Remissão de úlcera de Martorell a partir de intervenção multidimensional de medicina do estilo de vida em portador de hipertensão refratária / Martorell ulcer remission following multidimensional lifestyle medicine intervention in patients with refractory hypertension

INTRODUÇÃO E/OU FUNDAMENTO: Em 1945 Martorell descreveu uma série de casos de úlceras supramaleolares dolorosas secundárias a arteriolosclerose subcutânea em hipertensos mal controlados. Estas úlceras hipertensivas (UH) acometem predominantemente a região laterodorsal do tornozelo, na ausência de doença arterial oclusiva periférica (DAOP), insuficiência venosa crônica ou outras vasculites. Afetam mais comumente mulheres entre 50 e 60 anos, são intensamente dolorosas e estão associadas a hipertensão arterial (HA) mal controlada. MÉTODOS: Relatamos o caso de um paciente de sexo masculino, 56 anos, negro, portador de obesidade grau 2 (peso 115 kg; IMC 37), acompanhado por HA primária refratária, que evoluiu com úlcera maleolar laterodorsal direita crônica e intensamente dolorosa. Apesar da prescrição de 7 classes de anti-hipertensivos (olmesartana, clortalidona, anlodipino, espironolactona, atenolol, hidralazina e clonidina), retornou com Monitorização Residencial da Pressão Arterial (MRPA) fora da meta (média: 146/88mmHg). Na ausência de diabetes, DAOP, insuficiência venosa e outras formas de vasculites, a úlcera foi caracterizada como hipertensiva. O paciente foi então submetido a intervenção comportamental multidimensional como parte de protocolo institucional de medicina do estilo de vida (MEV). O protocolo incluiu telemonitoramento da pressão arterial e da tomada da medicação, além da orientação alimentar e da promoção de atividade física e equilíbrio emocional assistidos via aplicativo gratuito. RESULTADOS: Após duas semanas, obteve-se controle da pressão arterial. Após 6 meses, o paciente apresentou perda de peso de 10 quilos e redução progressiva dos anti-hipertensivos (suspensas hidralazina e clonidina). Cursou com cicatrização completa da UH. Retornou às atividades físicas, manteve adesão ao tratamento e não apresentou recidiva da UH até o momento. CONCLUSÕES: A UH de Martorell é uma condição infrequente e não universalmente reconhecida como entidade clínica independente, não sendo mencionada nos principais textos de referência em HA. No entanto, as características clínicas e histopatológicas dos casos reportados na literatura parecem justificar o diagnóstico, que mais frequentemente é definido por dermatologistas e cirurgiões vasculares. O controle da HA é considerado fundamental para a remissão da úlcera, mas enfrenta o desafio da adesão do paciente ao tratamento. Este é o primeiro relato na literatura a reportar remissão da UH mediante intervenções não farmacológicas fundamentadas na MEV. Independentemente da etiologia, a MEV tem o potencial de atingir a causa primária e de ser benéfica para praticamente todas as formas de úlceras de membros inferiores. Intervenções de MEV deveriam integrar sistematicamente a abordagem terapêutica destes pacientes.

Anterior cingulate cortex neuro-metabolic changes underlying lithium-induced euthymia in bipolar depression: A longitudinal 1H-MRS study.

The diagnosis and treatment of bipolar depression (BDep) poses complex clinical challenges for psychiatry. Proton magnetic resonance spectroscopy (1H-MRS) is a useful imaging tool for investigating in vivo levels of brain neuro-metabolites, critical to understanding the process of mood dysregulation in Bipolar Disorder. Few studies have evaluated longitudinal clinical outcomes in BDep associated with 1H-MRS metabolic changes. This study aimed to longitudinally assess brain 1H-MRS metabolites in the anterior cingulate cortex (ACC) correlated with improvement in depression (from BDep to euthymia) after lithium treatment in BDep patients versus matched healthy controls (HC). Twenty-eight medication-free BDep patients and 28 HC, matched for age and gender, were included in this study. All subjects were submitted to a 3-Tesla brain 1H-MRS scan in the ACC using a single-voxel (8cm3) PRESS sequence at baseline. At follow-up (6 weeks), 14 BDep patients repeated the exam in euthymia. Patients with current BDep had higher baseline Myo-inositol/Cr (mI/Cr) and Choline/Cr (Cho/Cr) compared to HC. After six weeks, mI/Cr or Cho/Cr levels in subjects that achieved euthymia no longer differed to levels in HC, while high Cho/Cr levels persisted in non-responders . Elevated ACC mI/Cr and Cho/Cr in BDep might indicate increased abnormal membrane phospholipid metabolism and phosphatidylinositol (PI) cycle activity. Return of mI/Cr and Cho/Cr to normal levels after lithium-induced euthymia suggests a critical regulatory effect of lithium targeting the PI cycle involved in mood regulation.

The CACNA1C risk allele rs1006737 is associated with age-related prefrontal cortical thinning in bipolar I disorder.

Calcium channels control the inflow of calcium ions into cells and are involved in diverse cellular functions. The CACNA1C gene polymorphism rs1006737 A allele has been strongly associated with increased risk for bipolar disorder (BD) and with modulation of brain morphology. The medial prefrontal cortex (mPFC) has been widely associated with mood regulation in BD, but the role of this CACNA1C polymorphism in mPFC morphology and brain aging has yet to be elucidated. One hundred seventeen euthymic BD type I subjects were genotyped for CACNA1C rs1006737 and underwent 3 T three-dimensional structural magnetic resonance imaging scans to determine cortical thickness of mPFC components (superior frontal cortex (sFC), medial orbitofrontal cortex (mOFC), caudal anterior cingulate cortex (cACC) and rostral anterior cingulate cortex (rACC)). Carriers of the CACNA1C allele A exhibited greater left mOFC thickness compared to non-carriers. Moreover, CACNA1C A carriers showed age-related cortical thinning of the left cACC, whereas among A non-carriers there was not an effect of age on left cACC cortical thinning. In the sFC, mOFC and rACC (left or right), a negative correlation was observed between age and cortical thickness, regardless of CACNA1C rs1006737 A status. Further studies investigating the direct link between cortical thickness, calcium channel function, apoptosis mechanism and their underlying relationship with aging-associated cognitive decline in BD are warranted.

Oxygen uptake, respiratory exchange ratio, or total distance: a comparison of methods to equalize exercise volume in Wistar rats.

This study compared strategies to equalize the volume of aerobic exercise performed with different intensities by Wistar rats, based on the distance covered during exercise bouts and energy expenditure (EE, isocaloric sessions) obtained from oxygen uptake (V̇O2) or respiratory exchange ratio (RER). Thirty-three male rats (270.5±12.8 g) underwent maximal exercise tests to determine V̇O2 reserve (V̇O2R), being randomly assigned to three groups: moderate-intensity continuous exercise at speed corresponding to 50% V̇O2R (MIC; n=11); high-intensity continuous exercise at 80% V̇O2R (HIC; n=11); and high-intensity intermittent exercise (HII; n=11) at 60% V̇O2R (3 min) and 80% V̇O2R (4 min). Exercise duration was calculated individually to elicit EE of 5 kcal in each session. No difference between groups was found for total running distance (MIC: 801±46, HIC: 734±42, HII: 885±64 m; P=0.13). Total EE measured by RER was systematically underestimated compared to values obtained from V̇O2 (HII: 4.5% and MIC: 6.2%, P<0.05). Total EE (calculated from V̇O2), and duration of HIC bouts (2.8 kcal and 30.8±2.2 min) were lower (P<0.0001) than in MIC (4.9 kcal and 64.7±1.8 min) and HII (4.7 kcal and 46.9±2.2 min). Predicted and actual values of total V̇O2, total EE, and duration of isocaloric sessions were similar in MIC and HII (P>0.05), which were both higher than in HIC (P<0.0001). In conclusion, the time to achieve a given EE in exercise bouts with different intensities did not correspond to the total distance. Therefore, the volume of aerobic exercise in protocols involving Wistar rats should be equalized using EE rather than total covered distance.

The influence of lithium on hippocampal volume in elderly bipolar patients: a study using voxel-based morphometry.

Recent studies have demonstrated that lithium (Li) exerts neuronal protective and regenerative effects both in vitro and in vivo. However, the effects of long-term Li treatment in the brain areas associated with memory impairment of elderly bipolar patients are still unknown. The aim of this study was to compare the hippocampal volumes of elderly bipolar patients using Li, elderly bipolar patients not using Li and healthy controls. Sociodemographic, clinical and magnetic resonance imaging data from 30 elderly euthymic bipolar patients who had been using Li for an average of >61 months; 27 elderly euthymic bipolar patients not taking Li for an average of 45 months; and 22 elderly healthy controls were analyzed. Volumetric differences in the hippocampus between groups were investigated with voxel-based morphometry (VBM) based on the Statistical Parametric Mapping technique. No statistical differences in sociodemographic and clinical characteristics and course of bipolar disorder between the two bipolar groups were observed. Using small volume correction in the VBM analysis (analysis of variance (ANOVA)), one voxel cluster of statistical significance was detected in the left hippocampus (P<0.05 corrected for multiple comparisons, extent threshold >10 voxels). Post hoc unpaired t-tests revealed increased left hippocampal volume in the Li-treated group compared with the non-Li-treated group, and decreased left hippocampal volume in the non-Li group relative to controls. Additional exploratory two-group comparisons indicated trends toward reduced right-hippocampal volumes in the non-Li-treated group relative to both the Li-treated group and controls. The findings suggested that the use of Li may influence the volume of the hippocampus, possibly due to its neuroprotective effects.

Low-dose estradiol and endothelial and inflammatory biomarkers in menopausal overweight/obese women.

OBJECTIVE: We aimed to investigate the effects of low-dose transdermal estrogen on endothelial and inflammatory biomarkers in menopausal overweight/obese women. METHODS: We recruited 44 menopausal women (47-55 years; body mass index 27.5-34.9 kg/m(2)) and divided them into estradiol (1 mg/day; n = 22) or placebo groups (n = 22). They were double-blinded, followed and treated for 3 months. At baseline and post-intervention, inflammatory biomarkers (hs-CRP, IL-1ß, IL-6, MCP-1 and TNF-α) and of vascular injury (activated circulating endothelial cells, CEC-a) and repair (endothelial progenitor cells, EPC) were quantified. Resting CECs (CEC-r) were also assessed. Microvascular reactivity and vasomotion were analyzed by laser-Doppler flowmetry. RESULTS: Volunteers (51.8 ± 2.3 years; mean body mass index 31.5 ± 2.5 kg/m(2)) had been menopausal for 3 (range 2-5) years. After treatment, no changes were observed in the placebo group, while levels of CEC-r and EPC increased in the estradiol group. In this group, no changes in inflammatory biomarkers were observed but it required a lower cumulative dose of acetylcholine to achieve peak velocity during endothelial-dependent vasodilatation and there was increased endothelial-independent vasodilatation. CONCLUSIONS: The short-term use of low-dose transdermal estradiol therapy in overweight/obese menopausal women increased markers of vascular repair and improved microvascular reactivity without changing the inflammatory biomarkers. CLINICAL TRIAL REGISTRATION: NCT01295892 at www.clinicaltrials.gov .

Oxygen uptake, respiratory exchange ratio, or total distance: a comparison of methods to equalize exercise volume in Wistar rats

This study compared strategies to equalize the volume of aerobic exercise performed with different intensities by Wistar rats, based on the distance covered during exercise bouts and energy expenditure (EE, isocaloric sessions) obtained from oxygen uptake (V̇O2) or respiratory exchange ratio (RER). Thirty-three male rats (270.5±12.8 g) underwent maximal exercise tests to determine V̇O2 reserve (V̇O2R), being randomly assigned to three groups: moderate-intensity continuous exercise at speed corresponding to 50% V̇O2R (MIC; n=11); high-intensity continuous exercise at 80% V̇O2R (HIC; n=11); and high-intensity intermittent exercise (HII; n=11) at 60% V̇O2R (3 min) and 80% V̇O2R (4 min). Exercise duration was calculated individually to elicit EE of 5 kcal in each session. No difference between groups was found for total running distance (MIC: 801±46, HIC: 734±42, HII: 885±64 m; P=0.13). Total EE measured by RER was systematically underestimated compared to values obtained from V̇O2 (HII: 4.5% and MIC: 6.2%, P<0.05). Total EE (calculated from V̇O2), and duration of HIC bouts (2.8 kcal and 30.8±2.2 min) were lower (P<0.0001) than in MIC (4.9 kcal and 64.7±1.8 min) and HII (4.7 kcal and 46.9±2.2 min). Predicted and actual values of total V̇O2, total EE, and duration of isocaloric sessions were similar in MIC and HII (P>0.05), which were both higher than in HIC (P<0.0001). In conclusion, the time to achieve a given EE in exercise bouts with different intensities did not correspond to the total distance. Therefore, the volume of aerobic exercise in protocols involving Wistar rats should be equalized using EE rather than total covered distance.

Association between the epidermal growth factor gene polymorphism and endometriosis in women from Brazil.

The aim of this study was to verify the association between the epidermal growth factor (EGF) +61 G/A polymorphism and the susceptibility to endometriosis using a case-control design study. The control group included fertile women without endometriosis and the case group included endometriosis patients. Polymerase chain reaction-restriction fragment length polymorphism analysis was used to genotype the EGF +61 G/A polymorphism. Initially, a total of 184 individuals were analyzed. After matching by ethnicity, the control group was composed of 57 individuals, while the endometriosis group was composed of 57 patients. No statistically significant associations were observed between EGF +61 variants and the risk of endometriosis development (P>0.05). This is the first study correlating the EFG +61 G/A polymorphism and endometriosis in women from Brazil, and demonstrates that EFG +61 G/A is not associated with endometriosis susceptibility in Brazilian women.

Aerobic exercise improves microvascular dysfunction in fructose fed hamsters.

Fructose is a major diet component directly related to severe damages to the microcirculation and to diseases such as obesity, diabetes and hypertension to which physical activity is pointed out as an important non-pharmacological treatment since its positive effects precede anthropometric improvements. In this study we have investigated the effects of a light/moderate aerobic exercise training (AET) on microcirculatory dysfunction elicited by carbohydrate overload during a period of 5 months. Male hamsters (Mesocricetus auratus) whose drinking water was substituted (F) or not (C) by 10% fructose solution, during 20 weeks, associated or not to AET in the last 4 weeks (EC and EF subgroups) had their microcirculatory function evaluated on the cheek pouch preparation, glucose and insulin tolerance (GTT and ITT) tested. Arterial blood was collected for pO2, pCO2, HCO3(-), pH, total CO2, saturated O2 and lactate determinations. Liver fragments were observed using an electron microscope. Microcirculatory responses to acetylcholine [Ach, an endothelium-dependent vasodilator; 10(-8)M - *123.3±7.5% (C), 119.5±1.3% (EC), *98.1±3.2% (F) and 133.6±17.2% (EF); 10(-6)M - *133.0±4.1% (C), 135.6±4.3% (EC), *103.4±4.3% (F) and 134.1±5.9% (EF); 10(-4)M - *167.2±5.0% (C), 162.8±5.4% (EC), *123.8±6.3% (F) and 140.8±5.0% (EF)] and to sodium nitroprusside [SNP, an endothelium-independent vasodilator; 10(-8)M - 118.8±6.8% (C), 114.0±5.0% (EC), 100.2±2.9% (F), 104.9±4.4% (EF); 10(-6)M - 140.6±11.7% (C), 141.7±5.5% (EC), 125.0±4.7% (F), 138.3±2.8% (EF); 10(-4)M - 150.4±10.9% (C), 147.9±6.5% (EC), 139.2±7.3% (F), 155.9±4.7% (EF)] and macromolecular permeability increase induced by 30 min ischemia/reperfusion (I/R) procedure [14.4±3.5 (C), 30.0±1.9 (EC), *112.0±8.8 (F) and *22.4±0.9 leaks/cm(2) (EF)] have shown that endothelium-dependent vasodilatation was significantly reduced and I/R induced macromolecular permeability augmented in sedentary fructose (F) subgroup and both improved after AET. Electron microscopy analysis of the liver showed significant differences between exercised and sedentary subgroups with greater amount of glycogen in F subgroups compared to other ones. No significant changes on mean arterial pressure, heart rate or blood gase between subgroups could be detected. Our results point out that AET could normalize microcirculatory dysfunction elicited by long term substitution of drinking water by 10% fructose solution.

Neuropsychological testing of cognitive impairment in euthymic bipolar disorder: an individual patient data meta-analysis.

OBJECTIVE: An association between bipolar disorder and cognitive impairment has repeatedly been described, even for euthymic patients. Findings are inconsistent both across primary studies and previous meta-analyses. This study reanalysed 31 primary data sets as a single large sample (N = 2876) to provide a more definitive view. METHOD: Individual patient and control data were obtained from original authors for 11 measures from four common neuropsychological tests: California or Rey Verbal Learning Task (VLT), Trail Making Test (TMT), Digit Span and/or Wisconsin Card Sorting Task. RESULTS: Impairments were found for all 11 test-measures in the bipolar group after controlling for age, IQ and gender (Ps ≤ 0.001, E.S. = 0.26-0.63). Residual mood symptoms confound this result but cannot account for the effect sizes found. Impairments also seem unrelated to drug treatment. Some test-measures were weakly correlated with illness severity measures suggesting that some impairments may track illness progression. CONCLUSION: This reanalysis supports VLT, Digit Span and TMT as robust measures of cognitive impairments in bipolar disorder patients. The heterogeneity of some test results explains previous differences in meta-analyses. Better controlling for confounds suggests deficits may be smaller than previously reported but should be tracked longitudinally across illness progression and treatment.

The CACNA1C risk allele selectively impacts on executive function in bipolar type I disorder.

OBJECTIVE: Calcium channels are important for converting electrical activity into biochemical events. A single nucleotide polymorphism (SNP) (rs1006737) in the CACNA1C gene has been strongly associated with increased risk for Bipolar disorder (BD) in genome-wide association studies. Recently, this same SNP has been reported to influence executive function in schizophrenia and controls, but it remains unclear whether this SNP affects behaviour, especially cognition in subjects with BD. METHOD: A total of 109 BD type I subjects and 96 controls were genotyped for CACNA1C rs1006737 and assessed with an executive function tests battery [Wechsler Adult Intelligence Scale III (WAIS-III) Letter-Number Sequence subtest (WAIS-LNS), digit span (WAISDS), trail making test (TMT), and WCST (Wisconsin Card Sorting Test)]. RESULTS: In patients with BD, the CACNA1C genotype Met/Met was associated with worse performance on all four executive function tests compared to Val/Val. No influence of CACNA1C was observed in the cognitive performance of healthy controls. CONCLUSION: Our data indicate for the first time that the CACNA1C risk allele is likely associated with executive dysfunction as a trait in BD, as this association was found regardless the presence of mood symptoms. Larger studies should evaluate the potential influence of CACNA1C on other cognitive domains in BD.

Pharmacological approaches in bipolar disorders and the impact on cognition: a critical overview.

OBJECTIVE: Historically, pharmacological treatments for bipolar disorders (BD) have been associated with neurocognitive side-effects. We reviewed studies which assessed the impact of several psychopharmacological drugs on the neurocognitive function of BD patients. METHOD: The PubMed database was searched for studies published between January 1980 and February 2011, using the following terms: bipolar, bipolar disorder, mania, manic episode, or bipolar depression, cross-referenced with cognitive, neurocognitive, or neuropsychological, cross-referenced with treatment. RESULTS: Despite methodological flaws in the older studies and insufficient research concerning the newer agents, some consistent findings emerged from the review; lithium appears to have definite, yet subtle, negative effects on psychomotor speed and verbal memory. Among the newer anticonvulsants, lamotrigine appears to have a better cognitive profile than carbamazepine, valproate, topiramate, and zonisamide. More long-term studies are needed to better understand the impact of atypical antipsychotics on BD patients' neurocognitive functioning, both in monotherapy and in association with other drugs. Other agents, like antidepressants and cognitive enhancers, have not been adequately studied in BD so far. CONCLUSION: Pharmacotherapies for BD should be chosen to minimize neurocognitive side-effects, which may already be compromised by the disease process itself. Neurocognitive evaluation should be considered in BD patients to better evaluate treatment impact on neurocognition. A comprehensive neuropsychological evaluation also addressing potential variables and key aspects such as more severe cognitive deficits, comorbidities, differential diagnosis, and evaluation of multiple cognitive domains in longitudinal follow-up studies are warranted.

Translating neurotrophic and cellular plasticity: from pathophysiology to improved therapeutics for bipolar disorder.

OBJECTIVE: Bipolar disorder (BD) likely involves, at a molecular and cellular level, dysfunctions of critical neurotrophic, cellular plasticity and resilience pathways and neuroprotective processes. Therapeutic properties of mood stabilizers are presumed to result from a restoration of the function of these altered pathways and processes through a wide range of biochemical and molecular effects. We aimed to review the altered pathways and processes implicated in BD, such as neurotrophic factors, mitogen-activated protein kinases, Bcl-2, phosphoinositol signaling, intracellular calcium and glycogen synthase kinase-3. METHODS: We undertook a literature search of recent relevant journal articles, book chapter and reviews on neurodegeneration and neuroprotection in BD. Search words entered were 'brain-derived neurotrophic factor,''Bcl-2,''mitogen-activated protein kinases,''neuroprotection,''calcium,''bipolar disorder,''mania,' and 'depression.' RESULTS: The most consistent and replicated findings in the pathophysiology of BD may be classified as follows: i) calcium dysregulation, ii) mitochondrial/endoplasmic reticulum dysfunction, iii) glial and neuronal death/atrophy and iv) loss of neurotrophic/plasticity effects in brain areas critically involved in mood regulation. In addition, the evidence supports that treatment with mood stabilizers; in particular, lithium restores these pathophysiological changes. CONCLUSION: Bipolar disorder is associated with impairments in neurotrophic, cellular plasticity and resilience pathways as well as in neuroprotective processes. The evidence supports that treatment with mood stabilizers, in particular lithium, restores these pathophysiological changes. Studies that attempt to prevent (intervene before the onset of the molecular and cellular changes), treat (minimize severity of these deficits over time), and rectify (reverse molecular and cellular deficits) are promising therapeutic strategies for developing improved treatments for bipolar disorder.

Chemical Analysis and Study of Phenolics, Antioxidant Activity, and Antibacterial Effect of the Wood and Bark of Maclura tinctoria (L.) D. Don ex Steud.

Maclura tinctoria (L.) D. Don ex Steud. has one of the highest qualities among the coefficients for Brazilian woods (up to 9.6) and resistance rates equivalent to Indian teak (Tectona grandis). In this study, the macromolecular constituents and total phenols compounds as well as the antioxidant and antibacterial activities of this wood were evaluated. Total phenols and proanthocyanidin levels were higher in wood when compared with bark levels. The antioxidant activity of wood extracts (IC(50) = 18.7 µg/mL) was more effective than that of bark extracts (IC(50) = 20.9 µg/mL). Wood and bark extracts revealed a high potential for inhibition of aerobic and anaerobic bacteria. The bark extracts were the most active (MIC from 20 to 60 µg/mL). Both antioxidant activity and high potential for bacteria inhibition turn these extracts promising for drug formulations, especially as antibacterial agent.

Antibacterial activity of 15-deoxygoyazensolide isolated from the stems of Minasia alpestris (Asteraceae) against oral pathogens.

This work reports the isolation of the sesquiterpene lactone 15-deoxygoyazensolide from the stems of Minasia alpestris and the evaluation of its antimicrobial activity against the following oral pathogens: Enterococcus faecalis, Streptococcus salivarius, Streptococcus sobrinus, Streptococcus mutans, Streptococcus mitis, Streptococcus sanguinis, and Lactobacillus casei. Despite the cytotoxicity and genotoxicity of other sesquiterpene lactones of the furanoheliangolide-type, our results revealed that this compound exhibits low antibacterial activity against the evaluated oral pathogens; however, an interesting selectivity against E. faecalis (minimum inhibitory concentration [MIC]=40 µg mL(-1)) and S. sobrinus (MIC=60 µg mL(-1)) was observed.

Intestinal obstruction due to internal hernia following pancreas transplantation.

BACKGROUND: Simultaneous pancreas-kidney transplantation has evolved as the best treatment for type 1 diabetic patients at end-stage renal disease. The surgical complication rate is high, which is an important barrier to the success of this procedure. The frequent complications that require relaparotomies include fistulas, graft thromboses, and intra-abdominal abscesses. Intestinal obstructions after pancreas transplantation due to internal herniation are not common. PURPOSE: The objective of this article was to review the literature about this problem and describe our personal experience in pancreas transplantation. METHODS: We examined the cases of small bowel obstruction secondary to an internal hernia after following 292 pancreas transplantations in our center from 2000 to 2009 as well as performed a Medline literature review. RESULTS: Only 2 articles described the diagnosis and treatment of internal hernias after pancreas transplantation. However, both contribution were from the same center reporting the same 3 cases, with surgical versus radiologic perspectives. We have described our 2 cases of young pancreas-kidney transplant patients who presented with acute intestinal obstruction due to internal hernia. CONCLUSION: Although internal hernias are rare, they are potentially fatal and difficult to diagnose when they occur after pancreas transplantation. Detection with early surgery demands a high degree of clinical vigilance.

Reação farmacodérmica decorrente do uso do levamisol: relato de caso / Pharmacodermic adverse reaction due to levamisole: a case report

Relata-se a ocorrência de um caso de farmacodérmica pelo levamisol e discute-se sobre a manifestação clínica e o estabelecimento do diagnóstico dessa reação cutânea adversa. O animal desenvolveu lesões exsudativas na face, com resolução espontânea após a suspensão do fármaco.

Unilateral mydriasis after nasal reconstruction surgery.

PURPOSE: To present a case of iatrogenic, unilateral pupillary dilatation after general anesthesia for nasal surgery. Unilateral pupillary dilatation after general anesthesia has sinister implications, which might prompt further investigations. However, in patients undergoing nasal surgery, it might be caused by the action of drugs injected intranasally. Consideration of iatrogenic causes of pupillary dilatation might help clinicians to avoid time-consuming and costly investigations. CLINICAL FEATURES: A 24-yr-old healthy woman underwent a general anesthetic for septoplasty and bilateral turbinectomy. She was hemodynamically stable and did not suffer any hypoxia intraoperatively. At the end of the operation her right pupil was dilated (8 mm diameter). Her left pupil was normal. No other abnormality was detected. After she woke up, her vision was grossly normal. Neurological examination did not show any other abnormality. Six to eight hours later, both pupils were equal (2 mm in diameter) and reacting normally to light and accommodation. CONCLUSION: The patient was a healthy 24-yr-old who underwent an operation in which there was no incident of hypoxia or hemodynamic instability. Since the patient recovered completely within six to eight hours, the pupillary dilatation was probably caused by epinephrine, which could have entered the eye through the nasolacrimal duct. Although pupillary dilatation after general anesthesia has been described, this is the first case report where the most likely causative agent was epinephrine, injected into the nasal submucosa.