Optical Coherence Tomography Angiography Microvascular Variations in Pre- and Posttreatment of Retinoblastoma Tumors.

INTRODUCTION: The purpose of this study is to describe variations in microvasculature before and after treatment of treatment-naive lesions and during consolidation therapy of retinoblastoma lesions using an investigational portable optical coherence tomography angiography (OCTA) system. METHODS: This study is a single-center, prospective, observational case series. Recruited subjects were either undergoing surveillance for retinoblastoma or had newly detected retinoblastoma. Nine tumors from 7 eyes in 6 patients were included. During exams under anesthesia, the tumors were imaged with an investigational portable OCTA system. OCTA images were analyzed to assess vascular changes before and after treatment. RESULTS: In all 6 presented cases, OCTA imaging revealed distinctive vascular patterns, such as dilated feeder arteries and draining veins, disorganized and complex branching patterns, irregular vessel calibers, and dilation and tortuosity of vessels. After treatment, OCTA imaging revealed decreased intrinsic tumor vascularity and reduced dilation of draining and feeder vessels. Tumor relapse demonstrated prominent vascularity (n = 1) that resolved on repeat OCTA after transpupillary thermotherapy treatment. Type 2 (n = 1), 3 (n = 6), and 4 (n = 1) tumor regression patterns were seen in our patients after treatment, and OCTA findings were consistent with a previously published report. Interestingly, in one of the presented cases, OCTA demonstrated clear feeder, draining, and intrinsic tumor vessels that were not as evident on fluorescein angiography. CONCLUSIONS: OCTA may offer a noninvasive and sensitive technique to evaluate the vasculature of both the tumor and the surrounding retina in retinoblastoma. With additional research and development into its use in patients with retinoblastoma, OCTA may one day be useful in assessing treatment response and residual tumor activity.

Choroidal nevus with retinal invasion, clinical and imaging features.

PURPOSE: To report a clinically challenging case of a choroidal nevus with retinal invasion with accompanying ancillary testing. OBSERVATIONS: A 60-year-old Caucasian female was referred for a suspicious melanocytic choroidal lesion in her left eye. Ophthalmoscopic examination revealed a melanocytic choroidal lesion, measuring 10 mm × 10 mm in basal diameter. The lesion had a clinically evident area of retinal invasion seen as a protruding choroidal mass at its center, darker in appearance compared to the rest of the lesion, obscuring retinal vessels. The choroidal nevus had associated chronic retinal changes and the absence of overlying orange pigment or subretinal fluid. On fundus autofluorescence, there was a hypoautofluorescent area showing the site of retinal invasion. Fluorescein angiography at the lesion site exhibited central blocked perfusion corresponding to the area of retinal invasion. Ultrasonography showed a dome-shaped choroidal lesion that was optically dense with a medium-high internal reflectivity measuring 3.3mm in thickness. The optical coherence tomography showed a choroidal mass extruding through a break in Bruch's membrane with inner retinal invasion. A watchful waiting strategy was adopted, and at 28 months follow-up, the choroidal lesion did not show growth or presence of new suspicious features of malignant transformation. CONCLUSION AND IMPORTANCE: This case highlights the importance of recognizing the key features of choroidal nevi with retinal invasion, which can prevent the treatment of a benign condition and assist in the arrival of a correct diagnosis. These lesions should be monitored for long-term.

Clinical and Functional Results of Broström-Gould Procedure With Suture Tape Augmentation: An Evaluation Using Three Scales.

The mechanical superiority of suture tape augmentation associated with the Broström-Gould procedure for treating lateral ankle instability has been reported. This study aimed to describe functional results using the visual analog scale (VAS), American Orthopedic Foot & Ankle Society (AOFAS) scale, and Short Form of Quality of Life Survey (SF-36) in patients with ankle lateral instability who underwent the modified Broström-Gould repair and suture tape augmentation and to determine the recurrence of injury and the impact on the perception of its stability. This retrospective cohort study included patients with lateral ankle instability treated using the modified Broström-Gould procedure and suture tape augmentation from December 2015 to July 2018 with a 6- to 36-month follow-up. Clinical and functional results were evaluated using the 3 aforementioned scales. p ≤ 0.05 was considered statistically significant. Twenty-eight patients were included, 18 (64%) males and 10 (36%) females (mean ± standard deviation age of 33.25 ± 12.73). The mean pre- and postoperative VAS scores were 6 ± 1.18 and 0.53 ± 0.92, respectively. The average pre- and postoperative AOFAS scores were 65.89 ± 15.08 and 94.60 ± 6.88, respectively; results were excellent (91 to 100) in 18 (64%) patients and good (81 to 90) in 10 (36%). Three patients experienced recurrence of injury treated with physical therapy, and their progress was satisfactory; stability perception was maintained. Excellent clinical and functional results were demonstrated in our study using suture tape augmentation in the modified Broström-Gould procedure, which probably protects against the recurrence of lateral ankle instability.

Brd4 and P300 Confer Transcriptional Competency during Zygotic Genome Activation.

The awakening of the genome after fertilization is a cornerstone of animal development. However, the mechanisms that activate the silent genome after fertilization are poorly understood. Here, we show that transcriptional competency is regulated by Brd4- and P300-dependent histone acetylation in zebrafish. Live imaging of transcription revealed that genome activation, beginning at the miR-430 locus, is gradual and stochastic. We show that genome activation does not require slowdown of the cell cycle and is regulated through the translation of maternally inherited mRNAs. Among these, the enhancer regulators P300 and Brd4 can prematurely activate transcription and restore transcriptional competency when maternal mRNA translation is blocked, whereas inhibition of histone acetylation blocks genome activation. We conclude that P300 and Brd4 are sufficient to trigger genome-wide transcriptional competency by regulating histone acetylation on the first zygotic genes in zebrafish. This mechanism is critical for initiating zygotic development and developmental reprogramming.

Optimized CRISPR-Cpf1 system for genome editing in zebrafish.

The impact of the CRISPR-Cas biotechnological systems has recently broadened the genome editing toolbox available to different model organisms further with the addition of new efficient RNA-guided endonucleases. We have recently optimized CRISPR-Cpf1 (renamed Cas12a) system in zebrafish. We showed that (i) in the absence of Cpf1 protein, crRNAs are unstable and degraded in vivo, and CRISPR-Cpf1 RNP complexes efficiently mutagenize the zebrafish genome; and (ii) temperature modulates Cpf1 activity especially affecting AsCpf1, which experiences a reduced performance below 37 °C. Here, we describe a step-by-step protocol on how to easily design and generate crRNAs in vitro, purify recombinant Cpf1 proteins, and assemble ribonucleoprotein complexes to carry out efficient mutagenesis in zebrafish in a constitutive and temperature-controlled manner. Finally, we explain how to induce Cpf1-mediated homology-directed repair using single-stranded DNA oligonucleotides. In summary, this protocol includes the steps to efficiently modify the zebrafish genome and other ectothermic organisms using the CRISPR-Cpf1 system.

Acceso vascular intraóseo: evaluación de los conocimientos anatómicos de los sitios de abordaje en profesionales de la salud / Intraosseous vascular access: evaluation of the anatomical knowledge of the boarding sites in health professionals

Introducción: El acceso intraóseo es considerado actualmente como una alternativa rápida y eficaz en situaciones en las cuales no es posible lograr un acceso intravenoso en un tiempo preestablecido, principalmente en pacientes que presenten shock grave o paro cardiorrespiratorio, siendo de vital importancia los conocimientos relacionados con su colocación, desde los reparos anatómicos hasta los dispositivos utilizados para su realización. Objetivos: Determinar los conocimientos que poseen los profesionales de la salud acerca del acceso intraóseo. Material y Metodo: Estudio descriptivo y transversal. Encuestas al personal de la salud que concurre a la institución. Resultados: Se realizaron 222 encuestas a enfermeros (37), estudiantes de enfermería (86), médicos (46) y estudiantes de medicina (53). El rango etario fue de 21-59 años. 27, 03% (60) conoce la vía intraósea como acceso vascular; 25, 22% (56) han recibido algún tipo de formación acerca de la colocación de accesos intraóseos, siendo la misma cantidad de profesionales los que pudieron enumerar los sitios anatómicos correspondientes. Sólo un 13, 06% pudieron indicar precisamente los reparos anatómicos necesarios para su colocación y, por último, únicamente 23, 42% de los encuestados conocía si su lugar de desempeño disponía de sets para la colocación de dicha vía. Conclusión: Son muy pocos los profesionales de la salud que tienen conocimientos acerca de la colocación del acceso vascular intraóseo, siendo escasamente promovidos durante su formación. Es de suma importancia promover programas de instrucción para la utilización de dicho acceso, ya que es bien sabido la gran utilidad que presenta el mismo, más aún en casos de riesgo de vida en el que no es posible contar con otro acceso vascular.

Introduction: Intraosseous access is currently considered a quick and effective alternative in situations in which it is not possible to achieve intravenous access in a pre-established time, mainly in patients presenting with severe shock or cardiorespiratory arrest, being of vital importance the knowledge related to its placement, from the anatomical repairs to the devices used for its realization. Objectives: To determine the knowledge held by health professionals about intraosseous access. Material and Method: Descriptive and transversal study. Surveys to health personnel who attend the institution. Results: 222 surveys were carried out to nurses (37), nursing students (86), doctors (46) and medical students (53). The age range was 21-59 years. 27, 03% (60) know the intraosseous route as vascular access; 25, 22% (56) have received some type of training about the placement of intraosseous accesses, with the same number of professionals being able to list the corresponding anatomical sites. Only 13, 06% could precisely indicate the anatomical repairs necessary for their placement and, finally, only 23, 42% of the respondents knew if their place of performance had sets for the placement of said route. Conclusion: Very few health professionals have knowledge about the placement of intraosseous vascular access, being poorly promoted during their training. It is very important to promote instructional programs for the use of such access, since it is well known that it is very useful, especially in cases of life risk in which it is not possible to have another vascular access.

CRISPR-Cpf1 mediates efficient homology-directed repair and temperature-controlled genome editing.

Cpf1 is a novel class of CRISPR-Cas DNA endonucleases, with a wide range of activity across different eukaryotic systems. Yet, the underlying determinants of this variability are poorly understood. Here, we demonstrate that LbCpf1, but not AsCpf1, ribonucleoprotein complexes allow efficient mutagenesis in zebrafish and Xenopus. We show that temperature modulates Cpf1 activity by controlling its ability to access genomic DNA. This effect is stronger on AsCpf1, explaining its lower efficiency in ectothermic organisms. We capitalize on this property to show that temporal control of the temperature allows post-translational modulation of Cpf1-mediated genome editing. Finally, we determine that LbCpf1 significantly increases homology-directed repair in zebrafish, improving current approaches for targeted DNA integration in the genome. Together, we provide a molecular understanding of Cpf1 activity in vivo and establish Cpf1 as an efficient and inducible genome engineering tool across ectothermic species.

Concurrent subarachnoid haemorrhage and ST elevation myocardial infarction.

Rare case of concurrent subarachnoid haemorrhage and ST elevation myocardial infarction, highlighting the importance of detailed history in an emergency.

Ultrasonografía aplicada a la valoración hemodinámica del paciente critico / Ultrasonography applied to the hemodynamic assessment of the critical patient

Introducción: La reanimación de los pacientes críticos resulta fundamental para la correcta recuperación de los mismos. Mediante la evaluación de la VCI por ecografía se puede valorar si esta reanimación es adecuada, evidenciando su compresión y su diámetro. La utilización de la US resulta de gran practicidad e importancia, ya que es un método seguro, rápido, de bajo costo y de simple aprendizaje para aplicarlo en la urgencia. Objetivos: Demostrar la utilidad de la ecografía en la valoración de la VCI en la reanimación de los pacientes críticos Material y Método: Diseño prospectivo observacional descriptivo se consideraron dos periodos de trabajo. Primer Periodo: realización de jornadas, cursos y talleres de US desde junio 2016 a diciembre 2016. Se adquirieron conocimientos de la US como método diagnostico (enseñanza del manejo de la ecografía y su aplicación en talleres prácticos). Segundo Periodo: se realizaron ecografías de pacientes críticos en guardia y en UTI, de pacientes quirúrgicos y con diversas patologías, en el Hospital Aeronáutico Central y en el Hospital Municipal de Morón durante enero 2017 a Mayo de 2017. Se realizó previa y posterior a la reanimación con fluidos y su respuesta al tratamiento. Resultados: se registraron 220 pacientes, 128 (58,18 %) se le realizo ecografía. Del total realizadas 95 (74,2 %) eran pacientes cursando posoperatorio y 33 (25,78 %) pacientes quirúrgicos de manejo clínico. Las patologías predominantes en pacientes quirúrgicos fueron: politraumatismo, 61 pacientes (64,2 %), 21 heridos de arma blanca (22,1 %) y 13 heridos de arma de fuego (13,6%). En cuanto a los 33 pacientes no quirúrgicos las patologías fueron: pancreatitis en n° 15 (45,45 %), NIH en n° de 11 (33,43 %) y Shock séptico n° 7 (21,2 %). Se evidencio que 105 pacientes (82,03 %), respondieron de forma favorable a la reposición inicial, mientras que el 23 (17,96 %) restante no demostró mejoría. Conclusión: La US proporciona un método simple, eficaz y práctico para la identificación de la VCI. La capacitación del personal médico, a través de talleres y cursos resulta fundamental para su aplicación en la sala de urgencias. La realización de la US en los pacientes críticos permite la evaluación de la VCI previo y posterior a la reanimación inicial con fluidos. La medición de la VCI (su compresión y su diámetro) permite valorar si la reposición de líquidos realizada es la correcta y si la respuesta es la esperada.

Introduction: The resuscitation of critical patients is essential for the correct recovery of them. By the evaluation of the ICV by ultrasound, it can be assessed if this resuscitation is adequate, evidencing its compression and its diameter. The use of the US is very practical and important, since it is a safe, fast, low cost and simple learning method to apply in the emergency. Objectives: To demonstrate the usefulness of ultrasound in the assessment of ICV in the resuscitation of critical patients. Material and method: Prospective descriptive observational design Two work periods were considered. First Period: realization of conferences, courses and workshops of US from June 2016 to December 2016. Knowledge of the US was acquired as a diagnostic method (teaching the management of ultrasound and its application in practical workshops). Second Period: ultrasound of critically ill patients on guard and in ICU, of surgical patients and with various pathologies, were performed at the Central Aeronautical Hospital and the Municipal Hospital of Morón from January 2017 to May 2017. It was carried out before and after surgery resuscitation with fluids and their response to treatment. Results: 220 patients were registered, 128 (58.18%) underwent an ultrasound. Out of the total, 95 (74.2%) were patients in the postoperative period and 33 (25.78%) were surgical patients with clinical management. The predominant pathologies in surgical patients were: Polytrauma, 61 patients (64.2%), 21 stab wounded (22.1%) and 13 firearm wounded (13.6%). Regarding the 33 non-surgical patients, the pathologies were: pancreatitis n ° 15 (45.45%), NIH n ° of 11 (33.43%) and septic shock n ° 7 (21.2%). It was evidenced that 105 patients (82.03%), responded favorably to the initial replacement, while the remaining 23 (17.96%) did not show improvement. Conclusion: The US provides a simple, effective and practical method for the identification of the ICV. The training of physicians, through workshops and courses, is essential for its application in the emergency room. The realization of the US in critical patients allows the evaluation of the ICV before and after the initial resuscitation with fluids. The measurement of the ICV (its compression and its diameter) makes it possible to assess whether the fluid replacement performed is correct and if the response is the expected one

Utilización de la ultrasonografía y aplicación del Doppler para la evaluación de ejes vasculares periféricos y la prevención del síndrome compartimental / Using ultrasonography and doppler application for evaluating vascular axes and prevention of compartmental syndrome

La ultrasonografía es un método de evaluación rápido y eficaz en los departamentos de emergencias, siempre en manos entrenadas. La lesión vascular periférica es un cuadro que en lo que trauma se refiere, debe tener un veloz diagnóstico y tratamiento por los riesgos que significa: En lesiones abiertas, la hemorragia; y en lesiones cerradas se añade el síndrome compartimental. Lograr la evaluación de la indemnidad o no del árbol vascular en los miembros, se torna importante a la hora de prevenir eventos que requieran intervención quirúrgica (reparación y/o fasciotomía). El objetivo de este trabajo consiste en demostrar la utilidad del conocimiento del árbol vascular periférico y su evaluación mediante doppler para el manejo del traumavascular periférico, utilizando listas de verificación para la evaluación sistemática de la vasculatura. Se realiza-ron evaluaciones sistemáticas a 10 residentes de cirugía general, utilizando primero modelos inanimados y animados y luego se evaluaron en situaciones de guardia, dividido en periodos (febrero/abril 2016 y mayo/agosto 2016). Se correlacionaron los hallazgos con lo estipulado en la lista de verificación previamente realizada y se estableció la relación posterior con el desarrollo del síndrome compartimental. Se evaluaron 185 modelos animados: 1era evaluación: Reconocimiento de estructuras >60 %= 6 residentes. >80 %= 4 residentes. 2da evaluación: Reconocimiento de estructuras >60 %= 3 residentes. >80 %= 7 residentes. En la atención del politraumatizado: reconocimiento de estructuras >60 %= 3 residentes. >80%= 7 residentes. Pacientes con riesgo de síndrome compartimental (n=77) = 11 (14,78 %). Resolución: lesión vascular = 1 (1,3 %) síndrome compartimental= 1 (1,3 %) con resolución quirúrgica. La utilización de la ultrasonografía y del doppler para la evaluación vascular periférica es útil para el reconocimiento precoz del riesgo a desarrollar desde una lesión vascular simple hasta un síndrome compartimental. La utilización de listas de verificación durante la simulación para la generación del criterio, son útiles en la formación de residentes de cirugía.

Ultrasonography is with adequate training, a fast and effective evaluation method in emergency departments. Peripheral vascular injury is frequent in trauma and should have a rapid diagnosis and treatment, as risks include: open sores, bleeding; closed injuries and compartmental syndrome. Prompt evaluation of the integrity in the vascular tree becomes important in preventing events that require surgical intervention (repair and / or fasciotomy). The aim of this work is to demonstrate the usefulness of knowledge of peripheral vascular tree, ultrasound evaluation and Doppler for peripheral vascular trauma management,using checklists for the systematic evaluation of the vasculature. Systematic evaluations were realized in 10general surgery residents. Initially, using inanimate and animate models which were then evaluated intrauma situations. Divided into periods (February / April 2016 ­ May/August 2016). The findings with previouscriteria made the verification list and subsequent connection with the development of compartment syndromethat were established by correlation. Evaluation animated models: 1st assessment: Recognition of structures>60 % =6 residents. > 80 % =4 residents. The 2nd assessment: Recognition of structures > 60 % = 3residents. > 80 % = 7 residents. In the care of multiple trauma: recognition structures > 60% =3 residents.>80 % =7 residents. Patients at risk for compartmental syndrome (n=77)=11 (14.78 %). Resolution:Vascular Lesion 1 (1.3 %) compartmental syndrome: 1 (1.3 %) with surgical resolution. The use of ultrasonography and Doppler for peripheral vascular evaluation is useful for early recognition of risk from developing a single vascular lesion, to compartmental syndrome. The use of the checklists during simulation for the generation of criteria is useful in the training of surgical residents

Utilización del Ultrasonido como Valoración Inicial de la Indemnidad de la Pared Abdominal en Traumatismos por Herida de Arm a Blanca en Abdomen / Using Ultrasound as the Initial Assessment of the Indemnity abdominal wall Injuries stab wound in abdomen

Introducción: Los traumatismos abdominales penetrantes son debidos generalmente a heridas de arma blanca o heridas de arma de fuego. Todas deben explorarse instrumentalmente bajo anestesia local con el objetivo de determinar la integridad del peritoneo. El ultrasonido es una herramienta muy útil utilizada en trauma, además del FAST, se lo puede utilizar en la urgencia como método de gran ayuda al realzar la exploración inicial de la herida para evaluar la integridad del peritoneo. Objetivos: Destacar la importancia del conocimiento anatómico y la correlación anatomo-clínico quirúrgica y ecográfica en la interpretación de imágenes obtenidas por ultrasonografía en la evaluación de la integridad de la pared del abdomen en heridas penetrantes por arma blanca. Material y métodos: FAST y ecografía de partes blandas instrumentándose la herida abdominal bajo anestesia local evaluando la indemnidad del peritoneo mediante la observación por ultrasonografía del abdomen y de la pared antero lateral del mismo en 14 de 42 pacientes con heridas por arma blanca en abdomen en el Servicio de Emergencias del Hospital Municipal de Morón y en el Servicio de Cirugía General del Hospital Aeronáutico Central. Período entre Febrero 2014 y Marzo 2015. Resultados: 42 (100%) pacientes con heridas de arma blanca en abdomen. 28 (66,66%) fueron inicialmente intervenidos quirúrgicamente. A 14 (33,34%) se le realizó FAST en búsqueda de líquido libre y ecografía de partes blandas instrumentándose la herida abdominal bajo anestesia local evaluando la indemnidad del peritoneo. Conclusiones: El conocimiento de las estructuras anatómicas y la disposición de las mismas que componen la pared anterolateral del abdomen permiten facilitar el reconocimiento de la indemnidad o no del peritoneo en las imágenes obtenidas por ultrasonido en pacientes con heridas abiertas por arma blanca, evitando así la realización de procedimientos quirúrgicos innecesarios.(AU)

Introduction: Penetrating abdominal trauma are usually due to stab wounds or gunshot wounds. All instrumentally be explored under local anesthesia in order to determine the integrity of the peritoneum. Ultrasound is a very useful tool used in trauma, in addition to FAST, I can use the urgency as a means of great help to enhance the initial exploration of the wound to evaluate the integrity of the peritoneum. Objectives: Highlighting the importance of the anatomical knowledge and surgical and anatomical clinical ultrasound in interpreting images obtained by ultrasonography in the evaluation of the integrity of the abdominal wall in penetrating stab wounds correlation. Material and methods: FAST ultrasound was performed and soft tissue abdominal wound became operational under local anesthesia indemnity evaluating the peritoneum through observation by ultrasound of the abdomen and the anterolateral wall thereof in 14 of the 42 patients with stab wounds in the abdomen Service Municipal Emergency Hospital of Moron and the Department of General Surgery of the Central Aeronautical Hospital, period between February 2014 and March 2015. Results: Of the 42 (100%) patients with stab wounds to the abdomen, 28 (66.66%) initially underwent surgery, and 14 (33.34%) were performed in FAST Search of free fluid and soft tissue ultrasound became operational abdominal wound under local anesthesia indemnity evaluating the peritoneum. Conclusions: Knowledge of the anatomical structures and arrangement thereof comprising the anterolateral wall of the abdomen allow easy recognition of indemnity or not the peritoneum in the ultrasound images in patients with stab wounds open, thus avoiding making unnecessary surgical procedures.

Utilización de la ultrasonografía para la detección y guía para la colocación de accesos vasculares periféricos / The use of ultrasonography for detection and guidance for the placement of peripheral vascular accesses

Introducción: La realización de punciones y colocación de accesos vasculares periféricos es una práctica habitual durante tareas asistenciales. El éxito del procedimiento depende de múltiples factores. La utilización de la ultrasonografía (US) para la guía de abordajes vasculares incrementa el éxito de la práctica. La utilización de la US durante la realización de abordajes vasculares disminuye la aparición de eventos adversos. Objetivos: demostrar la utilización de la ultrasonografía como guía de accesos vasculares periféricos. Material y Método: prospectivo, observacional y descriptivo. Capacitación de personal médico en anatomía y ultrasonografía para el reconocimiento de accesos vasculares periféricos y la colocación de los mismos por este método. Se utilizaron planillas de registro de actividades para la evaluación mediante observación y supervisión directa. Resultados: 10 médicos en formación. Periodo de aprendizaje de anatomía: Nivel 2: capaz de reconocer estructuras anatómicas con supervisión: 5 (50%); Nivel 3: capaz de reconocer estructuras anatómicas con mínima supervisión: 2 (20%) Nivel 4: capaz de reconocer estructuras anatómicas sin supervisión: 3 (30%). Al Finalizar el periodo: Nivel 2: 2 (20%), Nivel 3: 2 (20%); Nivel 4: 6 (60%). Periodo de aprendizaje US: al iniciar el periodo: Nivel 3: 4 (40%); Nivel 4: 6 (60%). Al finalizar el periodo: Nivel 3: 1 (10%) Nivel 4: 9 (90%). Extracción venosa y colocación de accesos venosos periféricos: N= 201 Correctamente por ultrasonografía con mínima supervisión: 123 (60.7 %); Correctamente por ultrasonografía sin supervisión: 71 (35.3%); Realizado por el supervisor: 7 (4%). Conclusiones: La enseñanza y el aprendizaje del uso de la ultrasonografía para la extracción sanguínea y colocación de accesos venosos periféricos, permite mejorar la calidad asistencial y disminuir exponencialmente la aparición de eventos adversos. Debe ser incorporada en los programas de formación de profesionales. La implementación disminuye los índices de infecciones y morbimortalidad de los pacientes hospitalarios

Introduction: Performing punctures and placement of peripheral vascular accesses is a common practice during care assist. The success of the procedure depends on multiple factors. The use of ultrasonography (US) for the guidance of vascular approaches reduces the occurrence of adverse events. Objectives: demonstrate the use of ultrasonography as a guide for peripheral vascular access. Material and method: prospective, observational, and descriptive. Training physicians in anatomy and ultrasonography for the recognition of peripheral vascular accesses and the placement of the same by this method. Activity logs were used for evaluation through observation and direct supervision. Results: 10 physicians in training. Anatomy learning period: level 2: capable of recognizing anatomical structures with supervision: 5 (50%); level 3: able to recognize anatomical structures with minimal supervision: 2 (20%). Level 4: able to recognize anatomical structures without supervision: 3 (30%). At the end of the period: level 2: 2 (20%), level 3: 2 (20%); level 4: 6 (60%). Learning period US: at the beginning of the period: level 3: 4 (40%), level 4: 6 (60%). At the end of the period: level 3: 1 (10%), level 4: 9 (90%). Venous extraction and placement of peripheral venous accesses: N=201 correctly by ultrasonography with minimal supervision: 123(60.7%); correctly by ultrasonography without supervision: 71(35.3%); performed by the supervisor: 7 (4%). Conclusions: The teaching and learning of the use of ultrasonography for blood extraction and placement of peripheral venous accesses, can improve the quality care and decrease exponentially the occurrence of adverse events. It should be incorporated into professional training programs. Implementation decreases the rates of infections and morbidity and mortality of hospital patients.

Conocimiento y comprensión del consentimiento informado durante la formación médico legal y bioética de los residentes de Cirugía General / Knowledge and understanding of informed consent during the legal and bioethical medical training of residents of general surgery

Introducción: el consentimiento informado es una herramienta de información que debe ser clara, precisa y adecuada para una correcta relación médico paciente y debe ser inculcada durante la formación de los médicos residentes de cirugía general. El desconocimiento de los contenidos del consentimiento informado por parte de los médicos residentes, impide la correcta comunicación, por lo que se convierte en un documento incompleto y poco comprendido, disminuyendo la calidad asistencial y la confianza del paciente en el médico tratante, desmejorando así la calidad prestacional en los procedimientos quirúrgicos (11). El consentimiento informado es más que un acto puntual de información, es un proceso gradual que no termina con la firma del mismo, sino involucrando médico, paciente e institución. Dado los antecedentes mencionados, resulta importante inculcar a jóvenes profesionales los aspectos éticos de su formación e implicancias médico legales en su proceder. Objetivos: Analizar el conocimiento y capacidad de comprensión de los contenidos del consentimiento informado por parte de los médicos residentes de Cirugía General del Hospital Aeronáutico Central. Material y Método: Estudio prospectivo, descriptivo, observacional. Se consideró un primer periodo comprendido entre los meses de Diciembre 2015/febero2016, de capacitación en aplicación del consentimiento informado y comprensión de los contenidos del mismo a residentes de cirugía general con evolución de conocimientos, al inicio y finalización del mismo, y un segundo periodo, marzo 2016-mayo 2016, se realizó análisis del instrumento para la evaluación mediante observación directa y supervisión de residentes de cirugía general, evaluando el conocimiento durante la aplicación del mismo, donde se consideró el tipo de cirugía, procedimiento alternativo, consecuencia de no realizar el procedimiento, eventos adversos y complicaciones. Se consideró además la terminología y lenguaje utilizado para la transmisión de la información. Resultados: Del análisis obtenido de las evaluaciones realizadas durante el primer período, se obtuvieron los siguientes resultados: al inicio del periodo: n=10 médicos residentes de los cuales: conoce el consentimiento informado: 10 (100%).Conoce la ley que lo ampara: 3 (30%).Conoce la composición de la ley: 2 (20%). Función del consentimiento: 4 (40%). En el segundo periodo se realizó evaluación mediante observación directa y supervisión con su posterior análisis (tabla1) de los cuales se obtuvo: n= 120 procedimientos quirúrgicos en los cuales se cumplimiento con el consentimiento informado en la totalidad de los mismos (100%).Se realizó observación directa n= 104, de los cuales: en el 104 (100%) respuesta afirmativa respecto al conocimiento de la cirugía a realizar. La explicación del tratamiento propuesto 92 (88.4%) pudieron ser explicados. Consecuencias de no realizar el procedimiento: 102 (98%) arrojo respuesta afirmativa. Eventos adversos: 73 (70,1%) estaban completos y explicados de manera precisa. Utiliza terminología médica 101(97.1%) de los consentimientos. La explicación verbal con lectura se realizó en el 100% de los procedimientos quirúrgicos. Utiliza terminología adecuada al paciente 73 (70.1%). El 100% de los pacientes comprendió correctamente lo informado por el profesional. Conclusiones: El conocimiento del contenido del consentimiento informado, saber transmitirlo y la práctica constante, con lectura crítica del mismo, es fundamental para la formación del médico residente en el desarrollo de su relación quirúrgica con el paciente. Es de práctica habitual entre médicos cirujanos dar por sobre entendido que los médicos en formación puedan aplicar de manera correcta este documento. En muchas oportunidades suele ser incumplido sin la asistencia y supervisión constante de los mismos, perjudicando de esta manera la relación médico paciente. La educación médica respecto del consentimiento informado a través de talleres y clases resulta muy importante considerándose trascendental para la formación integral del residente. Enfatizar en promover la investigación de campo para evaluar en las prácticas quirúrgicas el cumplimiento del consentimiento informado.

Introduction: the informed consent is an information tool that should be clear, accurate and adequate for a correct patient medical relationship and shoul be inculcated during the training of resident physicians of general surgery. Ignorance of the contents of informed consent by the residents, prohibit the correct communication, so it becomes an incomplete and poorly understood document, reducingthe quality of care and patient trust in the treating physician, thus degrading the quality of surgical procedures(11). Informed consent is more than a punctual act of information, it is a gradual process that doesn ́t end with the signature of the same, but involving physician, patient and institution. Given the aforementioned antecedents, it is important to inculcate in young professionals the ethical aspects of their training and legal medical implications in their proceeding. Objectives: to analyze the knowledge and comprehension of the contents in the informed consent by the resident of General Surgery, of the Central Aeronautical Hospital. Material and method: prospective, descriptive, observational study. A first period from December 2015/February 2016, was considered to provide training in the application of informed consent and understanding of the contents of the same to residents of general surgery with the evolution of knowledge, at the beginning and end of the same, and a second period, March 2016- May 2016, analysis of the instrument for the evaluation by direct observation and supervision of residents of general surgery was carried out, evaluating the knowledge during the application of the instrument, where the type of surgery, alternative procedure, the procedure, adverse events and complications. The terminology and language used for the transmission of information were also considered Results: from the analysis obtained from the evaluations performed during the first period, the following results were obtained at the beginning of the period: n=10 resident physicians of whom, knows informed consent 10 (100%). It covers: 3 (30%). Knows The composition of the law: 2 (20%). In the second period, direct observation and supervision were carried out with the following analysis (table 1), of which: n=120 surgical procedures in which carrying out with the informed consent was obtained in all of them (100%). Direct observation n= 104, of which: in the 104 (100%) affirmative answer regarding the knowledge of the surgery to be performed. The explanation of the proposed treatment 92 (88.4%) could be explained. Consequences of not performing the procedure: 102 (98%) bold affirmative response. Adverse events 73 (70.1%) were complete and accurately explained. Uses medical terminology 101 (97.1%) of consents. The verbal explanation with reading was performed in 100% of the surgical procedures. Uses appropriate terminology to the patient 73 (70.1%). 100% of the patients correctly understood the information provided by the proffesional. Conclusions: Knowledge of the content of informed consent, knowing how to transmit it, and constant practice, with a critic al reading of it, is essential for the training of the resident physician in the development of his surgical relationship with the patient. It is common practice among surgeons to take it for granted that physicians in training can apply this document correctly. In many cases, it is then not followed up without the assistance and constant supervision of the patients, thus prejudicing the patient physician relationship. The medical education regarding the informed consent through workshops and classesis very important, considering it transcendental for the integral formation of the resident. Emphasize in promoting field research to evaluate fulfillment of the informed consent in surgical practices.

Ateneos virtuales anatomo clínico quirúrgicos como metodología de enseñanza en el proceso de toma de decisión / Anatomical clinical surgical virtual debates as teaching methodology in decision - making process

Introducción: Se puede afirmar que el uso de entornos virtuales ha transformado una gran parte de los espacios de enseñanza tradicionales en espacios virtuales de enseñanza y aprendizaje (EVEA). La implementación de aplicaciones móviles para el desarrollo del proceso de enseñanza aprendizaje virtual es una herramienta satélite de tipo sincrónica de masivo alcance. Objetivos: Evaluar la utilidad de las aplicaciones móviles en el desarrollo del proceso de toma de decisiones a través de casos clínicos quirúrgicos en posgrado. Material y Método: Estudio de tipo observacional, transversal, en 11 residentes de cirugía general pertenecientes al servicio de Cirugía General del Hospital Aeronáutico Central en un periodo comprendido entre julio 2013 y julio 2015. Se analizaron casos clínicos (descripción de caso, fotos y videos) mediante la implementación de aplicaciones móviles (Whatsapp®), evaluando la respuesta en tiempo real considerándose cuatro ítems: anatomía, impresión diagnostica, exámenes complementarios y tratamiento. Resultados: De 4 ítems analizados los residentes respondieron correctamente: anatomía 81,8%; impresión diagnóstica 66,6%; exámenes complementarios 50% y tratamiento 33,3%. En la evaluación de la ausencia de respuesta el 63.6% (7 residentes) argumentó falta de conexión y falla en la transmisión de datos, el 18,18% (2 residentes) que realizaban actividades quirúrgicas en ese momento y el 18,18% (2 residentes) estar en descanso. Conclusiones: La presentación de casos clínicos a través de aplicaciones móviles es un recurso que a partir de su utilización continua mejora el proceso de enseñanza-aprendizaje de posgrado ya que permite su evaluación en tiempo real así como su aprendizaje y entrenamiento permanente.

Introduction: We can reafirm that the use of virtual environments has transformed much of the traditional teaching spaces in virtual teaching and learning spaces (SVTA). The implementation of mobile application for the development of teaching virtual learning tool is a synchronous satellite type of massive scape Objectives: To evaluate the mobile applications in the development of decision making through postgraduate surgical clinical cases. Material and method: Observational, transversal study in 11 general surgery residents of Hospital Aeronáutico Central in the period between July 13 and July 2015. Clinical cases were analyzed (case description, photos and videos) by the implementation of mobile applications (Whatsapp®), evaluating the response in real time considerering four items: anatomy, diagnostic impression, additional tests and treatments. Results: Of the 4 items analyzed, residents responded correctly anatomy 81,8%, diagnostic impression 66,6%, complementary exams 50% and treatment 33.3%. In the assessment of non-response 63,6% (7 residents) argued lack of connection and transmission failure data held,18.18% (2 residents) argued that made surgical activities then and 18.18% (2 residents) argued to be at rest. Conclusions: The presentation of clinical cases through mobile application is a resource from its continued use, improves the teaching-learning graduate by allowing real-time evaluation as well as life long learning.

CRISPRscan: designing highly efficient sgRNAs for CRISPR-Cas9 targeting in vivo.

CRISPR-Cas9 technology provides a powerful system for genome engineering. However, variable activity across different single guide RNAs (sgRNAs) remains a significant limitation. We analyzed the molecular features that influence sgRNA stability, activity and loading into Cas9 in vivo. We observed that guanine enrichment and adenine depletion increased sgRNA stability and activity, whereas differential sgRNA loading, nucleosome positioning and Cas9 off-target binding were not major determinants. We also identified sgRNAs truncated by one or two nucleotides and containing 5' mismatches as efficient alternatives to canonical sgRNAs. On the basis of these results, we created a predictive sgRNA-scoring algorithm, CRISPRscan, that effectively captures the sequence features affecting the activity of CRISPR-Cas9 in vivo. Finally, we show that targeting Cas9 to the germ line using a Cas9-nanos 3' UTR led to the generation of maternal-zygotic mutants, as well as increased viability and decreased somatic mutations. These results identify determinants that influence Cas9 activity and provide a framework for the design of highly efficient sgRNAs for genome targeting in vivo.

Functional analysis of Hairy genes in Xenopus neural crest initial specification and cell migration.

BACKGROUND: Neural crest formation is one of the fundamental processes in the early stages of embryonic development in vertebrates. This transient and multipotent embryonic cell population is able to generate a variety of tissues and cell types in the adult body. hairy genes are transcription factors that contain a basic helix-loop-helix domain which binds to DNA. In Xenopus three hairy genes are known: hairy1, hairy2a, and hairy2b. The requirement of hairy genes was explored in early neural crest development although the late requirements of these genes during neural crest maintenance, migration and derivatives formation are still unknown. RESULTS: In this work, we extended the analysis of Xenopus hairy genes expression patterns and described new domains of expression. Functional analysis showed that hairy genes are required for the induction and migration of the neural crest and for the control of apoptosis. Moreover, we showed that hairy genes function as transcriptional repressors and that they are down-regulated by bone morphogenetic protein-Smad signaling and positively regulated by the Notch/Delta-Su(h) pathway. CONCLUSIONS: Our results indicate that hairy genes have a functional equivalence between them and that they are required for multiple processes during neural crest development.

Developmental expression and role of Kinesin Eg5 during Xenopus laevis embryogenesis.

BACKGROUND: The neural crest is a transient multipotent migratory cell population unique to vertebrates. These cells undergo an epithelial-to-mesenchymal transition and migrate extensively through the embryo. They differentiate into numerous diverse derivatives including the peripheral nervous system, melanocytes,and craniofacial cartilages. The development of the neural crest is mediated by complex interactions of multiple signals and transcription factors. The kinesin Eg5 is a plus end-directed microtubule-based motor protein that is essential for bipolar spindle formation during mitosis and meiosis, axon growth, and mammal embryonic development. RESULTS: We analyzed in detail the expression pattern of eg5 and established that it is expressed at the prospective neural fold, in the premigratory and migratory neural crest. Functional analysis revealed that in Xenopus, early embryogenesis eg5 function is required during neural crest induction, specification, and maintenance. eg5 is also required during neural crest migration and for derivatives formation. Moreover, we demonstrated a hierarchical relationship with the Indian Hedgehog signaling pathway. CONCLUSIONS: Our results show that eg5 is essential for the specification and maintenance of neural crest progenitors during Xenopus early embryogenesis rather than cell proliferation and survival.

Implementación de la lista de verificación del paciente con catéter venoso central (CVC) / Implementing patient checklist central venous catheter (CVC )

Introducción: La colocación de Catéteres Venosos Centrales (CVC) es un procedimiento de frecuente ejecución, debido al incremento de pacientes graves o que requieren terapéutica intravenosa durante largo tiempo. Deben utilizarse bajo ciertos criterios, con normas infectológicas, valorando el costo-beneficio en cada caso, ya que no es un procedimiento exento de complicaciones, riesgos y/o eventos adversos. Se implementó una Lista de Verificación de la Seguridad del Paciente con Catéter Venoso Central; con la intención de mejorar la calidad de atención, brindar seguridad al paciente, disminuir la morbimortalidad, la estadía hospitalaria y los costos sanitarios. Material y métodos: Se analizaron 136 registros de Listas de Verificación del Paciente con Catéter Venoso Central (CVC), entre enero 2012- enero 2013. Se realizó un análisis del lugar de realización y del material necesario para el procedimiento; se examinaron datos en cuatro etapas: antes, durante y luego del procedimiento; y durante el seguimiento del paciente post-colocación de catéter. Se analizaron las fallas detectadas en el registro de datos de filiación, del material necesario para el procedimiento y de cada etapa; finalmente se analizaron los registros del retiro del catéter. Resultados: 136 procedimientos realizados por médicos residentes de Cirugía General;125(91.91%) en quirófano, 6(4.42%) en la sala general, 4(2.94%) en UTI, y 1(0.73%) en UCO; 121(88.97%) de urgencia y 15(11.03%) en forma electiva; 76(55.88%) para medición de PVC y manejo hemodinámico; 27(19.86%) para antibioticoterapia ev; 15(11.03%) para nutrición parenteral;11(8.09%) por falta de accesos periféricos; y 7(5.14%) catéteres para diálisis. Se identificaron un total de 96 fallas: 11(11.45%) en el registro de datos filiatorios; y el resto en las cuatro etapas 23(23.96%) antes del procedimiento; 4(4.16%) durante el procedimiento; 31(32.29%) luego del procedimiento y 27(28.12%) durante el seguimiento...

Introduction: The placement of Central Venous Catheters (CVC) is a frequent procedure due to the increase in serious patientsor who require intravenous therapy for a long time. Be used under certain criteria, infection rules, valuing the benefit in each case;it is not free of complications, risks and adverse events. A Checklist for the Safety of Patients with Central Venous Catheter wasimplemented, with the intention of improving the quality of care, provide patient safety, and reduce morbidity and mortality, hospitalstay, and health costs.Material and methods: 136 records lists for verification of patient with central venous catheter (CVC), implemented in the serviceof General Surgery of the Central Air Force Hospital, were analyzed between january 2012 - january 2013. An analysis of the placeof preparation and equipment necessary for the procedure; discussed data in four stages: before, during and after the procedure.and follow-up of the patient post of catheter. Analyzed the failures detected in the data record of filiation, of the material needed forthe procedure and each stage; and finally analyzed records of the removal of the catheter.Results: 136 procedures were performed by medical residents in General Surgery; 125 (91.91%) in the operating room, 6 (4.42%) inthe general room, 4 (2.94%) in UTI, and 1 (0.73%) in UCO; 121 (88.97%) emergency and 15 (11.03%) in elective way; 76 (55.88%)for PVC and hemodynamic management measurement; 27 (19.86%) for antibiotic therapy iv; 15 (11.03%) for parenteral nutrition;11 (8.09%) for lack of peripheral access; and 7 (5.14%) catheters for dialysis. A total of 96 of failures were identified: 11 (11.45%)in the register of data and the rest in four stages 23 (23.96 %): before the procedure, 4 (4.16%) during the procedure; 31 (32.29%)after the procedure and 27 (28.12%) follow-up)...

Implementación de la lista de verificación del paciente con catéter venoso central (CVC)

Introducción: La colocación de Catéteres Venosos Centrales (CVC) es un procedimiento de frecuente ejecución, debido al incremento de pacientes graves o que requieren terapéutica intravenosa durante largo tiempo. Deben utilizarse bajo ciertos criterios, con normas infectológicas, valorando el costo-beneficio en cada caso, ya que no es un procedimiento exento de complicaciones, riesgos y/o eventos adversos. Se implementó una Lista de Verificación de la Seguridad del Paciente con Catéter Venoso Central; con la intención de mejorar la calidad de atención, brindar seguridad al paciente, disminuir la morbimortalidad, la estadía hospitalaria y los costos sanitarios. Material y métodos: Se analizaron 136 registros de Listas de Verificación del Paciente con Catéter Venoso Central (CVC), entre enero 2012- enero 2013. Se realizó un análisis del lugar de realización y del material necesario para el procedimiento; se examinaron datos en cuatro etapas: antes, durante y luego del procedimiento; y durante el seguimiento del paciente post-colocación de catéter. Se analizaron las fallas detectadas en el registro de datos de filiación, del material necesario para el procedimiento y de cada etapa; finalmente se analizaron los registros del retiro del catéter. Resultados: 136 procedimientos realizados por médicos residentes de Cirugía General;125(91.91%) en quirófano, 6(4.42%) en la sala general, 4(2.94%) en UTI, y 1(0.73%) en UCO; 121(88.97%) de urgencia y 15(11.03%) en forma electiva; 76(55.88%) para medición de PVC y manejo hemodinámico; 27(19.86%) para antibioticoterapia ev; 15(11.03%) para nutrición parenteral;11(8.09%) por falta de accesos periféricos; y 7(5.14%) catéteres para diálisis. Se identificaron un total de 96 fallas: 11(11.45%) en el registro de datos filiatorios; y el resto en las cuatro etapas 23(23.96%) antes del procedimiento; 4(4.16%) durante el procedimiento; 31(32.29%) luego del procedimiento y 27(28.12%) durante el seguimiento. En 115 (84.55%) casos se retiró el catéter por finalización de su indicación y en 21 (15.45%) por necesidad de recambio. Conclusiones: La Lista de Verificación del Paciente con Catéter Venoso Central es un sistema de control y registro útil para los médicos que realizan el procedimiento y para la seguridad de los pacientes; permite identificar situaciones de riesgo que podrían desencadenar complicaciones y/o eventos adversos relacionados. Es primordial una permanente educación en todas las áreas de trabajo para lograr una seria política de seguridad para el paciente; utilizando iniciativas colaborativas específicas, basadas en la implementación de estrategias y de medidas para mejorar el cumplimiento de las prácticas recomendadas basadas en la evidencia.(AU)

Introduction: The placement of Central Venous Catheters (CVC) is a frequent procedure due to the increase in serious patients or who require intravenous therapy for a long time. Be used under certain criteria, infection rules, valuing the benefit in each case; it is not free of complications, risks and adverse events. A Checklist for the Safety of Patients with Central Venous Catheter was implemented, with the intention of improving the quality of care, provide patient safety, and reduce morbidity and mortality, hospital stay, and health costs. Material and methods: 136 records lists for verification of patient with central venous catheter (CVC), implemented in the service of General Surgery of the Central Air Force Hospital, were analyzed between january 2012 - january 2013. An analysis of the place of preparation and equipment necessary for the procedure; discussed data in four stages: before, during and after the procedure. and follow-up of the patient post of catheter. Analyzed the failures detected in the data record of filiation, of the material needed for the procedure and each stage; and finally analyzed records of the removal of the catheter. Results: 136 procedures were performed by medical residents in General Surgery; 125 (91.91%) in the operating room, 6 (4.42%) in the general room, 4 (2.94%) in UTI, and 1 (0.73%) in UCO; 121 (88.97%) emergency and 15 (11.03%) in elective way; 76 (55.88%) for PVC and hemodynamic management measurement; 27 (19.86%) for antibiotic therapy iv; 15 (11.03%) for parenteral nutrition; 11 (8.09%) for lack of peripheral access; and 7 (5.14%) catheters for dialysis. A total of 96 of failures were identified: 11 (11.45%) in the register of data and the rest in four stages 23 (23.96 %): before the procedure, 4 (4.16%) during the procedure; 31 (32.29%) after the procedure and 27 (28.12%) follow-up). In 115 (84.55%) cases withdrew catheter for completion of its indication and in 21 (15.45%) by replacement need. Conclusions: The check list of patients with central venous catheter is a system of control and record useful for physicians who perform the procedure and the patient safety; It identifies risk situations that could trigger complications and adverse events related to the same. A permanent education in all areas of work is essential to achieve a serious policy of safety for the patient; using specific collaborative initiatives, based on the implementation of strategies and measures to improve adherence to evidence-based best practices.(AU)