Strategy to secure the neuraxial route in anaesthesia: Risk mapping and feedback from the application of the ISO 80369-6 standard NRFit® connectors.

INTRODUCTION: In anesthesia, a medication error would occur every 20 to 133 anesthesia procedures, and 14% is related to a route administration error. To secure neuraxial route, ISO group published a norm in 2016 to develop specific connectors, the "NRFit® connector". The main objective of this work, is to develop a risk mapping related to neuraxial medication errors therefore prepare the NRFit® implementation in anesthesia units in a French Universitary Hospital. METHODS: Failure modes, effects and criticality analysis (FMECA) methodology was used for our risk mapping which was divided in 3 anesthesia specialities. For each, the analysis was performed for accidental neuraxial administration of intravenous drugs, and its opposite error. Secondly, NRFit® devices were tested for 1 month by 3 experimented anesthetists. RESULTS: The majority of reported errors concerns epidural and intrathecal anesthesia, and more frequently in the field of obstetrics. Opioids and tranexamic acid, administered in neuraxial route, are drugs with the highest criticality. The tests were rather conclusive and made it possible to highlight the additional needs in medical devices. DISCUSSION: Obstetrics is the riskiest area due to the frequency of epidural anesthesia, the administration of critical drugs in intravenous and neuraxial route. This work increased the awareness of our group, improved the measure of this risk and harmonized practices. CONCLUSION: This work is the first step of the project to prevent administration route error in anesthesia during patient's drug management. The next step will be the NRFit® implementation for epidural and combined spinal-epidural anesthesia in our hospital.

Reconstruction of scaphoid waist non-unions using a radial approach: Preliminary outcome analyses.

This study aimed to evaluate clinical and radiographic outcomes in a consecutive series of patients who underwent open surgery via a radial approach for reconstruction of scaphoid waist non-union. Over a 2-year period, 16 males with scaphoid waist non-union received surgery using a radial approach; we performed limited styloidectomy, biconcave curettage, ovoid bone grafting from the styloidectomy fragment, and placement of a retrograde radial-entry screw. Mean patient age was 25.1 years (range 17-56 years). Bony union was determined on radiographs and computed tomography. Radiographic variables were measured on preoperative and final follow-up radiographs. Mean follow-up was 14 months (range 8-19 months). Subjective and objective outcomes were recorded. Radiographic healing was achieved in 14 of the 16 patients (88%) at a mean 4½ months after surgery (range 3-6 months). Significant postoperative improvements were found in mean carpal height ratio (from 0.48 to 0.53) and radiolunate angle (from 8.2° to 2.8°) compared to preoperative data. Mean postoperative wrist extension was 54° (range 32-67°) and mean flexion 49° (range 2-64°). Mean flexion arc after surgery was 84.1% that of the contralateral side. Mean grip strength was 85.2% that of the contralateral side. Subjective results comprised mean postoperative Modified Mayo Wrist score of 82.3 (range 55-90) and Quick Disabilities of the Arm, Shoulder and Hand score of 11.2 (range 0-36.4). Twelve of the 14 healed wrists were subjectively rated as good or excellent. Repair of scaphoid non-union via a radial approach was safe and effective. Union rates were high and outcomes were good.

[Prescription of phosphorus, calcium and magnesium: Choice of the millimole unit to establish the equivalence of doses between oral and injectable forms]. / Prescription de phosphore, calcium et magnésium : choix de l'unité millimole pour établir l'équivalence des apports entre les formes orales et injectables.

OBJECTIVES: Information available on the packaging of drugs indicated for patients electrolytes replenishment differs from one manufacturer to another. They relate, for example, the unit chosen to express elemental electrolyte concentration. These differences constitute a risk factor for medication errors. This article proposes a clinical decision support tool which defines dose equivalences between the oral and injectable formulation galenic forms for medications providing phosphorus, calcium and magnesium and a calculated replenishment ratio. METHODS: The amounts of elemental electrolyte were determined from the information contained on the packaging and the summaries of product characteristics. Only the specialties of our hospital drug formulary were studied. For each element, the replenishment ratio was determined from published data. RESULTS: Equivalence tables were created for the phosphorus, calcium and magnesium between oral and injectable formulation. A clinical decision support tool was developed from these data. CONCLUSION: The use of this tool is a first way to reduce the risk of medication errors. It remains to determine the conditions for its dissemination and evaluation. This issue raises the questions of the exclusive use of the millimole unit on packaging and for prescription, and that of the integration of this type of tool into prescription software and decision support systems.

[Hysterectomy: Practices evolution between 2009 and 2019 in France]. / Hystérectomie : évolution des pratiques entre 2009 et 2019 en France.

OBJECTIVE: Hysterectomy is the most common procedure in women. We wanted to make an assessment of the hysterectomy in France in 2019. We also assessed the variations over time in the indications and the surgical approch for hysterectomy, this with regard to the various events that may have been at the origin of the modification practices. METHODS: We used the Medical Information Systems Program in Medicine, Surgery, Obstetrics and Dentistry to extract all acts relating to a hysterectomy regardless of its route of approach from 2009 to 2019. RESULTS: Hysterectomy is a frequent procedure which was performed in nearly 60,000 women in France in 2019. The most frequently used surgical approach is now laparoscopy, performed in 30% of hysterectomies, followed by laparotomic (29%), then vaginal approaches (26%) and coelio-vaginal (15%). Laparoscopic procedures are performed more often in public than private hospitals. Adnexectomy is associated with 41% of hysterectomies. A decrease in the number of hysterectomies was observed between 2008 and 2019, from approximately 72,000 in 2008 to approximately 60,000 in 2019. This decrease occurs during a period in which new therapies have emerged as well as new recommendations. CONCLUSION: The evolution of the number of hysterectomies is correlated with the development of therapeutic alternatives for pathologies for which a hysterectomy has traditionally been performed.

[Menopause hormone treatment in practice. Postmenopausal women management: CNGOF and GEMVi clinical practice guidelines]. / Le traitement hormonal de la ménopause en pratique. RPC Les femmes ménopausées du CNGOF et du GEMVi.

Menopause Hormonal Treatment (MHT) was initially developed to correct the climacteric symptoms induced by postmenopausal estrogen deficiency. In non-hysterectomized women, MHT combines estrogens and a progestogen, the latter opposing the negative impact of estrogen on endometrial proliferation. In France, and contrary to the USA and Northern European countries, MHT mainly combines 17ß-estradiol, which is the physiological estrogen produced by the ovary, and progesterone or its derivative, dihydrogesterone. France has been a pioneer in the development of cutaneous administration routes (gel or transdermal patch) for estradiol, allowing better metabolic tolerance and a reduction of the risk of venous thromboembolism compared to the oral route. The choice of the doses as well as the treatment regimen is underpinned by tolerance as well as acceptance and compliance. The risk of breast cancer, which is one of the main risks of MHT, is higher with estro-progestogen combinations than with estrogens alone ; the preferential use of progesterone or dihydrogesterone being likely to limit the excess risk of breast cancer associated with MHT at least for duration of treatment of less than 5 to 7 years. The question of the optimal duration of MHT remains an issue and must take into account the initial indication of treatment as well as the benefit-risk balance, which is specific to each woman. Continuation of MHT is conditioned by the benefit-risk balance, which must be evaluated regularly, but also by the evolution of symptoms when MHT is stopped as well as menopause-related health risks or induced by MHT. After stopping MHT, it is necessary to maintain a medical follow-up to be adapted to the clinical situation of each woman and in particular, her cardiovascular and gynecological risk factors.

Surgical approaches to the trapeziometacarpal joint for the insertion of implants and prostheses (non-arthroscopy).

The two approaches most often used for placing implants and trapeziometacarpal prostheses are the laterodorsal approach and the lateropalmar approach. The advantages and disadvantages of these two approaches are set out. Each one allows optimal joint exposure while preserving or repairing the peritrapezial musculotendinous structures. They allow the insertion of partial or total trapeziometacarpal implants and modern coupled trapeziometacarpal prostheses. Each approach must be practiced and mastered on cadaver specimens before being used for trapeziometacarpal surgery.

[The left outflow tract: Abnormal features]. / La voie d'éjection gauche : aspects inhabituels.

The good knowledge of the characteristics of the left outflow tract allows us to detect but also to identify anomalies such as conal VSD and conotruncal anomalies. The analysis of this specific area of the heart must always be performed as part of a global analysis of the outflow tracts, combining the analysis of the right outflow tract with the assessment of the three vessel and trachea view.

[Breech Presentation: CNGOF Guidelines for Clinical Practice - External Cephalic Version and other Interventions to turn Breech Babies to Cephalic Presentation]. / Présentation du siège. Recommandations pour la pratique clinique du CNGOF ­ Version par manœuvre externe et techniques de version alternatives.

OBJECTIVES: To provide guidelines regarding efficiency and safety of external cephalic version (ECV) attempt and alternatives methods to turn breech babies to cephalic presentation. METHODS: MedLine and Cochrane Library databases search in French and English and review of the main foreign guidelines between 1980 and 2019. RESULTS: ECV is associated with a decreasing rate of breech presentation at birth (LE2), and potentially with a lower rate of cesarean section (LE3) without an increase of severe maternal (LE3) and perinatal morbidity (LE3). It is therefore recommended to inform women with a breech presentation at term that ECV should be attempt (Professional consensus). ECV attempt should be performed with immediate access to an operating room for emergency cesarean (Professional consensus). The ECV attempt before 37 weeks, compared to ECV attempt after 37 weeks, increases the rate of cephalic presentation at birth (LE2) but with a small increase risk of moderate prematurity (LE2). ECV attempt should be performed from 36SA (Professional consensus). The main factors associated with successful ECV attempt are multiparity (LE3) and no maternal obesity (LE3). Parenteral tocolysis (ß mimetic or atosiban), for ECV attempt at term is associated with a higher success rate (LE2), higher rate of achieved cephalic presentation in labor (LE2) and a lower cesarean section rate (LE2). It is recommended to use parenteral tocolysis for ECV attempt at term in order to increase its success rate (grade B). The ECV attempt is associated with an increase in transient FHR abnormalities (LE3), it is therefore recommended that cardiotocography should be performed prior and during 30minutes after the procedure (Professional consensus). There is no argument for recommending the practice of delayed cardiotocography after ECV attempt (Professional consensus). The risk of significant positivity (>30mL) of the Kleihauer test after ECV attempt is low (<0.1%) (LE3), it is not recommended to systematically perform a Kleihauer test after ECV attempt (professional consensus). In case of RH-1 negative women, it is recommended to ensure systematic RH-1 prophylaxis (Professional consensus). In case of breech presentation at term, acupuncture, moxibustion and postural methods are not effective in reducing breech presentation at birth (LE2), and are therefore not recommended (Grade B). CONCLUSION: According to the clear benefits and the low risks of ECV attempt, all women with a breech presentation at term should be informed that ECV should be attempted to decrease breech presentation at birth and cesarean section.

[Anatomical description of the retro-caruncular approach and its application in oculoplastics: A cadaveric study]. / Bases anatomiques de la voie rétro-caronculaire et ses applications cliniques en oculoplastique : étude sur cadavre.

PURPOSE: To describe the anatomical landmarks of the retro-caruncular approach and its clinical applications based on a cadaveric study. PATIENTS AND METHOD: A dissection of 8 orbits providing from 4 fresh cadavers was carried out at the anatomical laboratory of the University Hospital of Nice, France between October 2018 and January 2019. RESULTS: Main anatomical relationships encountered are anteriorly the Duverney-Horner muscle and the lacrimal sac, posteriorly the anterior and posterior ethmoidal arteries, superiorly the pulley of the superior oblique muscle, inferiorly the lacrimonasal duct and the tendon of the inferior oblique muscle. The retro-caruncular approach allows a safe surgical access behind the lacrimal sac and Duverney-Horner muscle. Many oculoplastic surgical procedures can be performed through this approach: dacryocystorhinostomy, medial orbital fractures repair, "médial" orbital "décompression", biopsy of medial and extraconal tumours, medial periosteal fixation in third-nerve palsy. CONCLUSION: The retro-caruncular approach is a safe procedure avoiding skin incision. It allows a wide surgical space even if it is reduced compared to a more conventional skin route. It requires a great anatomical knowledge and a longer surgical learning curve.

[The left outflow tract: Normal features]. / La voie d'éjection gauche : aspects habituels.

Congenital heart disease remains an important cause of perinatal morbidity and mortality. Screening for these is based on a good knowledge of normal fetal heart anatomy and ultrasound views to be performed. After recommending the use of the four chambers and the right outflow tract views in 2005, CNEOF proposes recently adding the left outflow tract assessment. The use of this one should sensitize the operator to the notion of sweeping essential to obtain all these views and make it possible to improve the detection of the conal VSD and conotruncal pathologies.

[Surgical management of deep endometriosis with colorectal involvement: CNGOF-HAS Endometriosis Guidelines]. / Prise en charge chirurgicale de l'endométriose profonde avec atteinte digestive, RPC Endométriose CNGOF-HAS.

Deep endometriosis with colorectal involvement is considered one of the most severe forms of the disease due to its impact on patients' quality of life and fertility but also by the difficulties encountered by the clinicians when proposing a therapeutic strategy. Although the literature is very rich, evidence based medicine remains poor explaining the great heterogeneity concerning the management of such patients. Surgery therefore remains a therapeutic option. It improves the intensity of gynecological, digestive and general symptoms and the quality of life. Concerning the surgical approach, it appears that laparoscopy should be the first option; the laparoscopic robot-assisted route can also be proposed. The techniques of rectal shaving, discoid resection and segmental resection are the three techniques used for surgical excision of colorectal endometriosis. The parameters taken into account for the use of either technique are: the surgeon's experience, the depth of infiltration of the lesion within the rectosigmoid wall, the lesion size and circumference, multifocality and the distance of the lesion from the anal margin. In the case of deep endometriosis with colorectal involvement, performing an incomplete surgery increases the rate of pain recurrence and decreases postoperative fertility. In case of surgery for colorectal endometriosis, pregnancy rates are similar to those obtained after ART in non-operated patients. Existing data are insufficient to formally recommend first line surgery or ART in infertile patients with colorectal endometriosis. The surgery for colorectal endometriosis exposes to a risk of postoperative complications and recurrence of which the patients should be informed preoperatively.

Surgical treatment by percutaneous anterior screw fixation of scaphoid fractures.

The aim of this study was to evaluate the results of percutaneous screw fixation of scaphoid waist fractures in our surgery unit by comparing them with recent data from the literature. This was a retrospective, descriptive study conducted between January 2010 and September 2016. Patients operated due to a recent scaphoid fracture and treated by percutaneous anterograde screw fixation with a Herbert screw were included in this study. Our cohort was a sub-set from a scaphoid fracture group; other fracture sites, other treatment techniques and fractures associated with scapholunate ligament lesions were excluded. The time to union and union rate were recorded. The Youm and McMurtry indices, scaphoid and scapholunate angles were measured on radiographs. A total of 21 patients were included. The mean age was 30 years (18-44) and the sex ratio (male/female) was 9.5. The union rate was 95% with an average follow-up of 24 months. Four patients had a mobility deficit in the sagittal plane of about 9°. No malunion was found, and no major complications were observed. Based on this study, percutaneous fixation of the scaphoid with Herbert's screw is a reliable technique that leads to union in most cases with limited postoperative immobilization.

[Management of pregnant women with recurrent herpes. Guidelines for clinical practice from the French College of Gynecologists, Obstetricians (CNGOF)]. / Suspicion de lésion d'herpès génital chez une femme enceinte ayant un antécédent d'herpès génital connu. Recommandations pour la pratique clinique du Collège national des gynécologues obstétriciens français (CNGOF).

OBJECTIVE: To provide guidelines for the management of woman with genital herpes during pregnancy or labor and with known history of genital herpes. METHODS: MedLine and Cochrane Library databases search and review of the main foreign guidelines. RESULTS: Genital herpes ulceration during pregnancy in a woman with history of genital herpes correspond to a recurrence. In this situation, there is no need for virologic confirmation (Grade B). In case of recurrent herpes during pregnancy, antiviral therapy with acyclovir or valacyclovir can be administered but provide low efficiency on duration and severity of symptoms (Grade C). Antiviral treatment proposed is acyclovir (200mg 5 times daily) or valacyclovir (500mg twice daily) for 5 to 10 days (Grade C). Recurrent herpes is associated with a risk of neonatal herpes around 1% (LE3). Antiviral prophylaxis should be offered for women with recurrent genital herpes during pregnancy from 36 weeks of gestation and until delivery (Grade B). There is no evidence of the benefit of prophylaxis in case or recurrence only before the pregnancy. There is no recommendation for systematic prophylaxis for women with history of recurrent genital herpes and no recurrence during the pregnancy. At the onset of labor, virologic testing is indicated only in case of genital ulceration (Professional consensus). In case of recurrent genital herpes at the onset of labor, cesarean delivery will be all the more considered if the membranes are intact and/or in case of prematurity and/or in case of HIV positive woman and vaginal delivery will be all the more considered in case of prolonged rupture of membranes after 37 weeks of gestation in an HIV negative woman (Professional consensus). CONCLUSION: In case of recurrent genital herpes at the onset of labor and intact membranes, cesarean delivery should be considered. In case of recurrent genital herpes and prolonged rupture of membranes at term, the benefit of cesarean delivery is more questionable and vaginal delivery should be considered.

[Observational study of outpatient unit duration of stay depending on the route of administration (intravenous vs subcutaneous) for a targeted therapy]. / Étude observationnelle du temps passé en hôpital de jour selon la voie d'administration (intraveineuse vs sous-cutanée) d'une thérapie ciblée.

New routes of administration available for some targeted therapies, especially subcutaneous injections, have an impact not only on the patients' daycare experience, but also on the unit's organization. This observational study conducted on 48 voluntary patients at the Institut universitaire du cancer Toulouse-Oncopole shows that the mean duration of the outpatient unit stay is diminished by one hour when a subcutaneous injection is used instead of an intravenous route. This duration decrease is mainly caused by an 82% average reduction in treatment duration. However, the waiting times before and after the treatment itself are not significantly impacted. Organizational methods related to the treatment prescription and preparation remain indeed the same. Anticipated prescription is not noticeably impacted either. This reduction of the duration of stay will truly be obtained if the whole unit's organization is adapted.

The radial approach to the wrist with styloidectomy: A cadaver study.

The radial approach to the wrist is already used in several surgical techniques such as radial styloidectomy and Zaidemberg's vascularized radial graft. The aim of our work was to describe the surgical anatomy of that approach and to determine the acceptable limits of radial oblique styloidectomy that does not damage the anterior and posterior radiocarpal ligaments. This radial approach was performed on 11 cadaver specimens. The superficial branches of the radial nerve and the antebrachial cephalic vein were carefully located in the superficial plane. The radiocarpal articular capsule was opened longitudinally between the first and second compartments of the extensor tendons. We drew the oblique radial styloidectomy line at 3, 6 and 9mm from the apex of radial styloid process on the articular surface and then measured the width of ligaments theoretically taken away by the styloidectomy. An oblique radial styloidectomy of less than 6mm preserved the anterior and posterior radiocarpal ligaments. There was one case of radial artery damage while opening the joint capsule. The radial approach to the wrist as described in this work provided good access to the radial styloid process, the radioscaphoid joint and the proximal pole of the scaphoid, if the approach is done carefully to preserve the superficial branches of the radial nerve, the antebrachial cephalic vein and the radial artery. Radial styloidectomy can be performed up to 6mm from the apex without significantly damaging the radiocarpal ligaments, particularly the volar ones.

[Mode of delivery in spontaneous preterm birth]. / Mode d'accouchement en cas de prématurité spontanée.

OBJECTIVE: To evaluate the benefit/risk balance of way of birth according to fetal presentation, to assess monitoring during preterm labor, to discuss method of delivery and practice of delayed cord clamping in case of spontaneous preterm birth. METHODS: Bibliographic research from the Pubmed database and recommendations issued by the main scientific societies, and assignment of a level of evidence and a recommendation grade. RESULTS: In case of vertex presentation, no studies suggest that cesarean section improve neonatal outcome during spontaneous preterm birth (LE4). Nevertheless, cesarean is associated with higher maternal morbidity than vaginal delivery. Thus, routine cesarean is not recommended simply because of a spontaneous preterm labor (professional consensus). The available data do not allow specific recommendations about the choice of mode of delivery for preterm breech presentation in view of the low levels of proof (Professional consensus). Fetal rate monitoring is necessary during preterm labor (Professional consensus). Current data about second lines method for fetal surveillance (fetal scalp blood for pH or lactates) are insufficient to recommend their use before 34 WG (Professional consensus). Systematic assisted vaginal delivery is not recommended during preterm birth (Professional consensus). Use of vacuum is possible after 34 WG when cranial vertex ossification is considered satisfactory (Professional consensus). Systematic use of episiotomy in case of preterm birth is not recommended (Professional consensus). A delayed cord clamping is possible if the neonatal or maternal state so permits (Professional consensus). The available data are insufficient to recommend a systematic use of this procedure (LE3). CONCLUSION: In case of preterm delivery, the available data do not allow specific recommendations about the choice of mode of delivery regardless of fetal presentation.

[Hepatitis B and pregnancy. Part 2. Nine practical issues about delivery and neonatal care]. / Hépatite B et grossesse. Partie 2. Neuf questions pratiques concernant l'accouchement et la prise en charge néonatale.

In France, the hepatitis B maternal-fetal transmission prevention strategy is based on serovaccination at birth. Serum therapy is to inject 30IU/kg of anti-HBs specific immunoglobulins of human origin in the first hours of life, which in practice corresponds to 1ml or 100IU. Vaccination should also be performed during the first hours of life, and a new injection should be performed at 1month and 6months. In infants less than 32weeks and/or less than 2kg, lower vaccine response leads to prescribe an additional injection at 2months. This serovaccination reduces the risk of mother to child transmission from 57 to 4 %. The failure risk factors of serovaccination are high maternal viral load (greater than or equal to 7 log) and/or the presence of HBeAg. The delivery route does not change the risk of maternal-fetal transmission of hepatitis B when serovaccination at birth was well conducted. Likewise, breastfeeding does not change the risk of maternal-fetal transmission of hepatitis B after serovaccination. It is recommended by WHO. During labor, the pH in utero should be done only when strictly necessary, the published data do not allow to conclude on the risk of transmission.

[Evaluation of adherence to French guidelines concerning the information of the women having a scarred uterus on their mode of delivery]. / Évaluation du suivi des recommandations concernant l'information des patientes ayant un utérus cicatriciel sur leur mode d'accouchement.

OBJECTIVE: To evaluate adherence of obstetricians from our maternity to French practice guidelines concerning information to give to pregnant patients with a history of scarred uterus. MATERIALS AND METHODS: Observational retrospective study performed on medical files from June to August 2014 and concerning women with a scarred uterus that gave live-birth after 37weeks of gestation. Information of patients had to concern the risks of a history of caesarean, the benefits and risks of the various delivery modes. RESULTS: On 758 deliveries, 77 cases were studied: 48 patients were followed up from the beginning of pregnancy, 23 from the 2nd trimester and 6 were not followed. Among patients followed from the beginning, no data was written on medical file concerning information that should to be given in immediate post-partum, in preconception counseling, and at the beginning of pregnancy about the risks of scarred uterus and the mode of delivery. In the 8th month, information about benefits and risks of the planned delivery mode was noticed in 45% of files. CONCLUSION: The information that need in theory to be given to the patients with scarred uterus appeared little or insufficiently noticed on medical files; which can be due either to an inaccurate information, or to a lack of transcription of the information nevertheless given. A check-list in obstetrical file would help to systematize the information to provide in scarred uterus patients.

[Hysterectomy for benign gynaecological disease: Surgical approach, vaginal suture method and morcellation: Guidelines]. / Hystérectomie pour pathologie bénigne: choix de la voie d'abord, technique de suture vaginale et morcellement: recommandations.

OBJECTIVE: To provide clinical practice guidelines from the French college of obstetrics and gynaecology (CNGOF), based on the best evidence available, concerning the surgical approach, the vaginal suture method, the surgeon's experience and morcellation to avoid complications with hysterectomy for benign gynaecological disease. MATERIAL AND METHODS: English and French review of literature about complications with hysterectomy for benign gynaecological disease, excluding cancer. RESULTS AND CONCLUSION: For benign gynaecological disease, vaginal (VH) or laparoscopic (LH) hysterectomy are recommended (grade B). In case of big uterus, VH or LH are recommended (grade C). VH is not contraindicated in nulliparous (Grade C). VH is not contraindicated in case of previous caesarean (grade C). In obese women, VH and LH are recommended (grade C). It should be recommended to perform at least 30 hysterectomies during learning curve (grade C). Hysterectomy should be performed by surgeon doing at least 10 hysterectomies each year (grade C). No vaginal suture method is recommended (grade C). It is recommended to assess cancer risk before (histological sample and/or imagery) when morcellation is planned (expert opinion).