Multi-objective extensive hypothesis testing for the estimation of advanced crash frequency models.

Analyzing crash data is a complex and labor-intensive process that requires careful consideration of multiple interdependent modeling aspects, such as functional forms, transformations, likely contributing factors, correlations, and unobserved heterogeneity. Limited time, knowledge, and experience may lead to over-simplified, over-fitted, or misspecified models overlooking important insights. This paper proposes an extensive hypothesis testing framework including a multi-objective mathematical programming formulation and solution algorithms to estimate crash frequency models considering simultaneously likely contributing factors, transformations, non-linearities, and correlated random parameters. The mathematical programming formulation minimizes both in-sample fit and out-of-sample prediction. To address the complexity and non-convexity of the mathematical program, the proposed solution framework utilizes a variety of metaheuristic solution algorithms. Specifically, Harmony Search demonstrated minimal sensitivity to hyperparameters, enabling an efficient search for solutions without being influenced by the choice of hyperparameters. The effectiveness of the framework was evaluated using two real-world datasets and one synthetic dataset. Comparative analyses were performed using the two real-world datasets and the corresponding models published in literature by independent teams. The proposed framework showed its capability to pinpoint efficient model specifications, produce accurate estimates, and provide valuable insights for both researchers and practitioners. The proposed approach allows for the discovery of numerous insights while minimizing the time spent on model development. By considering a broader set of contributing factors, models with varied qualities can be generated. For instance, when applied to crash data from Queensland, the proposed approach revealed that the inclusion of medians on sharp curved roads can effectively reduce the occurrence of crashes, when applied to crash data from Washington, the simultaneous consideration of traffic volume and road curvature resulted in a notable reduction in crash variances but an increase in crash means.

Knee-Loading Predictions with Neural Networks Improve Finite Element Modeling Classifications of Knee Osteoarthritis: Data from the Osteoarthritis Initiative.

Physics-based modeling methods have the potential to investigate the mechanical factors associated with knee osteoarthritis (OA) and predict the future radiographic condition of the joint. However, it remains unclear what level of detail is optimal in these methods to achieve accurate prediction results in cohort studies. In this work, we extended a template-based finite element (FE) method to include the lateral and medial compartments of the tibiofemoral joint and simulated the mechanical responses of 97 knees under three conditions of gait loading. Furthermore, the effects of variations in cartilage thickness and failure equation on predicted cartilage degeneration were investigated. Our results showed that using neural network-based estimations of peak knee loading provided classification performances of 0.70 (AUC, p < 0.05) in distinguishing between knees that developed severe OA or mild OA and knees that did not develop OA eight years after a healthy radiographic baseline. However, FE models incorporating subject-specific femoral and tibial cartilage thickness did not improve this classification performance, suggesting there exists an optimal point between personalized loading and geometry for discrimination purposes. In summary, we proposed a modeling framework that streamlines the rapid generation of individualized knee models achieving promising classification performance while avoiding motion capture and cartilage image segmentation.

Towards a Transferable Modeling Method of the Knee to Distinguish Between Future Healthy Joints from Osteoarthritic Joints: Data from the Osteoarthritis Initiative.

Computational models can be used to predict the onset and progression of knee osteoarthritis. Ensuring the transferability of these approaches among computational frameworks is urgent for their reliability. In this work, we assessed the transferability of a template-based modeling strategy, based on the finite element (FE) method, by implementing it on two different FE softwares and comparing their results and conclusions. For that, we simulated the knee joint cartilage biomechanics of 154 knees using healthy baseline conditions and predicted the degeneration that occurred after 8 years of follow-up. For comparisons, we grouped the knees using their Kellgren-Lawrence grade at the 8-year follow-up time and the simulated volume of cartilage tissue that exceeded age-dependent thresholds of maximum principal stress. We considered the medial compartment of the knee in the FE models and used ABAQUS and FEBio FE softwares for simulations. The two FE softwares detected different volumes of overstressed tissue in corresponding knee samples (p < 0.01). However, both programs correctly distinguished between the joints that remained healthy and those that developed severe osteoarthritis after the follow-up (AUC = 0.73). These results indicate that different software implementations of a template-based modeling method similarly classify future knee osteoarthritis grades, motivating further evaluations using simpler cartilage constitutive models and additional studies on the reproducibility of these modeling strategies.

Atlas-based finite element analyses with simpler constitutive models predict personalized progression of knee osteoarthritis: data from the osteoarthritis initiative.

New technologies are required to support a radical shift towards preventive healthcare. Here we focus on evaluating the possibility of finite element (FE) analysis-aided prevention of knee osteoarthritis (OA), a disease that affects 100 million citizens in the US and EU and this number is estimated to increase drastically. Current clinical methods to diagnose or predict joint health status relies on symptoms and tissue failures obtained from clinical imaging. In a joint with no detectable injuries, the diagnosis of the future health of the knee can be assumed to be very subjective. Quantitative approaches are therefore needed to assess the personalized risk for the onset and development of knee OA. FE analysis utilizing an atlas-based modeling approach has shown a preliminary capability for simulating subject-specific cartilage mechanical responses. However, it has been verified with a very limited subject number. Thus, the aim of this study is to verify the real capability of the atlas-based approach to simulate cartilage degeneration utilizing different material descriptions for cartilage. A fibril reinforced poroviscoelastic (FRPVE) material formulation was considered as state-of-the-art material behavior, since it has been preliminary validated against real clinical follow-up data. Simulated mechanical tissue responses and predicted cartilage degenerations within knee joint with FRPVE material were compared against simpler constitutive models for cartilage. The capability of the atlas-based modeling to offer a feasible approach with quantitative evaluation for the risk for the OA development (healthy vs osteoarthritic knee, p < 0.01, AUC ~ 0.7) was verified with 214 knees. Furthermore, the results suggest that accuracy for simulation of cartilage degeneration with simpler material models is similar to models using FPRVE materials if the material parameters are chosen properly.

Impactación fecal por semillas de maboque

Introducción: La impactación fecal se caracteriza por la presencia de heces fecales compactas en el recto o colon, que no pueden ser evacuadas. La ingestión del fruto del árbol maboque (Strychnos spinosa Lam), que contiene numerosas semillas, es un hábito alimentario en algunos países africanos. Objetivo: Describir las particularidades del diagnóstico y tratamiento de la impactación fecal por la ingestión de semillas de maboque. Caso clínico: Varón de 12 años, que ingirió gran cantidad de semillas de maboque; no conseguía defecar ni expulsar gases; presentaba dolor abdominal y anal. Al examen físico se constató taquicardia, distensión abdominal y aumento de los ruidos hidroaéreos. A la exploración rectal se constató impactación, de consistencia pétrea. Al no conseguir la extracción, en el salón de urgencias, se fragmentó y extrajo la masa fecal, por vía anal, con sedación anestésica. Conclusiones: La ingestión de semillas de maboque es un hábito alimentario en África y los bezoares o impactación fecal que puede producir este hábito, no se consideran un problema de salud. Para el diagnóstico es necesario el antecedente de la ingestión del fruto, realizar un exhaustivo examen físico de las regiones abdominales, ano-rectal y finalmente, la extracción de la masa fecal.

Introduction: Fecal impaction is characterized by the presence of compact feces in the rectum or colon, which cannot be evacuated. Eating the fruit of the Spiny Monkey-orange tree (Strychnos spinosa Lam), which contains numerous seeds, is a dietary habit in some African countries. Objective: To describe the particularities of the diagnosis and treatment of fecal impaction due to the ingestion of Spiny Monkey-orange seeds. Clinical case: 12-year-old male, who ingested a large quantity of Spiny Monkey-orange seeds; he couldn't defecate or pass gas; She had abdominal and anal pain. Physical examination revealed tachycardia, abdominal distension, and increased air-fluid noises. A rectal examination revealed impaction with a stony consistency. When the extraction was not possible, in the emergency room, the fecal mass was fragmented and extracted, through the anus, with anesthetic sedation. Conclusions: The ingestion of Spiny Monkey-orange seeds is a dietary habit in Africa and the bezoars or fecal impaction that this habit can produce are not considered a health problem. For the diagnosis it is necessary the antecedent of the ingestion of the fruit, to carry out an exhaustive physical examination of the abdominal and anorectal regions and finally, the extraction of the fecal mass.

Hoja de cuchillo retenida en el hueco axilar

Introducción: El hallazgo de un cuerpo extraño retenido, específicamente una hoja de cuchillo es infrecuente. En ocasiones, estos cuerpos extraños pasan inadvertidos y se diagnostican de forma diferida o retrasada. Objetivo: Describir el diagnóstico y tratamiento de un paciente con una hoja de cuchillo retenida en el hueco de la axila. Caso clínico: Varón de 25 años, agredido con un cuchillo, que sufrió una herida en la región posterior del hombro y fue suturado sin realizar ningún examen complementario. Dos semanas después acudió por molestias en el hombro lesionado, se indicó radiografía en la cual apareció una imagen radiopaca que correspondió con una hoja de cuchillo en proyección subescapular. Refería molestias del hombro e impotencia funcional. Se opera con anestesia general, se realiza incisión axilar, se identifica el objeto, en íntimo contacto con la vena axilar; la punta hacia el vértice axilar, cruzando bajo la vena axilar en su entrada al tórax. Se extrajo el cuerpo extraño bajo visión directa, sin complicaciones. El paciente evolucionó favorablemente. Conclusiones: Los cuerpos extraños retenidos, que pasan inadvertidos son raros, sin embargo, existen regiones como la axila en que por las características anatómicas del espacio se dificulta su diagnóstico. En este caso coincidió una combinación poco usual de fenómenos, la actitud defensiva del lesionado y la dirección de la herida, que propiciaron quedara la hoja en el hueco axilar.

Introduction: The finding of a retained foreign body, specifically a knife blade, is a rare event. Sometimes these foreign bodies go unnoticed and are diagnosed deferred or delayed. Objective: To describe the diagnosis and treatment of a patient with a knife blade retained on axillary hole. Clinical case: 25-year-old male, attacked with a knife, who suffered a wound in the posterior region of the shoulder and was sutured without performing any complementary examination. Two weeks later, he came due to discomfort from the injured shoulder. An X-ray of the shoulder was indicated, where a radiopaque image appeared that corresponds to the knife blade, in subscapular projection. He refers shoulder discomfort and functional impotence. It is operated under general anesthesia, axillary incision, the object is identified in intimate contact with the axillary vein, the tip towards the axillary vertex, crossing under the axillary vein at its entrance to the thorax, the foreign body is removed under direct vision and without complications. Evolved favorably. Conclusions: Retained foreign bodies that go unnoticed are rare. However, there are regions such as the armpit where, due to the anatomical characteristics of the space, their diagnosis is difficult. In this case, an unusual combination of phenomena coincided, the defensive attitude of the injured person and the direction of the lunge, which led to the blade remaining in the axillary hole.

A novel knee joint model in FEBio with inhomogeneous fibril-reinforced biphasic cartilage simulating tissue mechanical responses during gait: data from the osteoarthritis initiative.

We developed a novel knee joint model in FEBio to simulate walking. Knee cartilage was modeled using a fibril-reinforced biphasic (FRB) formulation with depth-wise collagen architecture and split-lines to account for cartilage structure. Under axial compression, the knee model with FRB cartilage yielded contact pressures, similar to reported experimental data. Furthermore, gait analysis with FRB cartilage simulated spatial and temporal trends in cartilage fluid pressures, stresses, and strains, comparable to those of a fibril-reinforced poroviscoelastic (FRPVE) material in Abaqus. This knee joint model in FEBio could be used for further studies of knee disorders using physiologically relevant loading.

Understanding Autonomous Shuttle Adoption Intention: Predictive Power of Pre-Trial Perceptions and Attitudes.

The capability of 'demand-responsive transport', particularly in autonomous shared form, to better facilitate road-based mobility is considered a significant advantage because improved mobility leads to enhanced quality of life and wellbeing. A central point in implementing a demand-responsive transit system in a new area is adapting the operational concept to the respective structural and socioeconomic conditions. This requires an extensive analysis of the users' needs. There is presently limited understanding of public perceptions and attitudes toward the adoption of autonomous demand-responsive transport. To address this gap, a theory-based conceptual framework is proposed to provide detailed empirical insights into the public's adoption intention of 'autonomous shuttle buses' as a form of autonomous demand-responsive transport. South East Queensland, Australia, was selected as the testbed. In this case study, relationships between perceptions, attitudes, and usage intention were examined by employing a partial least squares structural equation modeling method. The results support the basic technology acceptance model casual relationships that correspond with previous studies. Although the direct effects of perceived relative advantages and perceived service quality on usage intention are not significant, they could still affect usage intention indirectly through the attitude factor. Conversely, perceived risks are shown to have no association with perceived usefulness but can negatively impact travelers' attitudes and usage intention toward autonomous shuttle buses. The research findings provide implications to assist policymakers, transport planners, and engineers in their policy decisions and system plans as well as achieving higher public acknowledgment and wider uptake of autonomous demand-responsive transport technology solutions.

Comunicación de la verdad en oncología desde la visión de la bioética médica / Communication of the truth in oncology from the perspective of medical bioethics

RESUMEN Introducción: La relación médico paciente en oncología se basa en el respeto por la vida, unido de forma constante en la aceptación de la vulnerabilidad y al reconocimiento de la inevitabilidad de la muerte. La comunicación de la verdad, particularmente cuando se trata de informar malas noticias, es una situación estresante, difícil y que demanda la adecuada preparación del personal de la salud. Objetivo: Comentar sobre los fundamentos de la comunicación de la verdad en las enfermedades oncológicas y los puntos relevantes en la relación médico paciente. Desarrollo: Comunicar la verdad entraña varios dilemas éticos en oncología y a veces la información se maneja incorrectamente por el equipo médico. El consenso es no mentir, sin normas rígidas, "ocultar la verdad" y la "conspiración del silencio"; no son del todo errados, el profesional de la salud debe respetar el derecho del paciente de estar informado y a su autonomía, lo que facilitará la toma de decisiones. La relación médico paciente ya cede el terreno a formas más personalistas de relación y el respeto a la libertad individual. Conclusiones: Los fundamentos de la comunicación de la verdad en la enfermedad oncológica, se basan en los principios de la ética y bioética médica, la verdad garantiza una comunicación transparente y enriquecedora. Los puntos relevantes de la RMP consisten en lograr la adecuada alianza terapéutica entre el médico y paciente, en la mejora de su calidad de vida.

ABSTRACT Introduction: The doctor-patient relationship in oncology is based on respect for life, constantly linked to the acceptance of vulnerability and the recognition of the inevitability of death. The communication of the truth, particularly when it comes to reporting bad news, is a stressful and difficult situation that requires the proper preparation of health personnel. Objective: To comment the fundamentals of the communication of the truth in oncological diseases and the relevant points in the doctor-patient relationship. Development: Communicating the truth involves several ethical dilemmas in oncology and sometimes the medical team handles the information incorrectly. The consensus is not to lie, without rigid rules, "hide the truth" and the "conspiracy of silence"; are not entirely wrong, the health professional must respect the patient's right to be informed and their autonomy, which will facilitate decision-making. The doctor-patient relationship is already giving way to more personal forms of relationship and respect for individual freedom. Conclusions: The fundamentals of the communication of the truth in oncological disease are based on the principles of medical ethics and bioethics, the truth guarantees a transparent and enriching communication. The relevant points of the doctor patient relationship consist of achieving the adequate therapeutic alliance between the doctor and the patient, in order to improve their quality of life.

A random parameters with heterogeneity in means and Lindley approach to analyze crash data with excessive zeros: A case study of head-on heavy vehicle crashes in Queensland.

This study performed statistical analyses to identify likely crash contributing factors for Head-on Fatal and Serious Injury (FSI) collisions involving heavy vehicles (HVs) on the Queensland state road network. Head-on HV collisions are associated with the largest number of fatalities compared to other crash types in Queensland. However, there is limited relevant literature regarding this type of crashes. Recent studies on road safety research have focused on variants of random parameters models to capture unobserved heterogeneity that may influence the occurrence of crashes. Among such models, random parameters with heterogeneity in means has recently provided better results and has become popular. However, this study illustrates a potential limitation regarding the use of these models without explicitly factoring for excessive zero crash observations. To address this potential limitation, a random parameters with heterogeneity in means and a Lindley distribution is introduced in this study to factor for the unobserved heterogeneity using additional variables as well as site-specific variation from excessive zero crash observations. Results showed that a Poisson model with random parameters and heterogeneity in means using a Lindley distribution outperformed multiple alternative state-of-the-art specifications in terms of fit as well as overall prediction ability. The analyses using the proposed modelling approach revealed factors likely to affect the likelihood of Head-on FSI crashes involving HVs in Queensland including volume, segment length, period of analysis, terrain type being rolling, curve (moderate/sharp/very sharp) longer than 50% of the corresponding segment length, rural single carriageway with high (>=100 kph) and medium (>=50 and <100 kph) speed limits, and urban single carriageway. Unobserved heterogeneity regarding the parameter for road curvature was explained using rolling terrain type as an explanatory variable. This study has explained variation in the means of random parameters for a road attribute using the effect of a geometric variable, in which several stakeholders are primarily interested.

Prehospital and First Hospital System Response to a Terrorist Attack in Bogotá, Colombia.

Background: Assembling an effective medical response for an overwhelming number of casualties has become a priority worldwide. Terrorist attacks have been part of the Colombian contemporaneous history. On February 7, 2003, a terrorist car bomb explosion occurred inside a private club in Bogotá, causing the largest number of casualties of all terrorist attacks for over 15 years. The present study analyses the hospital and prehospital responses to this mass casualty event by characterizing the patterns of injury, resource allocation, and outcome in a tertiary-level hospital where most of the casualties were treated. Materials and methods: This is a retrospective chart review of the patients brought to a single hospital (La Clínica del Country), which was the nearest to the terrorist attack. Demographics, severity of injury, patterns of injury, prehospital care, and outcomes were determined from the hospital medical records and government registries. Results: Of the 240 victims, 35 died at the explosion site (immediate mortality 17%). The 205 survivors were dispersed throughout the city, of whom 63 patients came to La Clínica del Country hospital. Most of these patients were evaluated only clinically and deemed not serious. The main mechanism of trauma was blunt (81.4%). The mean injury severity score (ISS) was 5.6 ± 8.3. Ten patients required emergent surgical intervention and 14 patients were admitted. The in-hospital mortality was 20%. Conclusion: This mass casualty event was a true test for the Colombian emergency medical system and disaster preparedness. The medical response and resource optimization resulted in an overall mortality rate similar to those observed in the recent European and North American bombings. Despite the limited resources, the continuous challenge of terrorist's attacks in Colombia made the country feel the need for training and preparing the healthcare professionals, allowing effective delivery of medical care.

Introducción: La organización de una respuesta médica efectiva a un número excesivo de víctimas de ataques terroristas se ha convertido en una prioridad en el mundo. Los ataques terroristas han sido parte de la historia colombiana contemporánea. El 7 de Febrero de 2003, un carro bomba explotó en el interior de un club privado en Bogotá, resultando en el ataque terrorista con mayor numero de víctimas durante los últimos 15 años. El objetivo de este estudio es determinar la respuesta del sistema pre y hospitalario a un ataque terrorista masivo, caracterizar los patrones de lesión, utilización de recursos y desenlaces en un hospital de primer nivel, donde la mayoría de las víctimas fueron atendidas. Métodos: Este es un estudio retrospectivo de la revisión de 43 historias clínicas de 63 pacientes que fueron llevados al hospital privado más cercano después de un ataque terroristas. La información demográfica, la severidad, el patrón de las lesiones y los desenlaces fueron determinados a partir de las historias clínicas y los registros gubernamentales. Resultados: Treinta y cinco personas murieron en la escena y 205 personas fueron lesionadas (mortalidad inmediata de 17%). 63 pacientes fueron transferidos a nuestros hospitales. La mayoría de los pacientes fueron valorados clínicamente y no tenían lesiones serias. El principal mecanismos de trauma fue cerrado. El promedio de ISS fue 5.6 ± 8.3. Diez pacientes requirieron intervenciones quirúrgicas de urgencia y 14 fueron admitidos al hospital. La mortalidad crítica fue de 20%. Conclusione: Este incidente fue un verdadero examen a nuestro sistema médico de emergencias y plan de desastres hospitalario. Nuestro sistema médico optimizó los recursos resultando en una mortalidad crítica similar a la de las bombas ocurridas en Europa y Norte América. El desafío permanente de confrontar los ataques terroristas en Colombia ha proporcionado entrenamiento y preparación para asegurar un cuidado médico efectivo, aun con recursos limitados. Palabras clave: Ataque terrorista, Bomba, Evento con lesionados masivos, Respuesta medica.

The Feasibility of a Land Ferry System to Reduce Highway Maintenance Cost and Associated Externalities.

This study provides an economic evaluation for a Land Ferry, which is a rail system capable of carrying trucks and all other types of vehicles, passengers, and cargo. The Land Ferry system involves a sliding loading system to roll heavy loads onto a flatbed; as a result, loading and unloading of all vehicles and cargo could be accomplished simultaneously. The evaluation for this system included (1) the design of a new track alignment over which the Land Ferry system would run, (2) evaluation of various sources of power, (3) estimation of how many local jobs the Land Ferry would generate, and (4) a benefit-cost analysis. It was estimated that the Land Ferry would create over 45,788 temporary jobs in Nevada during the three-year construction period and 318 permanent jobs during operation. The majority of the benefits were attributed to savings in travel time ($356.4 M), vehicle operating costs ($1000.4 M), reduction of accidents ($544.6 M), and pavement maintenance ($503.2 M). These benefits would be a consequence of the shift of trucks from the highway, thus resulting in higher speeds, decrease fuel consumption, and decrease vehicle maintenance costs. The overall benefit-cost ratio of 1.7 implies a cost-effective project.

Traffic and Driving Simulator Based on Architecture of Interactive Motion.

This study proposes an architecture for an interactive motion-based traffic simulation environment. In order to enhance modeling realism involving actual human beings, the proposed architecture integrates multiple types of simulation, including: (i) motion-based driving simulation, (ii) pedestrian simulation, (iii) motorcycling and bicycling simulation, and (iv) traffic flow simulation. The architecture has been designed to enable the simulation of the entire network; as a result, the actual driver, pedestrian, and bike rider can navigate anywhere in the system. In addition, the background traffic interacts with the actual human beings. This is accomplished by using a hybrid mesomicroscopic traffic flow simulation modeling approach. The mesoscopic traffic flow simulation model loads the results of a user equilibrium traffic assignment solution and propagates the corresponding traffic through the entire system. The microscopic traffic flow simulation model provides background traffic around the vicinities where actual human beings are navigating the system. The two traffic flow simulation models interact continuously to update system conditions based on the interactions between actual humans and the fully simulated entities. Implementation efforts are currently in progress and some preliminary tests of individual components have been conducted. The implementation of the proposed architecture faces significant challenges ranging from multiplatform and multilanguage integration to multievent communication and coordination.

Development of a Comprehensive Database System for Safety Analyst.

This study addressed barriers associated with the use of Safety Analyst, a state-of-the-art tool that has been developed to assist during the entire Traffic Safety Management process but that is not widely used due to a number of challenges as described in this paper. As part of this study, a comprehensive database system and tools to provide data to multiple traffic safety applications, with a focus on Safety Analyst, were developed. A number of data management tools were developed to extract, collect, transform, integrate, and load the data. The system includes consistency-checking capabilities to ensure the adequate insertion and update of data into the database. This system focused on data from roadways, ramps, intersections, and traffic characteristics for Safety Analyst. To test the proposed system and tools, data from Clark County, which is the largest county in Nevada and includes the cities of Las Vegas, Henderson, Boulder City, and North Las Vegas, was used. The database and Safety Analyst together help identify the sites with the potential for safety improvements. Specifically, this study examined the results from two case studies. The first case study, which identified sites having a potential for safety improvements with respect to fatal and all injury crashes, included all roadway elements and used default and calibrated Safety Performance Functions (SPFs). The second case study identified sites having a potential for safety improvements with respect to fatal and all injury crashes, specifically regarding intersections; it used default and calibrated SPFs as well. Conclusions were developed for the calibration of safety performance functions and the classification of site subtypes. Guidelines were provided about the selection of a particular network screening type or performance measure for network screening.

Lesión del músculo pectoral por carcinoma lobulillar infiltrante / Pectoralis major muscle injure caused by infiltrating lobular carcinoma

Se presenta una paciente femenina de 69 años de edad, quien acudió en varias ocasiones al consultorio del médico de familia por notar aumento de volumen en la mama izquierda, considerado como resultado del efecto adverso a la ingestión de espironolactona. Se suspende el medicamento sin mejoría clínica. Se indicó ultrasonido de mama y se informa imagen de aspecto tumoral debajo del tejido mamario, que impresiona estar en relación con el músculo pectoral mayor; a esto se asocia una alteración del patrón mamario. Se realizó mamografía diagnóstica, se encuentra asimetría de volumen de la mama izquierda y una zona de aumento de la densidad cerca del pectoral, sin visualizar nódulo definido. Se realizó tomografía axial computarizada simple y contrastada. Se aprecia masa tumoral del músculo pectoral mayor izquierdo que infiltra tejido mamario y mediastino anterior, con diagnóstico imaginológico sugestivo de tumor del músculo pectoral mayor izquierdo. Se realizó biopsia por aguja fina de la lesión, guiada por ultrasonido y el diagnóstico fue carcinoma lobulillar infiltrante de mama. Se concluye que el comportamiento imaginológico puede estar relacionado con las pobres manifestaciones clínicas y, por tanto, con el diagnóstico tardío(AU)

The case of 69 years-old woman, who went several times to the family physician's office because of the increased volume of her left breast, was presented. This problem was considered to result from the adverse effect of the spironolactone intake. The drug consumption ceased but there was no clinical improvement. Breast ultrasound test was indicated in which a tumor-like image below the breast tissue was observed; it seemed to be related to the major pectoralis muscle, additionally, there was altered breast pattern. Diagnostic mammography was performed, asymmetric volume of the left breast was found together with an increased density area located near the pectoralis, without viewing a defined nodule. Simple and contrast computerized tomography were also performed. It was observed that there was tumor mass in the left pectoralis major muscle infiltrating into the breast tissue and the anterior mediastinum, with imaging diagnosis suggestive of left pectoralis major muscle tumor. Ultrasound-guided fine-needle biopsy of the lesion was applied and the resulting diagnosis was infiltrating lobular carcinoma of the breast. It was concluded that the imaging result could be related to poor clinical manifestations and thus, to late diagnosis(AU)

Lesión del músculo pectoral por carcinoma lobulillar infiltrante / Pectoralis major muscle injure caused by infiltrating lobular carcinoma

Se presenta una paciente femenina de 69 años de edad, quien acudió en varias ocasiones al consultorio del médico de familia por notar aumento de volumen en la mama izquierda, considerado como resultado del efecto adverso a la ingestión de espironolactona. Se suspende el medicamento sin mejoría clínica. Se indicó ultrasonido de mama y se informa imagen de aspecto tumoral debajo del tejido mamario, que impresiona estar en relación con el músculo pectoral mayor; a esto se asocia una alteración del patrón mamario. Se realizó mamografía diagnóstica, se encuentra asimetría de volumen de la mama izquierda y una zona de aumento de la densidad cerca del pectoral, sin visualizar nódulo definido. Se realizó tomografía axial computarizada simple y contrastada. Se aprecia masa tumoral del músculo pectoral mayor izquierdo que infiltra tejido mamario y mediastino anterior, con diagnóstico imaginológico sugestivo de tumor del músculo pectoral mayor izquierdo. Se realizó biopsia por aguja fina de la lesión, guiada por ultrasonido y el diagnóstico fue carcinoma lobulillar infiltrante de mama. Se concluye que el comportamiento imaginológico puede estar relacionado con las pobres manifestaciones clínicas y, por tanto, con el diagnóstico tardío.

The case of 69 years-old woman, who went several times to the family physician's office because of the increased volume of her left breast, was presented. This problem was considered to result from the adverse effect of the spironolactone intake. The drug consumption ceased but there was no clinical improvement. Breast ultrasound test was indicated in which a tumor-like image below the breast tissue was observed; it seemed to be related to the major pectoralis muscle, additionally, there was altered breast pattern. Diagnostic mammography was performed, asymmetric volume of the left breast was found together with an increased density area located near the pectoralis, without viewing a defined nodule. Simple and contrast computerized tomography were also performed. It was observed that there was tumor mass in the left pectoralis major muscle infiltrating into the breast tissue and the anterior mediastinum, with imaging diagnosis suggestive of left pectoralis major muscle tumor. Ultrasound-guided fine-needle biopsy of the lesion was applied and the resulting diagnosis was infiltrating lobular carcinoma of the breast. It was concluded that the imaging result could be related to poor clinical manifestations and thus, to late diagnosis.

Factores de riesgo relacionados con las relaparotomías después de cirugía gastrointestinal / Risk factors related to relaparotomies after gastrointestinal surgery

Se realizó un estudio retrospectivo y descriptivo de 73 pacientes que requirieron relaparotomías, de un total de 3 070 intervenciones gastrointestinales para un índice de 2,73. El objetivo fue identificar los factores de riesgo relacionados con las relaparotomías. Los datos se obtuvieron de las historias clínicas y de los informes de necropsias de los pacientes, y se procesaron estadísticamente. Predominaron los pacientes mayores de 50 años de edad y aquellos en que la operación inicial fue por oclusión intestinal durante una cirugía de urgencia. Las causas más frecuentes de reintervenciones fueron los procesos sépticos, seguidos de las eviseraciones y los sangramientos digestivos respectivamente. Los hallazgos encontrados en las reintervenciones estuvieron relacionados en su mayoría con dificultades en la técnica quirúrgica inicial. El índice de mortalidad global fue de 52,05 por ciento y estuvo directamente relacionado con el número de reintervenciones.

A retrospective and descriptive study was conducted among 73 patients that required relaparotomies of a total of 3 070 gastrointestinal interventions, accounting for 2.73. The objective was to identify the risk factors related to relaparotomies. The data were obtained from the medical histories and from the reports of the necropsies, and they were statistically processed. It was observed a prevalence of patients over 50 and of those whose initial operation was due to intestinal occlusion during an emergency surgery. The most frequent causes of surgical reintervention were mostly connected with difficulties in the initial surgical technique. The index of global mortality was 52.05 percent, and it was directly related to the number of surgical reinterventions.

Factores de riesgo relacionados con las relaparotomías después de cirugía gastrointestinal / Risk factors related to relaparotomies after gastrointestinal surgery

Se realizó un estudio retrospectivo y descriptivo de 73 pacientes que requirieron relaparotomías, de un total de 3 070 intervenciones gastrointestinales para un índice de 2,73. El objetivo fue identificar los factores de riesgo relacionados con las relaparotomías. Los datos se obtuvieron de las historias clínicas y de los informes de necropsias de los pacientes, y se procesaron estadísticamente. Predominaron los pacientes mayores de 50 años de edad y aquellos en que la operación inicial fue por oclusión intestinal durante una cirugía de urgencia. Las causas más frecuentes de reintervenciones fueron los procesos sépticos, seguidos de las eviseraciones y los sangramientos digestivos respectivamente. Los hallazgos encontrados en las reintervenciones estuvieron relacionados en su mayoría con dificultades en la técnica quirúrgica inicial. El índice de mortalidad global fue de 52,05 por ciento y estuvo directamente relacionado con el número de reintervenciones(AU)

A retrospective and descriptive study was conducted among 73 patients that required relaparotomies of a total of 3 070 gastrointestinal interventions, accounting for 2.73. The objective was to identify the risk factors related to relaparotomies. The data were obtained from the medical histories and from the reports of the necropsies, and they were statistically processed. It was observed a prevalence of patients over 50 and of those whose initial operation was due to intestinal occlusion during an emergency surgery. The most frequent causes of surgical reintervention were mostly connected with difficulties in the initial surgical technique. The index of global mortality was 52.05 percent, and it was directly related to the number of surgical reinterventions(AU)

Valor predictivo de la presión intra-abdominal en el diagnóstico de complicaciones posoperatorias abdominales / Predictive value of intra-abdominal pressure in the diagnosis of postoperative abdominal complications

Con el objetivo de determinar la discriminación diagnóstica de la medición de la presión intra-abdominal en el diagnóstico de complicaciones intra-abdominales posoperatorias, se diseñó un estudio de cribaje que incluyó a 190 pacientes intervenidos de cirugía abdominal ingresados en el Instituto Superior de Medicina Militar Dr. Luis Díaz Soto entre mayo de 2000 y diciembre de 2005. El estudio constó de 2 fases. En la primera, diseñada para hallar el intervalo de lo normal, se realizó la medición de la presión intra-abdominal por el método del cateterismo vesical a 100 pacientes intervenidos quirúrgicamente, seleccionados de forma aleatoria, con una evolución satisfactoria. Dicho intervalo quedó situado en un rango de 1-15 cm de H2O. En la segunda fase del estudio se utilizó como prueba de oro la relaparotomía y se realizó la medición de la presión intra-abdominal previa a la intervención a 90 pacientes con evolución post-operatoria desfavorable, que fueron reintervenidos quirúrgicamente. Se complicaron más los pacientes operados de urgencia (67,8 por ciento) que los intervenidos por cirugía electiva (32,2 por ciento). Predominaron las complicaciones infecciosas intra-abdominales (54,5 por ciento). La discriminación diagnóstica de la prueba permite utilizarla con alto grado de confianza y certeza para el diagnóstico de las complicaciones posoperatorias intra-abdominales. Existe una considerable relación entre la presión intra-abdominal, la frecuencia respiratoria, diuresis y relación PO2/FiO(AU)

Aimed at determining the diagnostic discrimination of the measurement of the intra-abdominal pressure in the diagnosis of postoperative intra-abdominal complications, it was designed a screening study that included 190 patients operated on of abdominal surgery that were admitted at Dr. Luis Díaz Soto Higher Institute of Military Medicine between May 2000 and December 2005. The study had two phases. In the first, designed to find out the normal interval, the intra-abdominal pressure was measured by the vesical catheterization method in 100 patients operated on that were selected at random, with a satisfactory evolution. Such an interval was in the range from 1 to 15 cm of H2O. In the second phase of the study, relaparotomy was used as a gold test, and the intra-abdominal pressure was measured previous to the operation of 90 patients with unfavorable postoperative evolution that had to undergo surgery again. The patients who had emergency operations presented more complications (67.8 percent) than those who underwent elective surgery (32.2 percent). It was observed a prevalence of infectious intra-abdominal complications (54.5 percent). The diagnostic discrimination of the test allowed its use with a high degree of reliability and accuracy for the diagnosis of postoperative intra-abdominal complications. There was a considerable relationship between intra-abdominal pressure, respiratory frequency, diuresis and PO2/FiO2 ratio(AU)