Injerto columelar extendido angulado. Método para prevenir la rotación cefálica y lateral de los injertos de cartílago en la punta nasal Angulated extended collumelar graft. A method to prevent the cephalic and lateral rotation of the cartilage graft in the nasal tip

El paciente mestizo generalmente posee una nariz pequeña, de base ancha, con fosas nasales redondas y dorso convexo. Los cartílagos alares son débiles, delgados y cortos, proporcionando un soporte estructural deficiente y pobre definición de la punta nasal. Los injertos de cartílago de la punta nasal se usan frecuentemente para corregir esta condición; sin embargo un problema común es la rotación cefálica, caudal y lateral de estos cartílagos. Empleamos un injerto columelar extendido angulado (ICEA) para proporcionar elongación y soporte columelar; la extensión angulada nos brinda a su vez un mejor control y predicción de la posición de los injertos de la punta nasal al prevenir su desplazamiento cefálico y lateral. El protocolo quirúrgico empleado incluyó historia clínica completa, desarrollo de un plan quirúrgico mediante análisis de la deformidad y fotografías pre y postoperatorias para el control de los pacientes a medio y largo plazo. Tratamos 95 pacientes usando este procedimiento; 75 con rinoplastia abierta y 20 con técnica cerrada. El rango del periodo de seguimiento fue de 6 meses a 4 años. Los resultados obtenidos fueron satisfactorios, mostrando mejor control y predicción de la forma de la punta nasal. En conclusión, creemos que el injerto columelar extendido angulado proporciona un mejor control de la proyección y angularidad de los injertos colocados en la punta nasal.The mestizo patient usually has a small nose, with wide base, round nostrils and convex dorsum. The alar cartilages are weak, thin and short, providing a deficient structural support and poor definition of the nasal tip. Cartilage graft in the nasal tip are very often used to correct this condition, but a commun problem of this procedure is the cephalic or lateral rotation of these grafts. We used an angulated extended collumalar graft to give collumelar support and elongation. The angulated extension of the graft provides a better control and prediction of the position of the grafts of the nasal tip preventing the lateral and cephalic displacement. The surgical protocol included a medical history, development of a surgical plan by analysis of the deformity and the use of pre/and postoperative photographs taken at both intermediate and long time, and long/term follow-up visits for evaluation of the results. Ninety-five patients underwent surgery using this procedure: 75 whit an open technique and 20 with a closed technique. Follow/up ranged from 6 months to 4 years. The results obtained were satisfactory, showing better control and prediction of the shape of the nasal tip. As a conclusion, in our experiencie, the angulated extended collumelar graft provides better control of the proyection and angularity of cartilage grafts pleced in the nasal tip

Cenozoic magmatism and extension in western Mexico: Linking the Sierra Madre Occidental Silicic Large Igneous Province and the Comondú Group with the Gulf of California rift

Emerging over the past decade has been a new view on the genesis of, and links between, the Sierra Madre Occidental silicic large igneous province, the Comondú Group of Baja California and the Gulf of California rift. Underpinning this has been a wealth of new data from both margins of the Gulf of California including offshore sampling, and marine geophysical data, in part seeded by the NSF Margins program where the Gulf of California was a principal focus site. Previously, the Sierra Madre Occidental silicic large igneous province and Comondú Group had been widely regarded as supra - subduction volcanism with the Comondú Group in particular, defining the location of the early to mid - Miocene supra - subduction zone volcanic arc, and therefore acting as both a spatial and temporal barrier to when rifting of the Gulf of California could begin. More broadly, this continental magmatism occurring during the last phase of subduction of the Farallon Plate between the Late Eocene and the Middle Miocene, shows little to n o petrogenetic connection to the active plate boundary and is more strongly linked to the progressive thinning of the upper plate and establishment of a shallow asthenospheric mantle beneath western Mexico. A database developed for this study of 4255 ages and chemical analyses for igneous rocks from 100 to 5 Ma from across western Mexico, reveals a significant transition period between 50 and 40 Ma where relatively low - volume magmatism was established across a broad area up to 800 km wide and extended up to 1000 km in board of the paleotrench. Since 40 Ma, magma fluxes greatly increased across this broad belt and compositions were initially silicic - dominated but quickly became bimodal by ~30 Ma. The space - time pattern of crustal extension is constrained in 39 areas, for which the approximate age of extension can be established on the basis of geologic relations or thermochronology. The onset of continental extension is constrained to the Eocene when extensional basins developed across the Central Plateau and the easternmost part of the Sierra Madre Occidental, approximately 500 km in board of the paleo - plate boundary. By the end of Oligocene, crustal extension had affected a wide region (250 km width) from the eastern Sierra Madre Occidental to the site of the future Gulf of California (wide rift mode). Concomitant with this extension was:\ud \ud 1) a widespread invasion of the mid to upper crust by mafic magmas with lithospheric signatures (the southern cordillera orogenic basaltic andesite suite or SCORBA), and lesser erupted volumes of uncontaminated asthenosphere - derived within - plate lavas, and;\ud \ud 2) crustal melting producing voluminous pulses of silicic ignimbrite eruptions (the SMO SLIP) with a ferroan (dry) and transitional within - plate signature. At ~19 Ma, ortho gonal extension became focused between the western side of the SMO and eastern Baja California in a ~80 - 100 km wide belt

Edoxaban versus warfarin in patients with atrial fibrillation

Contains fulltext : 125374.pdf (publisher's version ) (Open Access)BACKGROUND: Edoxaban is a direct oral factor Xa inhibitor with proven antithrombotic effects. The long-term efficacy and safety of edoxaban as compared with warfarin in patients with atrial fibrillation is not known. METHODS: We conducted a randomized, double-blind, double-dummy trial comparing two once-daily regimens of edoxaban with warfarin in 21,105 patients with moderate-to-high-risk atrial fibrillation (median follow-up, 2.8 years). The primary efficacy end point was stroke or systemic embolism. Each edoxaban regimen was tested for noninferiority to warfarin during the treatment period. The principal safety end point was major bleeding. RESULTS: The annualized rate of the primary end point during treatment was 1.50% with warfarin (median time in the therapeutic range, 68.4%), as compared with 1.18% with high-dose edoxaban (hazard ratio, 0.79; 97.5% confidence interval [CI], 0.63 to 0.99; P<0.001 for noninferiority) and 1.61% with low-dose edoxaban (hazard ratio, 1.07; 97.5% CI, 0.87 to 1.31; P=0.005 for noninferiority). In the intention-to-treat analysis, there was a trend favoring high-dose edoxaban versus warfarin (hazard ratio, 0.87; 97.5% CI, 0.73 to 1.04; P=0.08) and an unfavorable trend with low-dose edoxaban versus warfarin (hazard ratio, 1.13; 97.5% CI, 0.96 to 1.34; P=0.10). The annualized rate of major bleeding was 3.43% with warfarin versus 2.75% with high-dose edoxaban (hazard ratio, 0.80; 95% CI, 0.71 to 0.91; P<0.001) and 1.61% with low-dose edoxaban (hazard ratio, 0.47; 95% CI, 0.41 to 0.55; P<0.001). The corresponding annualized rates of death from cardiovascular causes were 3.17% versus 2.74% (hazard ratio, 0.86; 95% CI, 0.77 to 0.97; P=0.01), and 2.71% (hazard ratio, 0.85; 95% CI, 0.76 to 0.96; P=0.008), and the corresponding rates of the key secondary end point (a composite of stroke, systemic embolism, or death from cardiovascular causes) were 4.43% versus 3.85% (hazard ratio, 0.87; 95% CI, 0.78 to 0.96; P=0.005), and 4.23% (hazard ratio, 0.95; 95% CI, 0.86 to 1.05; P=0.32). CONCLUSIONS: Both once-daily regimens of edoxaban were noninferior to warfarin with respect to the prevention of stroke or systemic embolism and were associated with significantly lower rates of bleeding and death from cardiovascular causes. (Funded by Daiichi Sankyo Pharma Development; ENGAGE AF-TIMI 48 ClinicalTrials.gov number, NCT00781391.)