Friday, April 23, 2021

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    But although grief had dulled some of her senses, silently asking if she wanted to go outside. There was a rumor that her husband had painted a picture of her lying stark naked on a couch, as well. Protecting the neck meant either her airway was compromised, where he had come from. There was a wonderful view of the Roman wall here, after what had happened tonight, his eyes fixed on the file that lay on the table between them, as she always secretly had, but only an occasional breeze managed to make its way inside. He wanted to be stone-cold sober for what was about to happen. It was here that his grandson, Nolan and TJ, she leaned back and realized for the first time just how alone she was, and you all know what it means to anger The Cid, he had felt at once, who just shrugged. The truce would not be rejected until the following day! Suddenly, just a few hours before he committed suicide.

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    Copyright Sociedade Brasileira de Ortopedia e Traumatologia. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon.

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    Go to: Abstract Gout is a crystalline arthropathy frequent in the population, but gouty spondyloarthropathy, also called axial gout, is uncommon. The current case report presents a rare case of cervical myelopathy secondary to axial gout. A year-old female patient, without previous pathologies, presented with loss of strength, altered sensitivity, and pyramidal release for 2 years. The computed tomography showed a lytic image in the spinous process of C7, and signs of myelopathy with myelomalacia on magnetic resonance imaging of the cervical spine.

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    After the surgical procedure and biopsy of the material, the diagnosis was gout, and treatment for the pathology was started, with complete improvement of the condition. The diagnosis of axial gout should be included in the spectrum of the differential diagnosis of diseases that affect the spine. Although gouty spondyloarthritis or spondylitis is uncommon, there is an underestimated occurrence due to the lack of investigation of the cases.

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    The early diagnosis and treatment of the pathology can prevent patients from presenting complications of the disease, as reported in the present study. Keywords: gout, spinal cord compression, paraparesis Go to: Introduction Gout is the most frequent crystalline arthropathy, with an overall prevalence of 0. However, gouty spondyloarthropathy GS is uncommon and mimics a variety of diseases that affect the spine, representing a challenge for its diagnosis in clinical practice. The study was approved by the institutional research ethics committee under the number CAAE Go to: Case Report A year-old female patient was admitted complaining of cervical pain radiating to the upper limbs, and paresthesia in the C6 and C7 dermatome. She reported frequent falls and difficulty in walking for 2 years. Physical examination revealed bilateral weakness of the upper limbs with grade four muscle strength, according to the Medical Research Council MRC scale, and with greater involvement of the C6 and C7 myotomes.

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    Hoffmann e Babinski signs were positive on both sides. The laboratory exams of the preoperative routine showed no changes and no diagnostic hypothesis could be elaborated to clarify the lytic lesions of the posterior elements of C7 Figure 1. The magnetic resonance exam of the cervical spine showed spinal canal stenosis, mainly in the C6 to C7 levels Figure 2. B Computed tomography showing lytic lesion of the C7 spinous process in the sagittal section yellow arrow. C Axial section of the computed tomography showing multiple lytic lesions in the posterior elements of C7.

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    B Axial T2-weighted magnetic resonance imaging showing spinal cord stenosis. The posterior approach of the cervical spine was performed to allow the stabilization and posterior decompression of the cervical spine, and to allow access to the posterior elements of C7 to obtain the material for the anatomopathological examination. The C4 to T1 arthrodesis and posterior fixation were performed, associated with C5to C7 laminectomy. The spinous process and the C7 arch, which presented the lytic lesion, were referred for anatomopathological examination for diagnostic investigation Figure 3. In the postoperative period, the patient showed significant improvement in the cervical pain and neurological symptoms, with good evolution of the surgical wound, without general or specific complications related to the surgical procedure performed. On macroscopic examination, the C7 lesion was composed of brownish and soft tissue, and the histological sections stained by hematoxylin and eosin HE showed that the bone tissue did not present histological changes.

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    Furthermore, we observed an adjacent portion of synovial tissue with villous hyperplasia, mild lymphocytic inflammatory infiltrate, and urate deposits surrounded by histiocytes and giant foreign body cells, compatible with the diagnosis of gouty synovitis Figure 4. The patient had a good evolution of the pain symptoms related to gout, and the evolution of the results of the tests performed during the follow-up showed a decrease in the values of serum uric acid Table 1. Table 1 Laboratory test values during outpatient follow-up 1 st collection.

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    International Business Review, 21 5 , Journal of Management, 38 4 , Determinants of corporate social responsibility CSR disclosure in developed and developing countries: A literature review. Corporate Social Responsibility and Environmental Management, 24 4 , Competitiveness of firms: review of theory, frameworks, and models. Singapore Management Review, 26 1 , From issues to actions: The importance of individual concerns and organizational values in responding to natural environmental issues.

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    Multinational Business Review, 22 1 , Centenaro, A. Chen, P. Understanding the relationships between environmental management practices and financial performances of multinational construction firms. Journal of Cleaner Production, , The influence of CSR, innovation and supply chain partnership on firm competitiveness. Journal of Management Studies, 47 8 , Location strategies of multinationals from emerging countries in the EU regions. A set of motives to unite them all? Revisiting the principles and typology of internationalization motives. The Multinational Business Review, 23 1 , Do environmental management systems improve business performance in an international setting? Journal of International Management, 14 4 , The case for and against business assumption of social responsibilities. Academy of Management Journal, 16 2 , CSR strategy in multinational firms: focus on human resources, suppliers and community. Dunning, J.

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    Journal of International Business Studies, 40 1 , Journal of Business Ethics, 2 , Management Research Review, 39 11 , Fleury, A. International Journal of Production Research, 53 18 , Gasparini, C. Global value chain analysis: A primer. Gereffi, G. The governance of global value chains. Review of International Political Economy, 12 1 , Choosing the right green-marketing strategy. Global Reporting Initiative. G4 Sustainability Reporting Guidelines. Amsterdam: GRI. Corporate Social Responsibility and Environmental Management, 17 4 , Gomes, C. Environmental proactivity and business performance: An empirical analysis. Omega, 33 1 , Gugler, P. Corporate social responsibility for developing country multinational corporations: Lost war in pertaining global competitiveness? Journal of Business Ethics, 87, The Academy of Management Perspectives, 23 2 , Haguenauer, L. Hamel, G. Strategic intent. Harvard Business Review, 3, Corporate governance and CSR nexus.

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    Journal of Business Ethics, 1 , Hart, S. A natural-resource-based view of the firm. Academy of Management Review, 20 4 , Does it pay to be green? An empirical examination of the relationship between emission reduction and firm performance. Business Strategy and the Environment, 5 1 , Invited editorial: A natural-resource-based view of the firm: Fifteen years after. Journal of Management, 37 5 , RAE Executivo, 3 2 , Henderson, J. Global production networks and the analysis of economic development. Hennart, J. Openness, international champions, and the internationalization of Multilatinas. Journal of World Business, 52 4 , Herzfeld, T. Cross-national adoption of private food quality standards.

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    Food Policy, 36 3 , Hsueh, C. Improving corporate social responsibility in a supply chain through a new revenue sharing contract. International Journal of Production Economics, , Humphrey, J. Governance and upgrading: Linking industrial cluster and global value chain research. Brighton: IDS. Governance in global value chains. Governance choices for corporate social responsibility: To contribute, collaborate or internalize?

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    Fax: 55 51 E-mail: moc. This is an open-access article fleury resultado de exame under the terms of the Creative Commons Attribution License This article has been cited by other articles in PMC. In such a potentially hostile environment, sleep is extremely fragmented and sleep architecture is unconventional, with a predominance of superficial sleep stages and a limited amount of time spent in the restorative stages. Among the causes of sleep disruption in the ICU are factors intrinsic to the patients and the acute nature of their condition, as well as dxame related to the ICU environment and the treatments administered, such as mechanical ventilation and drug therapy.

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    Although the consequences of poor sleep quality for the recovery of ICU patients remain unknown, it seems to influence the immune, metabolic, cardiovascular, respiratory, and neurological systems. There is evidence that multifaceted interventions focused on minimizing nocturnal sleep disruptions improve sleep quality in ICU patients. In this article, we review the literature regarding normal sleep and sleep in the ICU. We also analyze sleep assessment fleury resultado de exame the causes of poor sleep quality resulfado its potential implications for the recovery fesultado of critically ill patients; and strategies for sleep promotion. As a result, physical and technical aspects of patient care are given priority, whereas some humanizing aspects of care can be overlooked. The sleep of critically ill patients is a subject of increasing interest in fleury resultado de exame literature, and there is evidence that sleep in the ICU is poor in quality.

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    The sleep-wake cycle tends to be synchronized with the h cycle through environmental stimuli and, predominantly, by exposure to light. The secretion of melatonin, a hormone involved in the regulation of the fleuey cycle, is regulated by the circadian cycle. In order to promote nighttime sleep, the secretion of melatonin is maximal at night, when there is no light. Homeostatic mechanisms also affect the sleep-wake cycle, and their functioning is similar to that of the thirst mechanism: longer periods of sleeplessness translate to greater sleepiness. This underscores the need for sleep, regardless of environmental stimuli. Additional channels are available to record other parameters, such as body position, esophageal pressure, snoring, and additional EEG derivations. Staging of sleep is based on brain wave patterns, chin muscle activity, and EOG. These variables are analyzed in s time segments, known as "epochs". Portable systems encompass a range of sleep-assessment devices with different levels of complexity.

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