metastases in Canine Mammary Cancer Patients Induced by Neoadjuvant Intratumoral Immunotherapy with Cowpea Mosaic Virus Nanoparticles and Anti-Canine PD-1.

Neoadjuvant intratumoral (IT) therapy could amplify the weak responses to checkpoint blockade therapy observed in breast cancer (BC). In this study, we administered neoadjuvant IT anti-canine PD-1 therapy (IT acPD-1) alone or combined with IT cowpea mosaic virus therapy (IT CPMV/acPD-1) to companion dogs diagnosed with canine mammary cancer (CMC), a spontaneous tumor resembling human BC. CMC patients treated weekly with acPD-1 (n = 3) or CPMV/acPD-1 (n = 3) for four weeks or with CPMV/acPD-1 (n = 3 patients not candidates for surgery) for up to 11 weeks did not experience immune-related adverse events. We found that acPD-1 and CPMV/acPD-1 injections resulted in tumor control and a reduction in injected tumors in all patients and in noninjected tumors located in the ipsilateral and contralateral mammary chains of treated dogs. In two metastatic CMC patients, CPMV/acPD-1 treatments resulted in the control and reduction of established lung metastases. CPMV/acPD-1 treatments were associated with altered gene expression related to TLR1-4 signaling and complement pathways. These novel therapies could be effective for CMC patients. Owing to the extensive similarities between CMC and human BC, IT CPMV combined with approved anti-PD-1 therapies could be a novel and effective immunotherapy to treat local BC and suppress metastatic BC.

Congenital ocular and adnexal disorders in reptiles.

Ocular and adnexal congenital disorders are those that manifest at birth and could involve single or multiple tissues. Several abnormalities have been reported in literature affecting reptilian ocular and/or adnexal tissues. The objectives of this review are: (i) review those disorders previously reported in reptile literature; (ii) present new cases; (iii) provide a basic classification of them according to the moment of occurrence and (iv) indirectly, encourage the clinician dealing with these cases to go further in their diagnosis. The authors consider that categorizing ocular and adnexal congenital disorders could help the clinician to deal with them. The categorization of these disorders required an intense review of cases previously reported in literature and allows the authors suspect that some of them could not have been accurately diagnosed according to the definitions of the anomalies and/or not accurately described. The authors consider that ocular and adnexal congenital disorders could have been underestimated in reptiles and further studies could be helpful to promote the description of new disorders and to expand the knowledge about those previously reported. The review will first describe abnormalities reported during organogenesis (describing possible etiopathogenesis, cases reported, an approach to their diagnosis and recommended therapeutic options).Then a mention of the ocular disorders occurring after organogenesis is made. These disorders are divided when possible in those affecting all or most part of the globe and those affecting only specific tissues (surface ectoderm, neurocrest and mesenchyma and neuroectoderm).

Insects, birds and lizards as pollinators of the largest-flowered Scrophularia of Europe and Macaronesia.

BACKGROUND AND AIMS: It has traditionally been considered that the flowers of Scrophularia are mainly pollinated by wasps. We studied the pollination system of four species which stand out for their large and showy flowers: S. sambucifolia and S. grandiflora (endemics of the western Mediterranean region), S. trifoliata (an endemic of the Tyrrhenian islands) and S. calliantha (an endemic of the Canary Islands). Our principal aim was to test whether these species were pollinated by birds or showed a mixed pollination system between insects and birds. METHODS: Censuses and captures of insects and birds were performed to obtain pollen load transported and deposited on the stigmas. Also, a qualitative and quantitative analysis of the flowers and inflorescences was carried out. KEY RESULTS: Flowers were visited by Hymenoptera and by passerine birds. The Canarian species was the most visited by birds, especially by Phylloscopus canariensis, and its flowers were also accessed by juveniles of the lizard Gallotia stehlini. The most important birds in the other three species were Sylvia melanocephala and S. atricapilla. The most important insect-functional groups in the mixed pollination system were: honey-bees and wasps in S. sambucifolia; bumble-bees and wasps in S. grandiflora; wasps in S. trifoliata; and a small bee in S. calliantha. CONCLUSIONS: The species studied show a mixed pollination system between insects and passerine birds. In S. calliantha there is, in addition, a third agent (juveniles of Gallotia stehlini). The participation of birds in this mixed pollination system presents varying degrees of importance because, while in S. calliantha they are the main pollinators, in the other species they interact to complement the insects which are the main pollinators. A review of different florae showed that the large showy floral morphotypes of Scrophularia are concentrated in the western and central Mediterranean region, Macaronesia and USA (New Mexico).

[Analysis of the results of a palliative care quality program for the last days of life. Ten years of experience]. / Análisis de los resultados de un programa de calidad en cuidados paliativos para los últimos días de vida. Diez años de experiencia.

The integrated care pathways for the last days of life propose quality standards optimizing the care of patients and families. The Pallium Multidisciplinary Assistance Program (PAMPA ©) was implemented based on standards of the International Collaborative for Best Care for the Dying Person in 4 phases: induction, implementation, dissemination and sustainability, in five health centres in Argentina, between 2008 and 2018. A total of 1237 adult patients in the last days of life were included and cared for by palliative care teams trained in PAMPA©. An audit was conducted before and after the implementation of the Program, which is still going on. The median range of follow up into five centres from the beginning of the pathway until death varied from 16 to 178 hours. Care goals were compared: symptom control, communication, multidimensional needs, hydration and nutrition, documentation of interventions and post-mortem care. The overall analysis showed an improvement in the number of records (p = 0.001). The goal of communication on care plan to the patient showed no difference (p = 0.173). Continuous training, support and permanent teams supervision were carried out and perceptions and impact of the implementation were registered. The main emerging items of the qualitative analysis were: attitudes towards the program, fundamental contributions, strengths, weaknesses and subjective definition of the program, recognition of institutional cultural singularities and its influence on care. PAMPA© demonstrated its feasibility as a model of end of life care for patients and families, based on international quality standards.

Las secuencias integradas de cuidado para últimos días de vida proponen estándares de calidad para optimizar la atención de pacientes y familias. Se implementó el Programa Asistencial Multidisciplinario Pallium (PAMPA©) basado en estándares del International Collaborative for Best Care for the Dying Person en cuatro fases: inducción, implementación, diseminación y sustentabilidad, en cinco centros de salud en Argentina, entre 2008 y 2018. Se incluyeron 1237 pacientes adultos en situación de últimos días de vida, en seguimiento por equipos de cuidados paliativos entrenados en el PAMPA©. Se efectuó una auditoría antes y después de la ejecución del programa, aún en curso. El rango de medianas de permanencia en los cinco centros desde el inicio de la secuencia hasta el fallecimiento fue de 16 a 178 horas. Se compararon objetivos de cuidado: control de síntomas, comunicación, necesidades multidimensionales, hidratación y nutrición, documentación de intervenciones y cuidados post mortem. El análisis conjunto mostró una mejoría del número de registros (p = 0.001). La comunicación del plan de cuidados con el paciente no mostró diferencias (p = 0.173). Se realizó capacitación y supervisión permanente a los equipos profesionales de quienes se registraron percepciones de la implementación. Los principales emergentes de este análisis cualitativo fueron: actitudes ante el programa, aportes fundamentales, fortalezas, debilidades y definición subjetiva del programa, reconocimiento de las singularidades culturales institucionales y su influencia en el cuidado. El PAMPA© demostró la factibilidad de un modelo de atención para pacientes y familias en final de vida, basado en estándares de calidad internacionales.

Use of the palliative outcome scale in Argentina: a cross-cultural adaptation and validation study.

Although measuring outcomes is essential to ensuring palliative care effectiveness, there is an absence of properly validated measures in many countries. We undertook a cross-cultural adaptation and validation of the Palliative Outcome Scale (POS) into a Spanish (Argentina) language and cultural context. The methodology used a sequence of phases: 1) verification of conceptual equivalence (literature review, professional interviews, and patient focus groups); 2) multiple translations; 3) committee review; and 4) field testing. Psychometric analysis entailed evaluation of quantitative content validity, construct validity, staff and patients' ratings comparison, internal consistency, test-retest reliability, and responsiveness to change. Conceptual equivalence was achieved. Multiple changes were introduced after the translations and field testing in 65 patients and 20 professionals. Content validity was high for all but one item. Construct validity against a validated quality-of-life measure (European Organization for Research and Treatment of Cancer Quality of Life C-30) was confirmed (rho=0.74, P<0.0005). There was acceptable agreement between staff and patients (Cohen's weighted kappa >0.3) for 5/10, 8/10, and 6/9 items at each of three time-point evaluations and good correlation for all but one item (Spearman coefficient >0.7). Internal consistency was acceptable (Cronbach's alpha=0.68-0.69 and 0.66-0.73) for patient and staff ratings, respectively, and test-retest reliability showed very high agreement for every item (>0.80). The Argentine POS showed adequate responsiveness to change, although significant difference was reached for only 3 out of 10 items for patients and staff, respectively. Completion of the POS did not take more than 12 and 6 minutes for patients and staff, respectively. This study indicates that the Argentine POS is a valid and reliable measure of palliative care outcomes with advanced cancer patients.

Análisis de los resultados de un programa de calidad en cuidados paliativos para los últimos días de vida. Diez años de experiencia / Analysis of the results of a palliative care quality program for the last days of life: ten years of experience

Las secuencias integradas de cuidado para últimos días de vida proponen estándares de calidad para optimizar la atención de pacientes y familias. Se implementó el Programa Asistencial Multidisciplinario Pallium (PAMPA ©) basado en estándares del International Collaborative for Best Care for the Dying Person en cuatro fases: inducción, implementación, diseminación y sustentabilidad, en cinco centros de salud en Argentina, entre 2008 y 2018. Se incluyeron 1237 pacientes adultos en situación de últimos días de vida, en seguimiento por equipos de cuidados paliativos entrenados en el PAMPA ©. Se efectuó una auditoría antes y después de la ejecución del programa, aún en curso. El rango de medianas de permanencia en los cinco centros desde el inicio de la secuencia hasta el fallecimiento fue de 16 a 178 horas. Se compararon objetivos de cuidado: control de síntomas, comunicación, necesidades multidimensionales, hidratación y nutrición, documentación de intervenciones y cuidados post mortem. El análisis conjunto mostró una mejoría del número de registros (p = 0.001). La comunicación del plan de cuidados con el paciente no mostró diferencias (p = 0.173). Se realizó capacitación y supervisión permanente a los equipos profesionales de quienes se registraron percepciones de la implementación. Los principales emergentes de este análisis cualitativo fueron: actitudes ante el programa, aportes fundamentales, fortalezas, debilidades y definición subjetiva del programa, reconocimiento de las singularidades culturales institucionales y su influencia en el cuidado. El PAMPA © demostró la factibilidad de un modelo de atención para pacientes y familias en final de vida, basado en estándares de calidad internacionales

The integrated care pathways for the last days of life propose quality standards optimizing the care of patients and families. The Pallium Multidisciplinary Assistance Program (PAMPA ©) was implemented based on standards of the International Collaborative for Best Care for the Dying Person in 4 phases: induction, implementation, dissemination and sustainability, in five health centers in Argentina, between 2008 and 2018. A total of 1237 adult patients in the last days of life were included and cared for by palliative care teams trained in PAMPA ©. An audit was conducted before and after the implementation of the Program, which is still going on. The median range of follow up into five centers from the beginning of the pathway until death varied from 16 to 178 hours. Care goals were compared: symptom control, communication, multidimensional needs, hydration and nutrition, documentation of interventions and post-mortem care. The overall analysis showed an improvement in the number of records (p = 0.001). The goal of communication on care plan to the patient showed no difference (p = 0.173). Continuous training, support and permanent teams' supervision were carried out and perceptions and impact of the implementation were registered. The main emerging items of the qualitative analysis were attitudes towards the program, fundamental contributions, strengths, weaknesses and subjective definition of the program, recognition of institutional cultural singularities and its influence on care. PAMPA © demonstrated its feasibility as a model of end of life care for patients and families, based on international quality standards

Dez anos de experiência. Resumo: As sequências integradas de cuidado para últimos dias de vida propõem padrões de qualidade para otimizar a atenção de pacientes e famílias. Implementou-se o Programa Assistencial Multidisciplinar Pallium (PAMPA ©) baseado em parâmetros do International Collaborative for Best Care for the Dying Person em quatro fases: indução, implementação, disseminação e sustentabilidade, em cinco centros de saúde na Argentina, entre 2008 e 2018. Se incluíram 1237 pacientes adultos em situação terminal, assistidos por equipes de cuidados paliativos treinadas no PAMPA ©. Fez-se uma auditoria antes e despois da execução do programa, que ainda está sendo desenvolvido. A média de permanência nos cinco centros desde o início da sequência até a morte deu entre 16 a 178 horas. Conferiram-se objetivos de cuidado: controle de sintomas, comunicação, necessidades multidimensionais, hidratação e nutrição, documentação de intervenções e cuidados post mortem.A análise conjunta tem evidenciado uma melhora do número de registros (p = 0.001). A comunicação do regime de cuidados com o paciente não mostrou diferenças (p = 0.173). Realizou-se capacitação e supervisão permanente às equipes profissionais e se registraram as percepções da implementação.Desta análise qualitativa surgiram notadamente: atitudes em fase do programa, contribuições fundamentais, fortalezas, fraquezas e definição subjetiva do programa, reconhecimento das singularidades culturais institucionais e sua influência no cuidado. O PAMPA © demonstrou a factibilidade de um modelo de atendimento para pacientes e famílias em estado terminal, baseado em padrões de qualidade internacionais

Efficacy of chess training for the treatment of ADHD: A prospective, open label study.

OBJECTIVE: To examine the effectiveness of playing chess as a treatment option for children with ADHD. METHODS: Parents of 44 children ages 6 to 17 with a primary diagnosis of ADHD consented to take part in the study. Parents completed the Spanish version of the Swanson, Nolan and Pelham Scale for parents (SNAP-IV) and the Abbreviated Conner's Rating Scales for parents (CPRS-HI) prior to an 11-week chess-training program. We used a paired t-test to compare pre- and post-intervention outcomes, and Cohen-d calculations to measure the magnitude of the effect. The statistical significance was set at P<.05. RESULTS: Children with ADHD improved in both the SNAP-IV (t=6.23; degrees of freedom (df)=41; P<.001) and the CPRS-HI (t=5.39; df=33; P<.001). Our results suggest a large effect in decreasing the severity of ADHD as measured by the SNAP-IV (d=0.85) and the CPRS-HI (d=0.85). Furthermore, we found a correlation between intelligence quotient and SNAP-IV improvement (P<.05). CONCLUSIONS: The results of our pilot study should be interpreted with caution. This pilot project highlights the importance of carrying out larger studies with a case-control design. If our results are replicated in better designed studies, playing chess could be included within the multimodal treatment of ADHD.

Planificación de los cuidados en el final de la vida. Perspectivas de profesionales de oncología y cuidados paliativos / End-of-life care planning. Oncologist and palliative care professionals perspectives / Planejamento dos cuidados em fim de vida. Perspectivas de oncologistas e profissionais de cuidados paliativos

Resumen El artículo aborda la perspectiva de profesionales de oncología y cuidados paliativos de Argentina sobre la planificación anticipada de los cuidados en el final de la vida de pacientes con enfermedades oncológicas avanzadas. A partir de un diseño de investigación cualitativa, basado en entrevistas semi-estructuradas con profesionales de diferentes disciplinas, se analizaron las dificultades para la participación de los y las pacientes en el proceso de toma de decisiones y en los procesos de consentimiento informado en torno a los cuidados en el final de la vida. Pese a valorar la planificación anticipada del cuidado e instrumentos como las directivas anticipadas, se identifican barreras para la implementación de estas prácticas. La falta de herramientas comunicacionales para abordar este tipo de conversaciones con los pacientes, el ocultamiento de la información sobre el diagnóstico y/o el pronóstico de la enfermedad, la falta de articulación entre equipos que realizan el seguimiento de pacientes con enfermedad avanzada, y la resistencia de familiares y pacientes, limitan los márgenes de decisión y consentimiento por parte de los pacientes.

Abstract The article addresses the perspective of oncologist and palliative care professionals of Argentina on the advance end of life care planning for patients with advanced cancer. Based on semi-structured interviews with professionals from different disciplines, the paper explores barriers for the patient participation in the decision-making process in end of life care. Despite the acceptance of advance care planning and instruments such as advance directives, barriers to the implementation of these practices are identified. The lack of communication skills to deal with this type of conversation with patients, the concealment of information on the diagnosis and prognosis of the disease, the lack of coordination between teams that keep track of patients with advanced disease, and the resistance from relatives and patients, limit the margins of decision and consent by patients.

Resumo O artigo aborda a perspectiva dos profissionais de oncologia e cuidados paliativos na Argentina sobre o planejamento antecipado dos cuidados de fim de vida para pacientes com doenças oncológicas avançadas. Partindo de um desenho de pesquisa qualitativa, com base em entrevistas semiestruturadas com profissionais de diferentes disciplinas, o artigo analisa as dificuldades para a participação dos pacientes no processo de tomada de decisão e nos processos de consentimento informado em torno aos cuidados de fim de vida. Apesar de valorizar o planejamento do cuidado antecipado e instrumentos como as diretrizes antecipadas, identificam-se barreiras para a implantação dessas práticas. A falta de instrumentos de comunicação para atender esse tipo de conversa com os pacientes, o encobrimento do diagnóstico e / ou prognóstico da doença, a falta de articulação entre as equipes que acompanham os pacientes com doença avançada e a resistência dos familiares e pacientes, limitam as margens de decisão e consentimento por parte dos pacientes.

Advance directives in the context of end-of-life palliative care.

PURPOSE OF REVIEW: To review the definition of advanced directive, understand the implications for the patient, family and healthcare team, and address the obstacles involved in the implementation. RECENT FINDINGS: Advanced directives propose a model of healthcare based on patient preferences. Although there is sufficient evidence related to their usefulness, various factors are known to affect the use of advanced directives. Therefore, rules need to be established in order to optimize the implementation process. SUMMARY: An advanced directive is a legal document based on the principle of autonomy that expresses the desire of the patient in relation to different medical treatments when the patient is unable to make those decisions. The advanced directives are represented in three formats: Living Will, Appointment of a Healthcare Proxy and Legal Status of Preferences. The uses of advanced directives have an impact not only on the patients and their families, but also on the healthcare team. Despite their utility being well known, there are several general barriers that affect implementation, as well as factors related to characteristics of each study population.

The continuum of primary retinal telangiectasia.

BACKGROUND: Primary retinal telangiectasia is characterized by abnormalities in the retinal vasculature. Any alteration of the normal retinal vasculature may result in variable degrees of retinal leakage, hemorrhages, and exudates. The retinal telangiectatic conditions of Coats' disease, Leber's miliary aneurysms, and idiopathic macular telangiectasia (IMT), although historically considered separate entities, may in fact be variants of the same pathophysiologic vascular process. This is based on observations noting that they share similarities in pathogenesis, histology, and clinical presentation. These observations are controversial and are contested in the literature. Conversely, others have documented Coats' disease, Leber's miliary aneurysms, and IMT as unique and separate retinal conditions, each with specific features. METHODS: Three cases are presented spanning the spectrum of primary retinal telangiectasia. Clinical evaluation, dilated fundus examination, and auxiliary testing document both the similar characteristics that the entities share as well as the distinct features, which define each disease's nomenclature and categorization. CONCLUSION: Coats' disease, Leber's miliary aneurysms, and IMT may be part of a singular clinical spectrum sharing pathophysiologic and histopathologic features and similarities in clinical presentation.

"Idiopathic" intracranial hypertension caused by venous sinus thrombosis associated with contraceptive usage.

BACKGROUND: Cerebral venous sinus thrombosis (CVST) is a life-threatening condition that may present with symptoms and signs identical to idiopathic intracranial hypertension (IIH). Both conditions consist of increased intracranial pressure (ICP); however, IIH shows no evidence of contributory intracranial pathology. Oral hormonally based contraceptive usage has been associated with both conditions as well. Because disc edema often occurs in CVST, and IIH and is evident in other sight- and life-threatening conditions such as intracranial mass lesions, neuroimaging and other ancillary testing must be conducted for definitive diagnosis. CASE: An 18-year-old white woman with IIH previously diagnosed presented with headaches and severe visual loss in the left eye. Bilateral disc edema with macular edema in the left eye (O.S.) was present. Threshold perimetry found bilaterally enlarged blind spots as well as a central scotoma O.S. Her medical history was significant for a right transverse, sigmoid and jugular siphon thrombosis secondary to a hypercoagulable state and associated with her use of oral birth control medication. Subsequent magnetic resonance venography (MRV) found the presence of CVST. Despite anticoagulation therapy and acetazolamide, she had severe, nonresolving papilledema. Treatment with oral prednisone was initiated. She recovered full visual fields and excellent visual acuity. CONCLUSION: Because of the similarity in clinical presentation of CVST and IIH, it is important to differentiate distinguishing characteristics of these diseases for correct diagnosis and prompt treatment.

Anatomía endosópica del III ventrículo: Componentes diencefálicos y estructuras adyacentes / Endoscopic anatomy of the third ventricle: Diencephalic components and adjacent structures

Objetivos: Estudiar la anatomía endoscópica de los componentes diencefálicos de las paredes del tercer ventrículo y de las estructuras adyacentes a éste. Establecer las bases anatómicas para la intervención quirúrgica con éxito de las lesiones que involucran al tercer ventrículo. Método: Se estudiaron 10 cadáveres adultos, obteniendose imágenes de 9 cirugías mediante técnica endoscópica. Se emplearon endoscopios rígidos de cero grados de angulación y de díametros de 1, 8 milímetros. En algunos casos fue necesario utilizar un endoscopio flexible. En todos los casos el abordaje fue precoronal y se utilizó instrumental específico para neuroendoscopía. Resultados: El Tercer ventrículo es una cavidad medial, estrecha, localizada por debajo de los ventrículos laterales, entre las masas diencefálicas. Se describen un techo y un piso, una pared anterior y otra posterior, y dos paredes laterales...

Anatomía quirúrgica endoscópica del acueducto mesencefálico / Surgical endoscopic anatomy of the mesancephalic aqueduct

Objetivos: Describir la anatomía endoscópica del acueducto mesencefálico. Detallar la técnica para el abordaje con éxito de la reción. Enumerar los reparos anatómicos endoscópicos que el cirujano debe conocer para llevar a cabo con éxito el abordaje endoscópico. Método: Se utilizaron diez cadáverez adultos, obteniendose imágenes de 14 cirugías. Utilizamos endoscopios rígidos de cero grados para la inspección del acueducto mesencefálico. En aquellos casos en los que se observó una estenosis del acueducto llevamos a cabo una acueductoplastia con balón. Con la ayuda de un endoscopio flexible se exploró el acueducto y el cuarto ventrículo y se preforaron las obstrucciones membranosas. en un caso fue necesario insertar un stent en el acueducto. Resultados: El acueducto mesencefálico, también llamado acueducto de Silvio, comunica el tercer ventrículo con el cuarto. La entrada al mismo se encuentra en la pared posterior del tercer ventrículo. Esta pared es muy estrecha y se pueden identificar en ella varias estructuras, que en sentido cráneo-caudal son: el receso suprapineal, la comisura habenular, el receso pineal, la comisura posterior, y la entrada al acueducto. En condiciones normales, la entrada al acueducto en el piso del tercer ventrículo es de un ancho aproximado de 1 mm, por lo tanto, el escaso diámetro impide su canulación segura con elementos endoscópicos. En los casos en que el acueducto se encuentra dilatado se constituye en el camino ideal para llegar al cuarto ventrículo y navegar a través del mismo sin dificultad. Conclusión: La región del acueducto es de difícil abordaje, por lo tanto es imprescindible conocer la anatomía endoscópica para poder llevar a cabo con éxito los diversos procedimientos quirúrgicos.

Aspectos históricos de los nervios craneales / Historical aspects of cranial nerves

Este trabajo revisa la perspectiva histórica en la descripción de los 12 nervios craneanos hecha por los anatomistas clásicos, utilizando textos tradicionales y traducciones modernas. La historia de la enumeración de los nervios se remonta a Galeno con su clasificación en 7 pares, pasando por los 9 pares de Willis (1664) y los 12 pares de Soemmerring (1778). Hubo contribuciones de anatomistas medievales como Achillini, Berengario de Carpi y Massa, a pesar de las prohibiciones que pesaron sobre los estudios anatómicos hasta el siglo XVI. La clasificación de los nervios craneanos en 9 pares se siguió utilizando hasta fines del siglo XIX, a pesar de que ya había sido aceptada su clasificación en 12 pares hacia 1778. Se recuerda también a aquellos autores que describieron estructuras individuales y las nombraron por primera vez.

Anatomía endoscópica del espacio epidural lumbar / Endoscopic anatomy of lumbar epidural space

El desarrollo de la técnica endoscópicas ha llevado a un renovado interés en el conocimiento del espacio epidural. En el presente trabajo se estudió el espacio epidural con un endoscopio rígido, pudiendose reconocerse la compartimentalización del mismo. Se identificó una condensación de tejido conjuntivo posterior que fija y limita el espacio epidural y unas bandas transversales que dividen el espacio posterior en dos sectores, uno ventral y otro dorsal. En el espacio epidural lateral fue posible observar los pedículos y la salida de la raíz nerviosa. El espacio anterior mostró una amplitud mayor, conteniendo mayor cantidad de tejido graso. Esta compartimentalización anatómica podría explicar la dificultad para introducir catéteres o la distribusción asimétria de los anestésicos inyectados...

Antecedentes históricos de la neuroendoscopía argentina / Hisotircal antecedents of the argentine neuroendoscopy

El primer procedimiento neuroendoscópico fue realizado por Lespinasse en 1910 y Dandy, doce años después, manifestó la utilidad de estos procedimientos. En Argentina Roque Orlando y Manuel Balado, trabajando por separado, publicaron sus experiencias en 1931, dejando establecidas las indicaciones y potencialidades de la endoscopía. Durante el año 1932, un segundo informe de Balado, menciona que Payr, en 1919, había expresado la posibilidad de utilizar la endoscopía con fines experimentales, y comentó el trabajo publicado por Volkmann en 1923. En la década del '70, Conesa y Dillon comenzaron los estudios de neuroanatomía endoscópica en Argentina, arribando a conclusiones que hoy se consideran verdades absolutas. Finalmente, en el año 2001, los autores crearon el primer laboratorio de neuroanatomía endoscópica en el país