Abstract Objective Given the divergence of opinions on the need for complementary tests such as ultrasonography (US) and electroneuromyography (ENMG) for the diagnosis of carpal tunnel syndrome (CTS), we aimed to elucidate which of them presents greater accuracy for the confirmation of the presence or not of this condition. Methods A total of 175 patients from a hand surgery outpatient clinic were clinically evaluated, and the results of clinical trials (Tinel, Phalen and Durkan), US (normal or altered), and ENMG (normal, mild, moderate and severe) were noted, crossed, and submitted to a statistical analysis to verify the agreement between them. Results with the sample had a mean age of 53 years, with a prevalence of female patients (159 cases). Of the patients with positive clinical test, 43.7% had normal US and 41.7% had no alterations on the ENMG. Negative results were found on the Tinel in 46.9%, on the Phalen in 47.4%, and on the Durkan in 39.7%. In the crossing between the results of the ENMG and those of the other diagnostic methods, there was little statistical agreement between them. Conclusion There was no agreement between the results of the clinical examinations, the US and the ENMG in the diagnosis of CTS, and there is no clinical or complementary examination for CTS that accurately determines the therapeutic approach. Level of Evidence IV, Case Series.

Resumo Objetivo Diante da divergência sobre a necessidade de exames complementares, como ultrassonografia (US) e eletroneuromiografia (ENMG) para o diagnóstico da síndrome do túnel do carpo (STC), objetivamos elucidar qual deles apresenta maior precisão na confirmação da presença ou não desta afecção. Métodos Um total de 175 pacientes de um ambulatório de cirurgia da mão foram avaliados clinicamente, e os resultados dos testes clínicos (Tinel, Phalen e Durkan), da US (normal ou alterada) e da ENMG (normal, leve, moderada e grave) foram anotados, cruzados, e submetidos a análise estatística para verificar a concordância entre eles. Resultados A idade média da amostra era de 53 anos, sendo prevalente o sexo feminino (159 casos). Dos pacientes com teste clínico positivo, 43,7% apresentavam US normal, e 41,7%, ENMG sem alterações. Foram encontrados resultados negativos no Tinel em 46,9% no Phalen em 47,4%, e no Durkan em 39,7%. No cruzamento entre a ENMG e os demais métodos diagnósticos, houve pouca concordância estatística. Conclusão Não houve concordância entre os resultados dos exames clínicos, da US e da ENMG no diagnóstico da STC, e não há exame clínico ou complementar para STC que determine a conduta terapêutica com precisão. Nível de Evidência IV, Série de Casos.

Resumo Objetivo Estudo anatômico das raízes usadas na transferência nervosa de C4 para C5 nas lesões altas do plexo braquial, com demonstração da técnica cirúrgica. Métodos Dissecção de 15 plexos braquiais de cadáveres de ambos os sexos, registro e análise das características morfológicas das raízes de C4 e C5 e simulação de neurotização. Resultados As características morfológicas encontradas nas raízes de C4 e C5 em todas as dissecções permitiram a mobilização das mesmas e a realização de uma neurotização sem a necessidade de usar enxerto nervoso. A técnica cirúrgica permitiu preservar ramos nervosos importantes na região abordada. Conclusão Com base nos dados encontrados no presente estudo, podemos concluir que é possível realizar a transferência entre C4 e C5 sem provocar déficit neurológico adicional nas lesões altas de plexo braquial.

Abstract Objective This is an anatomical study of C4 and C5 roots for nerve transfers in upper brachial plexus injuries, with surgical technique demonstration. Methods Fifteen brachial plexuses from both male and female cadavers were dissected. Morphological features of C4 and C5 roots were recorded and analyzed, followed by a neurotization simulation. Results In all dissections, C4 and C5 roots morphological features allowed their mobilization and neurotization with no need for a nerve graft. The surgical technique spared important regional nerve branches. Conclusion Based on these data, we conclude that C4-C5 nerve transfers are feasible and result in no additional neurological deficit in upper brachial plexus injuries.

RESUMO Objetivos: Avaliar o ângulo palmar cortical (APC) da extremidade distal do rádio, sua variação nas colunas lateral e intermédia, o formato e o padrão da watershed line (WL) e sua correlação com as placas volares bloqueadas disponíveis no mercado. Métodos: Foram analisados 27 ossos rádios do Departamento de Morfologia e nove placas de seis fabricantes diferentes. Medimos os APCs das colunas lateral e intermédia dos rádios e seus correspondentes nas placas, além de compararmos o relevo do terço distal do rádio e das placas. Quanto a WL, comparamos o formato nas peças e seu equivalente nas placas, sendo classificados em quatro tipos: biconvexo, convexo, convexo ulnar e plano. Resultados: O APC variou entre as colunas do rádio, sendo a média da coluna lateral 153,40° e, da intermédia 146,06°. Quatro das nove placas não apresentaram variação na angulação volar. Dos 27 rádios, 13 apresentaram padrão convexo e 12 biconvexo, enquanto a maioria das placas (sete das nove analisadas) tinham desenho biconvexo. Conclusão: A anatomia dos rádios foi variável entre as peças, sendo a coluna intermédia mais inclinada que a coluna lateral. A placa Synthes ® -2 foi a que apresentou relevo mais próximo dos achados anatômicos da extremidade distal do rádio, seguida pela Newclip ® -2. Nível de Evidência II, Estudo Anatômico Descritivo.

ABSTRACT Objective: To evaluate the volar cortical angle (VCA), the variation in lateral and intermediate columns, the shape and pattern of the watershed line (WL) of the distal radius and its correlation with locking volar plates available. Methods: 27 human cadaveric radial bones of the Department of Morphology and nine locking volar plates of six different companies were analyzed. VCA were measured from lateral and intermediate columns and their corresponding values on plates, as well as comparing the relief of radius and plates. In the WL analysis, we compared the standard format found on the radius and its equivalent on plates and divided into four types: biconvex, convex, ulnar convex and plan. Results: VCA varied between columns of the distal radius extremity. The mean in the lateral column was 153.40 degrees and 146.06 degrees in the intermediate. Four of nine plates showed no variation in volar angulation. From 27 distal radius, 13 showed convex pattern and 12 had biconvex, whereas most plates (seven of the nine analyzed) were biconvex drawing. Conclusion: Radial bone anatomy was variable. The intermediate column was, on average, steeper than lateral column. Synthes®-2 plate presented the closest design to the anatomy of the distal end of the radial bone, followed by Newclip®-2 plate. Level of Evidence II, Anatomic and Descriptive Study.

Abstract Studies involving the magnetic susceptibility (MS) of rocks are becoming increasingly frequent in geological surveys, mainly in those with petrogenetic approaches and in mineral prospecting. Portable devices have become a good alternative for data acquisition because of their practicality and low cost when compared to laboratory analyses. To assess the efficiency of data acquisition with such devices, 291 soil samples were measured with a Terra Plus KT-5 portable device in the field and with a double frequency Bartington MS2B sensor, with mass correction, in the laboratory. The data obtained allowed the characterization of four distinct populations, ranging from high to very low MS values. Statistical analysis showed good correlation between measurements with mass correction in the laboratory and those made with portable devices, resulting in a correlation coefficient (r) = 0.98. All samples obtained in the field and laboratory were utilized in this correlation. The populations identified by both means are in agreement, with subtle discrepancies, thereby demonstrating the efficiency of portable equipment for acquisition of MS data in geological studies.

Resumo Objetivo Verificar se existe associação entre o diagrama da parestesia da mão (DPM) e os resultados da eletroneuromiografia (ENMG) no diagnóstico da síndrome do túnel do carpo. Métodos Um total de 92 pessoas preencheram um desenho esquemático da mão com o local exato da parestesia (167 mãos). O autor principal classificou os diagramas de acordo com os critérios de Katz et al. Os resultados do DPM foram cruzados com os resultados positivos da ENMG para o diagnóstico da síndrome do túnel do carpo. Resultados O padrão possível do DPM foi prevalente tanto isoladamente quanto após o cruzamento com os graus da ENMG. Conclusão Não houve associação entre o DPM e a ENMG no diagnóstico da síndrome do túnel do carpo.

Abstract Objective Verify if there is an association between the hand diagram of paresthesia (HDP) and the results of electroneuromyography (ENMG) in the diagnosis of carpal tunnel syndrome. Methods A total of 92 people filled in a schematic drawing of the hand with the exact location of the paresthesia (167 hands). The main author classified the diagrams according to the criteria of Katz et al.5 The results of the HDP were crossed with the positive results of ENMG for the diagnosis of carpal tunnel syndrome. Results The possible pattern of the HDP was prevalent both in isolation and after crossing with the degrees of ENMG. Conclusion There was no association between the HDP and ENMG in the diagnosis of carpal tunnel syndrome.

ABSTRACT Soils originating from the Caiuá sandstone formation have low soil organic matter (SOM), clay content, and cation exchange capacity (CEC). The predominance of one component over the other might decisively influence the CEC of these soils. Particle size distribution and selective dissolution procedures associated to a suit of methods to determine the exchangeable capacity properties might clarify the relative importance of each soil component. The objective of this work was to evaluate the contribution of the different components of the solid fraction and their intrinsic attributes to the CEC of sandy-loam soils and their relation to the total organic carbon (TOC), C:N ratio, and soil mineralogy. For this purpose, 34 soil samples were selected from the Caiuá sandstone formation with significant variation in the carbon content. Clay size fraction was characterized by X-ray diffraction, routine chemical analysis, and total specific surface area-SSA T using EGME, before and after the removal of SOM with sodium hypochlorite solution. Different values of CEC and effective cation exchange capacity (ECEC) were determined following standard procedures. The soils presented high sand content (82.9 ± 5.9 %) and the mineralogy of the clay fraction is dominated by kaolinite (>80 %) with the presence of illite, 2:1 clay minerals, and small amounts of iron and aluminum oxides. The CEC and ECEC values at pH 7.0 and ~5.6, respectively due to the SOM are 408.6 and 148.7 cmol c kg -1 of carbon, respectively. The SOM was responsible for 32 to 84 % (average 52 %) and 24 to 67 % (average of 46 %) of the CEC and ECEC of the soils, respectively. The CEC and ECEC of the inorganic fraction are 2.32 and 0.78 cmol c kg -1 of minerals, respectively. The CEC of the clay fraction increased with the TOC but decreased exponentially with the clay content. The total carbon content increased linearly with the C/N ratio. The SSA T showed a significant (p<0.05) and positive correlation with the TOC and with the CEC of the soils.

RESUMO As composições de alumina-reforço foram preparadas para avaliar o efeito da fase vítrea como auxiliar de sinterização. Os compósitos apresentaram densificação abaixo de 1100 ° C. Os maiores valores de densidade (~ 95%) foram obtidos para composições baseadas respectivamente em vidros de borossilicato (G2 e G3) e soda e cal (G4), todos contendo Na no pó precursor. As amostras G1 (à base de K) e G5 (sem K ou Na no pó do vidro precursor) apresentaram morfologia irregular com presença de porosidade intergranular. As composições G2, G3 e G4 apresentaram morfologia uniforme, correspondendo a uma maior densificação.

ABSTRACT Alumina-Glass compositions were prepared to evaluate the effect of glass as sintering aids. The composites showed densification below 1100°C. The highest density values (~95%) were obtained for compositions based respectively on borosilicate (G2 and G3) and soda lime glasses (G4), all [A1] [A2] containing Na in the precursor powder. Samples G1 (K-based) and G5 (no K or Na in the precursor glass powder) presented irregular morphology with the presence of intergranular porosity. The composition G2, G3, and G4 presented uniform morphology corresponding to higher densification.

ABSTRACT Boron- B concentrations that cause deficiency and those that cause toxicity appear to be very similar, compared to other nutrients, which can complicate successful management of this element in soils. In this study, B adsorption onto two Oxisols from Brazil (Rhodic Eutroperox and Anionic Acroperox), two Alfisols (Natric Palexeralf and Aridic Paleustalf) and an Entisol (Xeric Torrifluvent) from the United States of America were evaluated. The samples were treated with sodium hypochlorite in order to remove soil organic matter. Both treated and untreated samples were used to determine B adsorption isotherms using different B concentrations (0-4.630 mmol L–1) and NaNO3 (0.05 M) as background electrolyte solution at pH 7. Boron adsorption envelopes were also measured using 0.463 mmol L–1 B at three ionic strengths (0.05, 0.1 and 1M) and NaNO3 as background electrolyte solutions at different pH values (3-12). The cation exchange capacity, specific surface area, free Al and Fe oxides, organic and inorganic carbon content, mineralogy and particle size distribution of the soils were also determined. The Langmuir isotherm and the constant capacitance model were fit to the B adsorption data and the parameters obtained were related to the chemical attributes by multiple linear regression equations. Boron maximum adsorption capacity (BMAC) and the complexation constant for the SH3BO4– inner-sphere complex (LogKB–) could be predicted under all experimental conditions. The Alc content was the main soil chemical attribute associated with the BMAC under the conditions evaluated and the LogKB–(int) in untreated and treated samples.

RESUMO Objetivo: Avaliar o resultado funcional dos pacientes com lesão traumática do plexo braquial submetidos à cirurgia de Oberlin. Métodos: Foram analisados 18 pacientes, sendo 17 homens (94,4%), com idade média de 29,5 anos (17 a 46 anos), com lesão traumática alta do plexo braquial (C5-C6 e C5-C7). Avaliamos a amplitude de movimento ativa do cotovelo, a força muscular de flexão do cotovelo e a força de preensão palmar, e aplicamos o questionário Disabilities of the Arm, Shoulder and Hand (DASH). Resultados: Quatro pacientes (22,2%) não obtiveram força eficaz de flexão do cotovelo BRMC (Grau 3). A amplitude de movimentação ativa apresentou média de 100,2° (± 45,6°) e observamos média de 35,5% (0 a 66,3%) de percentual de recuperação da força em relação ao membro contralateral. Foi observada menor força de flexão de cotovelo (p = 0,0001) e de preensão manual (p = 0,0001) no lado acometido. Conclusão: A cirurgia descrita por Oberlin para lesões do plexo braquial mostrou-se eficiente para a restauração da flexão do cotovelo e não deixou sequelas funcionais para a mão. Os resultados para a força do bíceps são melhores nas cirurgias realizadas com menos de 12 meses de lesão. Nível de evidência II, estudo retrospectivo.

ABSTRACT Objective: To evaluate the functional outcome of patients with traumatic brachial plexus injury undergoing the Oberlin procedure. Methods: Eighteen patients were assessed, comprising 17 men (94.4%) and 1 woman (5.6%), mean age 29.5 years (range 17-46 years), with upper traumatic brachial plexus injury (C5-C6 and C5-C7). We assessed active range of motion of the elbow, elbow flexion muscle strength and hand-grip strength, and applied the DASH (Disabilities of the Arm, Shoulder and Hand) questionnaire. Results: Four patients (22.2%) did not achieve effective elbow flexion strength (BMRC Grade 3). Mean active range of motion was 100.2° (±45.6°), and we observed a mean percentage of strength recovery relative to the contralateral limb of 35.5% (0-66.3%). Elbow flexion (p = 0.0001) and hand-grip (p = 0.0001) strength levels were lower on the affected side. Conclusion: The surgical technique described by Oberlin for brachial plexus injuries proved effective for restoring elbow flexion and produced no functional sequelae in the hand. Bicep strength outcomes were better when surgery was performed within 12 months of injury. Level of evidence II, retrospective study.

A enzima ∆¹-pirrolina-5-carboxilato sintetase (P5CS), codificada pelo gene p5cs, é o passo limitante da biossíntese de prolina, que age como um osmoprotetor. O lançamento de variedades comerciais transgênicas depende da caracterização fisiológica e fenotípica de eventos. O objetivo deste estudo foi avaliar cinco eventos (591, 14, 326, 164, 312) contendo o gene p5cs, através de análises fisiológicas e taxas de produção sob estresse hídrico. Plantas de eventos e controles irrigados e estressados (CI e CS) em estádio de florescimento foram submetidos a 16 dias de restrição hídrica. Foram avaliados: teor relativo de água (RWC); concentração de malondialdeído (MDA%); índice de estabilidade da membrana (MSI%); conteúdo de prolina; e taxas de produção. Como resultado, o efeito do estresse hídrico só foi percebido após 12 dias de restrição hídrica com uma diminuição nos valores de RWC. Plantas transgênicas apresentaram maiores níveis de prolina no 16º dia, comparado ao SC (33 a 62%). Os teores de MDA foram menores no 12º e 16º dias para todas as plantas avaliadas, mas os MSI foram semelhantes ao IC para os eventos 591, 326 e 164, demonstrando o efeito osmoprotetor. Porém, níveis altos de prolina não resultaram em maiores taxas de produção de grãos.

The enzyme ∆¹-pyrroline-5-carboxylate synthetase (P5CS), encoded by the p5cs gene, is the rate-limiting step for proline biosynthesis, which acts as an osmoprotectant. The launch of transgenic commercial varieties depends on physiological and phenotypic characterization of events. The objective of this study was to evaluate five p5cs gene events (591, 14, 326, 164, 312), through physiological analyses and production rates during droughts. Plants of events and irrigated (IC) and stressed controls (SC) in flowering stage were submitted to 16 days of complete water restriction. The following elements were evaluated: relative water content (RWC); malondialdehyde concentration (MDA%); membrane stability index (MSI%); proline content; and production rates. As a result, the effect of water stress was only perceived after 12 days of water restriction with a decrease in the RWC values. Transgenic plants showed higher proline levels on the 16th day, compared to the SC (33 to 62%). The levels of MDA were lower on the 12th and 16th days for all the plants evaluated, but the MSI were similar to the IC for the events 591, 326, and 164, demonstrating the osmoprotectant effect. However, higher levels of proline did not result in higher production rates in the transgenic plants.

RESUMO Objetivo: Determinar a relação entre o resultado funcional obtido com a cirurgia de Oberlin, o nível cognitivo do paciente e com o tempo decorrido entre o trauma e a cirurgia. Métodos: Foram analisados dezoito pacientes, sendo 17 homens (94,4%) e uma mulher (5,6%), com idade média de 29,5 anos (17 a 46 anos), com lesão traumática alta do plexo braquial (C5-C6 e C5-C7). Avaliamos a amplitude de movimento ativa, a força muscular de flexão do cotovelo e o questionário DASH (Disabilities of the Arm, Shoulder and Hand) e determinamos a correlação entre o resultado obtido e o nível cognitivo do paciente, avaliado pelo Mini Exame do Estado Mental (MEEM). Resultados: Observamos correlações de significância estatística entre MEEM e recuperação de força (84,4%, p<0,001), classificada como ótima; MEEM e BMRC - British Medical Research Council (78,4%, p> 0,001), classificada como boa. Conclusões: Verificamos correlação positiva entre a capacidade cognitiva e os resultados funcionais dos pacientes submetidos à cirurgia de Oberlin. O tempo decorrido entre o trauma e o procedimento cirúrgico apresenta uma relação inversamente proporcional com a recuperação da força. Nível de Evidencia II, Estudo retrospectivo.

ABSTRACT Objective: To determine the relationship between the functional outcome achieved following Oberlin transfer, the cognitive level of the patient, and the time elapsed between the trauma event and surgery. Methods: Eighteen patients with a traumatic injury to the brachial plexus (C5-C6 and C5-C7) were evaluated. Seventeen (94.4%) patients were males and one (5.6%) was female, with a mean age of 29.5 years (range 17-46 years). We evaluated the active range of motion, elbow flexion strength, and Disabilities of the Arm, Shoulder and Hand (DASH) and determined the correlation between the procedural outcome and the patient's cognitive level, as assessed by the Mini-Mental State Exam (MMSE). Results: We found statistically significant correlations between the MMSE scale and strength recovery (84.4%, p<0.001), which was classified as excellent, and between the MMSE and British Medical Research Council (BMRC) scales (78.4%, p>0.001), which classified cognitive level as good. Conclusions: We found a positive correlation between cognitive capacity and functional outcome of patients submitted to Oberlin surgery. The time elapsed between trauma and the surgical procedure showed an inversely proportional correlation with the strength of recovery. Level of Evidence II, Retrospective Study.

RESUMO Objetivo: A transferência de nervos é uma alternativa na reconstrução das lesões traumáticas do plexo braquial. Neste estudo, relatamos os resultados da reconstrução do plexo braquial com a transferência do nervo acessório para o nervo supraescapular. Métodos: Trinta e três pacientes com lesões traumáticas do plexo braquial foram submetidos à reconstrução cirúrgica com transferência do nervo acessório para o nervo supraescapular. Os pacientes foram divididos em grupos em que a cirurgia foi realizada dentro de 6 meses a partir da lesão ou mais de 6 meses depois da lesão. Os resultados foram avaliados com o escore Constant. Resultados: Não houve diferença significante entre os grupos com relação ao escore Constant. Conclusão: A transferência do nervo acessório para o nervo supraescapular não foi um método eficiente para recuperar a ADM ativa ou a força no ombro. No entanto, foi eficiente para melhorar o controle da dor e a estabilização do ombro. Nível de evidência II, Estudo Retrospectivo.

ABSTRACT Objective: Nerve transfers are an alternative in the reconstruction of traumatic brachial plexus injuries. In this study, we report the results of branchial plexus reconstruction using accessory to suprascapular nerve transfer. Methods: Thirty-three patients with traumatic brachial plexus injuries underwent surgical reconstruction with accessory to suprascapular nerve transfers. The patients were divided into groups in which surgery was performed either within 6 months after the injury or more than 6 months after the injury. Results were assessed using the Constant score. Results: There was no significant difference between the groups with respect to the Constant score. Conclusion: Accessory to suprascapular nerve transfer was not an efficient method for recovering active ROM or strength in the shoulder. However, it effectively improved pain control and shoulder stability. Level of evidence II, Retrospective Study.

ABSTRACT: Fe-rich Oxisols on mafic rocks in Brazil generally have high magnetic susceptibility with high contents of some trace elements. These are taxonomically similar soils; however, differences in magnetic and geochemical properties may affect agricultural or environmental usability and subsequent management. This study investigated the pedogenesis of Fe-rich Oxisols from various parent materials and evaluated the lithogenetic influence on magnetic susceptibility and trace elements contents. Soil samples were collected from Bw horizons in 13 Rhodic Oxisols and a Typic Oxisol developed from several parent materials in Minas Gerais State, Brazil. Soils were analyzed by X-ray diffractometry (XRD) and magnetometry. Soil chemical analyses consisted of sulfuric and total (tri-acid) digestions and selective Fe oxides dissolutions and statistical correlations were determined. Fe-rich Oxisols presented a typical mineralogical composition of highly weathered soils with structural stability. The results confirm the difficulty to identify accurately magnetic minerals in different grain sizes using XRD. However, coarse fractions still exert dominant influence on the magnetic properties of the Fe-rich Rhodic Oxisols. In addition, coarse fractions probably contribute to the enrichment of superparamagnetic particles for the clay fraction. Although highly weathered, Fe-rich Oxisols may have their geochemical attributes still controlled by the parent material, where trace elements seem to be correlated with the magnetic minerals in the coarse fractions. Thus, the natural replacement of some trace elements from soil-solution equilibrium reactions during plant development could be more effective in soils with higher magnetic particles concentrations in the coarse fractions.

RESUMO Objetivo: O objetivo deste estudo foi apresentar a proposta de uma classificação tomográfica das fraturas intra-articulares da extremidade distal do rádio. Métodos: Este estudo descritivo baseou-se na observação de imagens tomográficas de 74 pacientes com fratura da extremidade distal do rádio. Os casos foram agrupados por semelhança de acordo com a presença de alguns parâmetros determinantes da complexidade da fratura. Os resultados da análise descritiva foram transcritos na forma de uma classificação tomográfica. Resultados: A classificação tomográfica proposta para as fraturas intra-articulares da extremidade distal do rádio compreendeu três grupos maiores e nove subgrupos, organizados em ordem crescente de gravidade, de acordo com a presença de espaçamento entre os fragmentos articulares, desvio angular, perda da altura radial, afundamento cortical e luxação associada. Conclusão: Esta classificação tomográfica proposta para as fraturas intra-articulares da extremidade distal do rádio pode auxiliar os profissionais na indicação da conduta terapêutica. Nível de Evidência IV; Série de casos.

ABSTRACT Objective: The objective of this study was to present a proposal tomographic classification for intra-articular distal radius fractures. Methods: This descriptive study was based on observing tomographic images from 74 patients with distal radius fractures. The cases were grouped by similarity according to the presence of several parameters which determine fracture complexity; the results of the descriptive analysis were transcribed as tomographic classification. Results: The proposal tomographic classification for intra-articular distal radius fractures comprised three major groups and nine sub-groups, which are organized by increasing severity according to the presence of spacing between articular fragments, angulation, loss of radial height, cortical depression, and associated dislocation. Conclusion: This proposal tomographic classification for intra-articular distal radius fractures can help professionals indicate therapeutic options. Level of Evidence IV; Case series.