#lm 3.1.1

[cliozaur]

"Paris has a child, and the forest has a bird; the bird is called the sparrow; the child is called the gamin."

Yay! We've reached my favourite volume - Volume III!

Gavroche by Victor Hugo

[lesmisletters]

Congratulations, Les Mis Letters readers, on finishing Volume 2: Cosette! 🎊

A wild journey from Waterloo, to the ship Orion, to Montfermil, to the Gorbeau House in Paris, and finally to the Petit Picpus convent and a wacky coffin heist.

On to Volume 3!

[the-wraxall-illustrations]

[dolphin1812]

The worst part about today’s chapter is that every time Hugo talks about how Paris adopts gamins (children who can’t rely on their families due to abuse, neglect, poverty, etc), I remember that Enjolras will say that Rousseau abandoned his children but “he adopted the people,” and I think about how Paris is Rousseau’s opposite in this

[gavroche-le-moineau]

We've reached the chapter with my blog's namesake! I love this digression so much. What a wonderful way to introduce us to a city at a certain time period, to characterize it by its street urchins, those who perhaps know the city best and are of such a particular time and place.

“Paris a un enfant et la forêt a un oiseau ; l’oiseau s’appelle le moineau ; l’enfant s’appelle le gamin.” ... “Si l’on demandait à l’énorme ville : Qu’est-ce que c’est que cela ? elle répondrait : C’est mon petit.” ~ “Paris has a child, and the forest has a bird; the bird is called the sparrow; the child is called the gamin.” ... “If one were to ask that enormous city: 'What is that?' she would reply: 'That's my little one.'”

[alicedrawslesmis]

'If one were to ask that enormous city: “What is this?” she would reply: “It is my little one.”' - LM 3.1.1

One: so... what the hell is that?

Paris:

[everyonewasabird]

Brickclub 3.1.1 ‘Parvulus’

We begin a new tome and a new digression, this one on the Gamin.

Hugo describes the gamin as having arisen like a spark out of nothing but the city. Oddly, we’ve talked about spontaneous generation before in this text--or rather, the Straw Atheist Senator lectured Myriel about it once:

Voltaire mocked Needham, and he was wrong; for Needham’s eels prove that God is unnecessary. A drop of vinegar in a spoonful of dough supplied the fiat lux. Imagine the drop greater and the spoonful larger, and you have the world. Man is the eel.

@meta-squash wrote a really helpful explanation of wtf that all means here.

In the gamin’s case, it’s metaphorical in the literal sense--Gavroche, for instance, has a mundanely horrible backstory--but spiritually it’s true. The fact that Gavroche is whole and sound and alive owes a lot more to Paris than his parents. And the fact that he has any moral sense or capacity for affection or joy certainly didn’t come from the Thenardiers.

But it’s really interesting that we’re invoking an atheist’s sense of where life comes from here? We spent the last section going deep into Catholicism, and wherever we are, it’s sure not Catholicism anymore. Yet, true to the rest of this book, God, is far from unnecessary here: we don’t know what role God took in the spontaneous generation of the Gamin, but we're told it’s God’s will that children be innocent, no matter their surroundings or origins.

The God who imparts the divine spark to children who arise out of nothing and live like sparrows feels far closer to the God of this book than anything in the convent did.

[fremedon]

Brickclub 3.1.1, “Parvulus”

And we’re into Tome 3, Marius! Which begins, as the last two books did, with a digression: Book 1, “Paris Atomized,” introduces us to Paris from ground level, and via the study of its smallest component, the gamin.

It’s also our introduction to Gavroche, though he doesn’t come in until the end of “Paris Atomized.” Hugo likes to introduce characters by first sketching a type, and then relating them to it--he does this with the Thénardiers, with Gillenormand, with some of the students, and with a ton of the minor characters, as with the scathing sketch of the provincial dandy that suffices to introduce Bamatabois; I don’t think he does it for anyone else at quite the length he does here. Which fits, since Gavroche is the perfect type specimen of a type that’s going to be half-metaphorical by the time Hugo is done introducing them--the genius loci of Paris.

In a very non-metaphorical way, the gamin is the city’s own offspring: “If one asked this vast city, ‘What is this creature?’ it would answer, ‘It is my cub.’” Like Fantine and Feuilly, children sprung from The People, the gamin has no caretaker but the city itself; when we meet Gavroche in a few chapters, we will learn that “He was one of those children, most deserving of all of pity, who have both father and mother and yet are orphans.”

The number of other major characters in this book whose parents are The People or The City is really making me want to interpret Enjolras’s “My mother is the republic” completely literally.

Fursona watch: the gamin is associated with the fly and, especially, the sparrow. The sparrow is the one Hugo will keep coming back to, even in the refrain of Gavroche’s last song--Je suis petit oiseau / C’est la faute à Rousseau.

[cliozaur]

- Twelve more digression chapters, and we’ll get to Marius!

- Parvulus – the “little one” from the last sentence of the chapter, represents a homeless child, a gamin. This child is gender-specific, always referred to as “he” (but I suspect that in the spirit of time, this “he” stands for street girls as well). And of course, we know that this is an introduction to Gavroche. Only here, Hugo emphasizes that there are hundreds of such Gavroches, aged 7 to 13, on the streets of Paris.

- I don’t know why this depiction of a street child had to be so optimistic and cheerful. And why the depiction of Paris as a mother had to be so benevolent. For we know (and will further learn from the Brick) about the stories of abuse and children who were not able to adapt.

- I enjoyed parallels with animals: the gamin is like a sparrow and like… a fly.

- The motif of child’s innocence reappears: similar to Cosette who maintained her innocence despite her abusive environment, the gamins also possess this innocence as “pearls” in their hearts, that “are not to be dissolved in mud” (again, I find it overly optimistic).

[the-wraxall-illustrations]

[dolphin1812]

We’ve reached volume III!

Tonally, the beginning of this digression feels very distinct from what we’d expect. Gamins are children who have nothing, and based on Cosette, what we should want most for these children is a safe, loving home with adults who care for them, because the deprivation they face is a cruel product of social ills. Here, however, we get this:

“Paris has a child, and the forest has a bird; the bird is called the sparrow; the child is called the gamin.”

We repeat the link between children and birds (Cosette the lark, the gamin the sparrow), but in this case, the connection suggests that gamins are part of the “natural” environment of Paris. In the same way birds are part of a forest, gamins are part of Paris. They’re portrayed as “joyous” and deeply involved in Paris’ most famous features, particularly the theater (“he goes to the play every evening, if he sees good”). In addition to being happy, they’re “innocent” because they’re children, with their love of swears and obscenities being part of their entertainment and general irreverence more than anything else. As Paris’ children, it’s likely that the city herself shares their traits: she loves fun, doesn’t fully respect societal norms and is willing to challenge them, and manages to thrive in spite of poverty.

Even though the descriptions of the gamin are mostly positive, gamins are still impoverished children. They don’t eat every day, they have no consistent shelter, and they don’t have enough clothes. Neglect or the complete loss of their parents is inherent to their existence, with their families being so scattered that Hugo describes their clothes like this:

“He is from seven to thirteen years of age, he lives in bands, roams the streets, lodges in the open air, wears an old pair of trousers of his father’s, which descend below his heels, an old hat of some other father, which descends below his ears, a single suspender of yellow listing”

“His father” and “some other father” are equated through the same structure (“an old…”), suggesting that to the gamin, they’re basically the same. Paris is their family not only in the sense that they represent her, but in that they operate outside of the family structure held up as the norm. The fact that Hugo repeats “old” to describe their clothing also underscores that even the clothes they do have are likely worn down, which must make inclement weather (particularly rain, snow, and the general cold of winter) difficult. 7-13 is also a small age range, leading us to wonder how younger children cope with this same poverty and what happens to children who “age out” of being a gamin. As a symbol of Paris, then, the gamin also points out how flawed the city must be to have so many children abandoned on the streets, living without basic necessities.

[gpllife]

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[latestmarketresearch]

Global Teeth Whitening Products Market 2020 with Emerging Trends & Forecast To 2028

Apr 21, 2020: The global Teeth Whitening Products market was valued at $XX million in 2018, and Radiant Research analysts predict the global market size will reach $XX million by the end of 2028, growing at a CAGR of XX% between 2018 and 2028.

This report provides detailed historical analysis of global market for Teeth Whitening Products from 2013-2018, and provides extensive market forecasts from 2019-2028 by region/country and subsectors. It covers the sales volume, price, revenue, gross margin, historical growth and future perspectives in the Teeth Whitening Products market.

To Request A Sample Copy Of This Report @:   https://www.radiantinsights.com/research/2013-2028-report-on-global-teeth-whitening-products-market/request-sample

Leading players of Teeth Whitening Products including:

·         P&G

·         Colgate Palmolive

·         Unilever

·         Johnson & Johnson

·         GSK

·         Church &Dwight

·         Henkel

·         Lion

·         Ultradent Products

·         Trident Gum

·         Wrigley

·         Peelu

·         KoR Whitening

·         Hawley & Hazel Chemical

·         YUNAN BAIYAO

·         Beyond

·         Philips

·         Dentsply

·         DenMat

·         WOODPECKER

·         LM

·         Golden Eagles

·         Poseida

·         W&H

·         NSK

·         EMS

·         Dentamerica

·         LUSTER

·         Pac-Dent

Market split by Type, can be divided into:

·         Surface Whiteners

·         Bleaches

Market split by Application, can be divided into:

·         Professionally Applied

·         Consumer Applied

Market split by Sales Channel, can be divided into:

·         Direct Channel

·         Distribution Channel

Market segment by Region/Country including:

·         North America (United States, Canada and Mexico)

·         Europe (Germany, UK, France, Italy, Russia and Spain etc.)

·         Asia-Pacific (China, Japan, Korea, India, Australia and Southeast Asia etc.)

·         South America Brazil, Argentina, Colombia and Chile etc.)

·         Middle East & Africa (South Africa, Egypt, Nigeria and Saudi Arabia etc.)

To Browse Full Research Report @: https://www.radiantinsights.com/research/2013-2028-report-on-global-teeth-whitening-products-market

Table of Contents

Chapter 1 Teeth Whitening Products Market Overview

1.1 Teeth Whitening Products Definition

1.2 Global Teeth Whitening Products Market Size Status and Outlook (2013-2028)

1.3 Global Teeth Whitening Products Market Size Comparison by Region (2013-2028)

1.4 Global Teeth Whitening Products Market Size Comparison by Type (2013-2028)

1.5 Global Teeth Whitening Products Market Size Comparison by Application (2013-2028)

1.6 Global Teeth Whitening Products Market Size Comparison by Sales Channel (2013-2028)

1.7 Teeth Whitening Products Market Dynamics

1.7.1 Market Drivers/Opportunities

1.7.2 Market Challenges/Risks

1.7.3 Market News (Mergers/Acquisitions/ Expansion)

Chapter 2 Teeth Whitening Products Market Segment Analysis by Player

2.1 Global Teeth Whitening Products Sales and Market Share by Player (2016-2018)

2.2 Global Teeth Whitening Products Revenue and Market Share by Player (2016-2018)

2.3 Global Teeth Whitening Products Average Price by Player (2016-2018)

2.4 Players Competition Situation & Trends

2.5 Conclusion of Segment by Player

Chapter 3 Teeth Whitening Products Market Segment Analysis by Type

3.1 Global Teeth Whitening Products Market by Type

3.1.1 Surface Whiteners

3.1.2 Bleaches

3.2 Global Teeth Whitening Products Sales and Market Share by Type (2013-2018)

3.3 Global Teeth Whitening Products Revenue and Market Share by Type (2013-2018)

3.4 Global Teeth Whitening Products Average Price by Type (2013-2018)

3.5 Leading Players of Teeth Whitening Products by Type in 2018

3.6 Conclusion of Segment by Type

Chapter 4 Teeth Whitening Products Market Segment Analysis by Application

4.1 Global Teeth Whitening Products Market by Application

4.1.1 Professionally Applied

4.1.2 Consumer Applied

4.2 Global Teeth Whitening Products Sales and Market Share by Application (2013-2018)

4.3 Leading Consumers of Teeth Whitening Products by Application in 2018

4.4 Conclusion of Segment by Application

Continued………….

To See More Reports of This Category by Radiant Insights: https://latestmarkettrends.news.blog

About Radiant Insights: Radiant Insights is a platform for companies looking to meet their market research and business intelligence requirements. It assist and facilitate organizations and individuals procure market research reports, helping them in the decision making process. The Organization has a comprehensive collection of reports, covering over 40 key industries and a host of micro markets. In addition to over extensive database of reports, experienced research coordinators also offer a host of ancillary services such as, research partnerships/ tie-ups and customized research solutions.

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[marketnewsandtrends-blog]

Global E-learning Software Market 2018 – Industry Trend, Research, Insights and Forecast 2025

10-dec-2018 In 2017, the global E-learning Software market size was million US$ and it is expected to reach million US$ by the end of 2025, with a CAGR of during 2018-2025. This report focuses on the global E-learning Software status, future forecast, growth opportunity, key market and key players. The study objectives are to present the E-learning Software development in United States, Europe and China. The key players covered in this study • IBM • SAP • Net Dimensions • Citrix • Upside learning • Litmos • iSpring Solutions • Versal • Docebo • Absorb • Traineaze • Mindflash Technologies • SkyPrep • Accord LMS • Adobe • Configio Market segment by Type, the product can be split into • Mobile Content Authoring • E-books • Portable LMS • Mobile and Video-based Courseware • Interactive Assessments • Content Development • M-Enablement Request a Sample Copy of This Report: https://www.radiantinsights.com/research/global-e-learning-software-market-size-status-and-forecast-2018-2025/request-sample Market segment by Application, split into • BFSI • Healthcare • Government • Professional Services • Telecom and IT • Other Market segment by Regions/Countries, this report covers • United States • Europe • China • Japan • Southeast Asia • India • Central & South America The study objectives of this report are: • To analyze global E-learning Software status, future forecast, growth opportunity, key market and key players. • To present the E-learning Software development in United States, Europe and China. • To strategically profile the key players and comprehensively analyze their development plan and strategies. • To define, describe and forecast the market by product type, market and key regions. In this study, the years considered to estimate the market size of E-learning Software are as follows: • History Year: 2013-2017 • Base Year: 2017 • Estimated Year: 2018 • Forecast Year 2018 to Table of Contents 1 Report Overview 1.1 Study Scope 1.2 Key Market Segments 1.3 Players Covered 1.4 Market Analysis by Type 1.4.1 Global E-learning Software Market Size Growth Rate by Type (2013-2025) 1.4.2 Mobile Content Authoring 1.4.3 E-books 1.4.4 Portable LMS 1.4.5 Mobile and Video-based Courseware 1.4.6 Interactive Assessments 1.4.7 Content Development 1.4.8 M-Enablement 1.5 Market by Application 1.5.1 Global E-learning Software Market Share by Application (2013-2025) 1.5.2 BFSI 1.5.3 Healthcare 1.5.4 Government 1.5.5 Professional Services 1.5.6 Telecom and IT 1.5.7 Other 1.6 Study Objectives 1.7 Years Considered 2 Global Growth Trends 2.1 E-learning Software Market Size 2.2 E-learning Software Growth Trends by Regions 2.2.1 E-learning Software Market Size by Regions (2013-2025) 2.2.2 E-learning Software Market Share by Regions (2013-2018) 2.3 Industry Trends 2.3.1 Market Top Trends 2.3.2 Market Drivers 2.3.3 Market Opportunities Browse Full Research Report With TOC: https://www.radiantinsights.com/research/global-e-learning-software-market-size-status-and-forecast-2018-2025 3 Market Share by Key Players 3.1 E-learning Software Market Size by Manufacturers 3.1.1 Global E-learning Software Revenue by Manufacturers (2013-2018) 3.1.2 Global E-learning Software Revenue Market Share by Manufacturers (2013-2018) 3.1.3 Global E-learning Software Market Concentration Ratio (CR5 and HHI) 3.2 E-learning Software Key Players Head office and Area Served 3.3 Key Players E-learning Software Product/Solution/Service 3.4 Date of Enter into E-learning Software Market 3.5 Mergers & Acquisitions, Expansion Plans For the data information by region, company, type and application, 2017 is considered as the base year. Whenever data information was unavailable for the base year, the prior year has been considered.

[mellowgardencreation]

Wind Turbine Blade Market 2018 Industry Trends, Sales, Supply, Demand, Analysis & Forecasts to 2022

WiseGuyRerports.com Presents “Global Wind Turbine Blade Market Report 2017” New Document to its Studies Database

With the slowdown in world economic growth, the Wind Turbine Blade industry has also suffered a certain impact, but still maintained a relatively optimistic growth. The past four years, Wind Turbine Blade market size maintained the average annual growth rate of 12.47% from 6220 million $ in 2013 to 8850 million $ in 2016. Analysts believe that in the next few years, Wind Turbine Blade market size will be further expanded, we expect that by 2021, the market size of the Wind Turbine Blade will reach 11980 million $. This Report covers the manufacturers’ data, including: shipment, price, revenue, gross profit, interview record, business distribution etc., these data help the consumer know about the competitors better. This report also covers all the regions and countries of the world, which shows a regional development status, including market size, volume and value, as well as price data. Besides, the report also covers segment data, including: type segment, industry segment, channel segment etc. cover different segment market size, both volume and value. Also cover different industries clients information, which is very important for the manufacturers.

Section 1: Free——Definition

Section (2 3): 1200 USD——Manufacturer Detail LM Wind Power Vestas Enercon Tecsis Gamesa Suzlon TPI Composites Siemens GE Wind CARBON ROTEC Acciona Inox Wind Zhongfu Lianzhong Avic Sinoma TMT New United United Power Mingyang XEMC New Energy DEC Haizhuang Windpower Wanyuan CSR SANY

Request For Sample Report @ https://www.wiseguyreports.com/sample-request/2381595-global-wind-turbine-blade-market-report-2017                          

Section 4: 900 USD——Region Segmentation North America Country (United States, Canada) South America Asia Country (China, Japan, India, Korea) Europe Country (Germany, UK, France, Italy) Other Country (Middle East, Africa, GCC)

Section (5 6 7): 500 USD—— Product Type Segmentation (< 2.0 MW, 2.0-3.0 MW, 3.0 MW, 3.0-5.0 MW, ≥5.0 MW) Industry Segmentation () Channel (Direct Sales, Distributor) Segmentation

Section 8: 400 USD——Trend (2017-2021)

Section 9: 300 USD——Product Type Detail

Section 10: 700 USD——Downstream Consumer

Section 11: 200 USD——Cost Structure

Section 12: 500 USD——Conclusion

Complete Report Details @ https://www.wiseguyreports.com/reports/2381595-global-wind-turbine-blade-market-report-2017                  

Table Of Contents:      

Section 1 Wind Turbine Blade Product Definition

Section 2 Global Wind Turbine Blade Market Manufacturer Share and Market Overview     2.1 Global Manufacturer Wind Turbine Blade Shipments     2.2 Global Manufacturer Wind Turbine Blade Business Revenue     2.3 Global Wind Turbine Blade Market Overview

Section 3 Manufacturer Wind Turbine Blade Business Introduction     3.1 LM Wind Power Wind Turbine Blade Business Introduction       3.1.1 LM Wind Power Wind Turbine Blade Shipments, Price, Revenue and Gross profit 2013-2016       3.1.2 LM Wind Power Wind Turbine Blade Business Distribution by Region       3.1.3 LM Wind Power Interview Record       3.1.4 LM Wind Power Wind Turbine Blade Business Profile       3.1.5 LM Wind Power Wind Turbine Blade Product Specification

   3.2 Vestas Wind Turbine Blade Business Introduction       3.2.1 Vestas Wind Turbine Blade Shipments, Price, Revenue and Gross profit 2013-2016       3.2.2 Vestas Wind Turbine Blade Business Distribution by Region       3.2.3 Interview Record       3.2.4 Vestas Wind Turbine Blade Business Overview       3.2.5 Vestas Wind Turbine Blade Product Specification

   3.3 Enercon Wind Turbine Blade Business Introduction       3.3.1 Enercon Wind Turbine Blade Shipments, Price, Revenue and Gross profit 2013-2016       3.3.2 Enercon Wind Turbine Blade Business Distribution by Region       3.3.3 Interview Record       3.3.4 Enercon Wind Turbine Blade Business Overview       3.3.5 Enercon Wind Turbine Blade Product Specification

   3.4 Tecsis Wind Turbine Blade Business Introduction     3.5 Gamesa Wind Turbine Blade Business Introduction     3.6 Suzlon Wind Turbine Blade Business Introduction …

Section 4 Global Wind Turbine Blade Market Segmentation (Region Level)     4.1 North America Country       4.1.1 United States Wind Turbine Blade Market Size and Price Analysis 2013-2016       4.1.2 Canada Wind Turbine Blade Market Size and Price Analysis 2013-2016     4.2 South America Country       4.2.1 South America Wind Turbine Blade Market Size and Price Analysis 2013-2016     4.3 Asia Country       4.3.1 China Wind Turbine Blade Market Size and Price Analysis 2013-2016       4.3.2 Japan Wind Turbine Blade Market Size and Price Analysis 2013-2016       4.3.3 India Wind Turbine Blade Market Size and Price Analysis 2013-2016       4.3.4 Korea Wind Turbine Blade Market Size and Price Analysis 2013-2016

Continued…….                                                      

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CHẨN ĐOÁN VÀ ĐIỀU TRỊ VIÊM QUANH KHỚP VAI (Periarthritis humeroscapularis)

1. ĐẠI CƯƠNG Viêm quanh khớp vai (Periarthritis humeroscapularis) là thuật ngữ dùng chung cho các bệnh lý viêm các cấu trúc phần mềm quanh khớp vai: gân, túi thanh dịch, bao khớp; không bao gồm các bệnh lý có tổn thương đầu xương, sụn khớp và màng hoạt dịch như viêm khớp nhiễm khuẩn, viêm khớp dạng thấp… Theo Welfling (1981) có bốn thể lâm sàng của viêm quanh khớp vai: − Đau vai đơn thuần thường do bệnh lý gân. − Đau vai cấp do lắng đọng vi tinh thể. − Giả liệt khớp vai do đứt các gân của bó dài gân nhị đầu hoặc đứt các gân mũ cơ quay khiến cơ delta không hoạt động được. − Cứng khớp vai do viêm dính bao hoạt dịch, co thắt bao khớp, bao khớp dày, dẫn đến giảm vận động khớp ổ chảo - xương cánh tay. 2. NGUYÊN NHÂN − Thoái hóa gân do tuổi tác: Bệnh thường xảy ra ở người trên 50 tuổi. − Nghề nghiệp lao động nặng có các chấn thương cơ học lặp đi lặp lại, gây tổn thương các gân cơ quanh khớp vai như gân cơ trên gai, cơ nhị đầu cánh tay. − Tập thể thao quá sức, chơi một số môn thể thao đòi hỏi phải nhấc tay lên quá vai như chơi cầu lông, tennis, bóng rổ, bóng chuyền. − Chấn thương vùng vai do ngã, trượt, tai nạn ô tô, xe máy. − Một số bệnh lý khác (tim mạch, hô hấp, tiểu đường, ung thư vú, thần kinh, lạm dụng thuốc ngủ). 3. CHẨN ĐOÁN 3.1. Lâm sàng 3.1.1. Đau khớp vai đơn thuần (viêm gân mạn tính) Đau vùng khớp vai thường xuất hiện sau vận động khớp vai quá mức, hoặc sau những vi chấn thương liên tiếp ở khớp vai. Đau kiểu cơ học. Đau tăng khi làm các động tác co cánh tay đối kháng. Ít hạn chế vận động khớp. Thường gặp tổn thương gân cơ nhị đầu và gân cơ trên gai. Thường có điểm đau chói khi ấn tại điểm bám tận gân bó dài của gân cơ nhị đầu cánh tay (mặt trước của khớp vai, dưới mỏm quạ 1cm) hoặc gân trên gai (mỏm cùng vai). HƯỚNG DẪN CHẨN ĐOÁN VÀ ĐIỀU TRỊ CÁC BỆNH CƠ XƯƠNG KHỚP 155 3.1.2. Đau vai cấp (viêm khớp vi tinh thể) Đau vai xuất hiện đột ngột với các tính chất dữ dội, đau gây mất ngủ, đau lan toàn bộ vai, lan lên cổ, lan xuống tay, đôi khi xuống tận bàn tay. Bệnh nhân giảm vận động khớp vai nhiều thường có tư thế cánh tay sát vào thân, không thực hiện được các động tác vận động thụ động khớp vai, đặc biệt là động tác giạng (giả cứng khớp vai do đau). Vai sưng to nóng. Có thể thấy khối sưng bùng nhùng ở trước cánh tay tương ứng với túi thanh mạc bị viêm. Có thể có sốt nhẹ. 3.1.3. Giả liệt khớp vai (đứt mũ gân cơ quay) Đau dữ dội kèm theo tiếng kêu răng rắc, có thể xuất hiện đám bầm tím ở phần trước trên cánh tay sau đó vài ngày. Đau kết hợp với hạn chế vận động rõ. Khám thấy mất động tác nâng vai chủ động, trong khi vận động thụ động hoàn toàn bình thường, không có các dấu hiệu thần kinh. Nếu đứt bó dài gân nhị đầu khám thấy phần đứt cơ ở trước dưới cánh tay khi gấp có đối kháng cẳng tay. 3.1.4. Cứng khớp vai (đông cứng khớp vai) Đau khớp vai kiểu cơ học, đôi khi đau về đêm. Khám: hạn chế vận động khớp vai cả động tác chủ động và thụ động. Hạn chế các động tác, đặc biệt là động tác giạng và quay ngoài. Khi quan sát bệnh nhân từ phía sau, lúc bệnh nhân giơ tay lên sẽ thấy xương bả vai di chuyển cùng một khối với xương cánh tay. 3.2. Cận lâm sàng 3.2.1. Xét nghiệm máu Các xét nghiệm máu về hội chứng viêm sinh học thường âm tính. 3.2.2. Chẩn đoán hình ảnh − Đau khớp vai đơn thuần (viêm gân mạn tính): + Hình ảnh Xquang bình thường, có thể thấy hình ảnh calci hóa tại gân. + Siêu âm: Hình ảnh gân giảm âm hơn bình thường. Nếu gân bị vôi hóa sẽ thấy nốt tăng âm kèm bóng cản. Có thể thấy dịch quanh bao gân nhị đầu. Trên Doppler năng lượng thấy hình ảnh tăng sinh mạch trong gân hoặc bao gân. − Đau vai cấp (viêm khớp vi tinh thể): + Xquang: Thường thấy hình ảnh calci hóa kích thước khác nhau ở khoảng cùng vai - mấu động. Các calci hóa này có thể biến mất sau vài ngày. + Siêu âm: Có hình ảnh các nốt tăng âm kèm bóng cản (calci hóa) ở gân và bao thanh dịch dưới mỏm cùng vai, có thể có dịch (cấu trúc trống âm) ở bao thanh dịch dưới mỏm cùng vai. Trên Doppler năng lượng có hình ảnh tăng sinh mạch trong gân, bao gân, hoặc bao thanh dịch. − Giả liệt khớp vai (đứt gân mũ cơ quay): + Xquang: Chụp khớp vai cản quang phát hiện đứt các gân mũ cơ quay do thấy hình cản quang của túi thanh mạc dưới mỏm cùng cơ delta, chứng tỏ sự thông thương HƯỚNG DẪN CHẨN ĐOÁN VÀ ĐIỀU TRỊ CÁC BỆNH CƠ XƯƠNG KHỚP 156 giữa khoang khớp và túi thanh mạc. Gần đây thường phát hiện tình trạng đứt gân trên cộng hưởng từ. + Siêu âm: Đứt gân nhị đầu, không thấy hình ảnh gân nhị đầu ở hố liên mấu động hoặc phía trong hố liên mấu động; có thể thấy hình ảnh tụ máu trong cơ mặt trước cánh tay. Nếu đứt gân trên gai thấy gân mất tính liên tục, co rút hai đầu gân đứt. Thường có dịch ở vị trí đứt. − Cứng khớp vai (đông cứng khớp vai): − Xquang: Chụp khớp với thuốc cản quang, khó khăn khi bơm thuốc. Hình ảnh cho thấy khoang khớp bị thu hẹp (chỉ 5-10ml trong khi bình thường 30-35ml); giảm cản quang khớp, các túi cùng màng hoạt dịch biến mất. Đây là phương pháp vừa chẩn đoán vừa điều trị: bơm thuốc có tác dụng nong rộng khoang khớp, sau thủ thuật bệnh nhân vận động dễ dàng hơn. 3.3. Chẩn đoán xác định Dựa vào các triệu chứng lâm sàng và cận lâm sang. 3.4. Phân loại các thể lâm sàng Theo Welfling (1981) có bốn thể lâm sàng của viêm quanh khớp vai: − Đau vai đơn thuần − Đau vai cấp − Giả liệt khớp vai − Cứng khớp vai 3.5. Chẩn đoán phân biệt − Đau vai do các nguyên nhân khác như đau thắt ngực, tổn thương đỉnh phổi, đau rễ cột sống cổ … − Bệnh lý xương: Hoại tử vô mạch đầu trên xương cánh tay. − Bệnh lý khớp: Viêm khớp mủ, viêm khớp do lao, viêm do tinh thể như gút hoặc calci hóa sụn khớp, viêm khớp dạng thấp, viêm cột sống dính khớp… 4. ĐIỀU TRỊ 4.1. Nguyên tắc chung Điều trị viêm quanh khớp vai bao gồm điều trị đợt cấp và điều trị duy trì. Cần kết hợp nhiều biện pháp khác nhau như nội khoa, ngoại khoa, vật lý trị liệu, phục hồi chức năng. 4.2. Điều trị cụ thể 4.2.1. Nội khoa − Thuốc giảm đau thông thường. Sử dụng thuốc theo bậc thang của Tổ chức Y tế Thế giới. Chọn một trong các thuốc sau: acetaminophen 0,5g x 2-4 viên /24h; acetaminophen kết hợp với codein hoặc tramadol 2-4 viên/ 24h. HƯỚNG DẪN CHẨN ĐOÁN VÀ ĐIỀU TRỊ CÁC BỆNH CƠ XƯƠNG KHỚP 157 − Thuốc chống viêm không steroid: Chỉ định một trong các thuốc sau: + Diclofenac 50mg x 2 viên/24h. + Piroxicam 20mg x 1 viên/24h. + Meloxicam 7,5mg x 1-2 viên/24h. + Celecoxib 200mg x 1 – 2 viên/24h. − Tiêm corticoid tại chỗ áp dụng cho thể viêm khớp vai đơn thuần. Thuốc tiêm tại chỗ (vào bao gân, bao thanh dịch dưới cơ delta) thường sử dụng là các muối của corticoid như methylprednisolon acetat 40mg; betamethason dipropionat 5mg hoặc betamethason sodium phosphat 2mg tiêm 1 lần duy nhất; sau 3-6 tháng có thể tiêm nhắc lại nếu bệnh nhân đau trở lại. Tránh tiêm corticoid ở bệnh nhân có đứt gân bán phần do thoái hóa. Tiêm corticoid ở bệnh nhân này có thể dẫn đến hoại tử gân và gây đứt gân hoàn toàn. Nên tiêm dưới hướng dẫn của siêu âm. − Nhóm thuốc chống thoái hóa khớp tác dụng chậm: + Glucosamin sulfat: 1500mg x 1gói/24h. + Diacerein 50mg: 01-02 viên mỗi ngày. Có thể duy trì 3 tháng. − Có chế độ sinh hoạt vận động hợp lý. Trong giai đoạn đau vai cấp tính cần phải để cho vai được nghỉ ngơi. Sau khi điều trị có hiệu quả thì bắt đầu tập luyện để phục hồi chức năng khớp vai, đặc biệt thể đông cứng khớp vai. Tránh lao động quá mức trong thời gian dài, tránh các động tác dạng quá mức hay nâng tay lên cao quá vai. + Nội soi ổ khớp lấy các tinh thể calci lắng đọng. − Tiêm huyết tương giàu tiểu cầu tự thân áp dụng cho các thể đứt bán phần các gân mũ cơ quay do chấn thương ở bệnh nhân 60 tuổi), đứt gân do thoái hóa, chỉ định ngoại khoa cần thận trọng. − Cần tái khám định kỳ sau 1-3 tháng, tùy theo tình trạng bệnh. Có thể siêu âm khớp vai để kiểm tra tình trạng của gân, bao gân và khớp vai. 5. TIẾN TRIỂN VÀ BIẾN CHỨNG Đối với thể đau vai đơn thuần và đau vai cấp nếu không được chẩn đoán và điều trị sớm sẽ dẫn đến tình trạng đau dai dẳng và hạn chế vận động khớp vai, ảnh hưởng nhiều đến chất lượng cuộc sống của người bệnh và theo thời gian sẽ dẫn đến viêm quanh khớp vai thể đông cứng hoặc đứt gân. 6. PHÒNG BỆNH − Tránh lao động quá mức, tránh các động tác dạng quá mức hay nâng tay lên cao quá vai. HƯỚNG DẪN CHẨN ĐOÁN VÀ ĐIỀU TRỊ CÁC BỆNH CƠ XƯƠNG KHỚP 158 − Tránh các chấn thương ở vùng khớp vai. − Phát hiện và điều trị sớm các trường hợp đau vai đơn thuần và đau vai cấp. TÀI LIỆU THAM KHẢO 1. Trần Ngọc Ân; “Viêm quanh khớp vai”; Bệnh thấp khớp, Nhà xuất bản Y học 2002; trang 364- 374. 2. De Winter. AF, Jans MP, Scholten .RJ, Deville. W, van Schaardenburg. D, Bouter .LM; “Diagnostic classification of shoulder disorders: interobserver agreement and determinants of disagreement”; Ann Rheum Dis, 1999 ; p58 : 272-7. 3. Ebenbichler . GR, Erdogmus.CB, Resch. KL, et coll; “Ultrasound therapy for calcific tendinitis of the shoulder”; N Eng J Med 340(20), 1999; p1533. 4. Hurt .G, Baker .CL Jr; “Calcific tendinitis of the shoulder”; Orthop Clin North Am. 2003;34(4); p567–75. 5. Jess D Salinas Jr, Jerrold N Rosenberg; “Corticosteroid Injections of Joints and Soft Tissues”; Emedicine Specialities-Physical Medicine and Rehabilitation, 2009. HƯỚNG DẪN CHẨN ĐOÁN VÀ ĐIỀU TRỊ CÁC BỆNH CƠ XƯƠNG KHỚP 159.Bài viếtCHẨN ĐOÁN VÀ ĐIỀU TRỊ VIÊM QUANH KHỚP VAI (Periarthritis humeroscapularis) xuất hiện lần đầu tại website http://khamgiodau.com