Clinics, Volume: 64, Issue: 3, Published: 2009
  • In the march, 2009 issue of Clinics Editorial

    Rocha-e-Silva, Mauricio
  • The value of necropsy in quality control of medical diagnosis: the gold standard for years to come Editorial

    Gutierrez, Paulo Sampaio; Brito, Thales de; Lopes, Maria Beatriz Sampaio; Alves, Venancio Avancini Ferreira
  • Evaluating the center of gravity of dislocations in soccer players with and without reconstruction of the anterior cruciate ligament using a balance platform Clinical Sciences

    Alonso, Angelica Castilho; Greve, Júlia Maria D'Andréa; Camanho, Gilberto Luis

    Abstract in English:

    OBJECTIVE: The objective of this study was to compare the dislocation of the center of gravity and postural balance in sedentary and recreational soccer players with and withoutanterior cruciate ligament (ACL) reconstruction using the Biodex Balance System (BBS). METHOD: Sixty-four subjects were divided into three groups: a) soccer players who were post- anterior cruciate ligament reconstruction; b) soccer players with no anterior cruciate ligament injuries; and c) sedentary subjects. The subjects were submitted to functional stability tests using the Biodex Balance System. The instability protocols used were level eight (more stable) and level two (less stable). Three stability indexes were calculated: the anteroposterior stability index, the mediolateral stability index, and the general stability index. RESULTS: Postural balance (dislocation) on the reconstructed side of the athletes was worse than on the side that had not undergone reconstruction. The postural balance of the sedentary group was dislocated less on both sides than the reconstructed knees of the athletes without anterior cruciate ligament injuries. There were no differences in postural balance with relation to left/right dominance for the uninjured athletes and the sedentary individuals. CONCLUSION: The dislocation of the center of gravity and change in postural balance in sedentary individuals and on the operated limb of Surgery Group are less marked than in the soccer players from the Non Surgery Group and on the non-operated limbs. The dislocation of the center of gravity and the change in postural balance from the operated limb of the soccer players is less marked than in their non-operated limbs.
  • Significant performance variation among PCR systems in diagnosing congenital toxoplasmosis in São Paulo, Brazil: analysis of 467 amniotic fluid samples Clinical Sciences

    Okay, Thelma Suely; Yamamoto, Lidia; Oliveira, Léa Campos; Manuli, Erika Regina; Andrade Junior, Heitor Franco de; Del Negro, Gilda Maria Barbaro

    Abstract in English:

    INTRODUCTION: Performance variation among PCR systems in detecting Toxoplasma gondii has been extensively reported and associated with target genes, primer composition, amplification parameters, treatment during pregnancy, host genetic susceptibility and genotypes of different parasites according to geographical characteristics. PATIENTS: A total of 467 amniotic fluid samples from T. gondii IgM- and IgG-positive Brazilian pregnant women being treated for 1 to 6 weeks at the time of amniocentesis (gestational ages of 14 to 25 weeks). METHODS: One nested-B1-PCR and three one-round amplification systems targeted to rDNA, AF146527 and the B1 gene were employed. RESULTS: Of the 467 samples, 189 (40.47%) were positive for one-round amplifications: 120 (63.49%) for the B1 gene, 24 (12.69%) for AF146527, 45 (23.80%) for both AF146527 and the B1 gene, and none for rDNA. Fifty previously negative one-round PCR samples were chosen by computer-assisted randomization analysis and re-tested (nested-B1-PCR), during which nine additional cases were detected (9/50 or 18%). DISCUSSION: The B1 gene PCR was far more sensitive than the AF146527 PCR, and the rDNA PCR was the least effective even though the rDNA had the most repetitive sequence. Considering that the four amplification systems were equally affected by treatment, that the amplification conditions were optimized for the target genes and that most of the primers have already been reported, it is plausible that the striking differences found among PCR performances could be associated with genetic diversity in patients and/or with different Toxoplasma gondii genotypes occurring in Brazil. CONCLUSION: The use of PCR for the diagnosis of fetal Toxoplasma infections in Brazil should be targeted to the B1 gene when only one gene can be amplified, preferably by nested amplification with primers B22/B23.
  • Locoregional anesthesia for dental treatment in cardiac patients: a comparative study of 2% plain lidocaine and 2% lidocaine with epinephrine (1:100,000) Clinical Sciences

    Laragnoit, Alessandra Batistela; Neves, Ricardo Simões; Neves, Itamara Lúcia Itagiba; Vieira, Joaquim Edson

    Abstract in English:

    OBJECTIVES: This study analyzes hemodynamic changes in patients with cardiac valvular diseases submitted to dental treatment under local anesthesia containing epinephrine. METHODS: This randomized clinical trial was performed at the Dental Division of the Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (Brazil). Patients were separated into two groups with the help of an aleatory number table: 2% plain lidocaine (PL, n= 31) and 2% lidocaine with epinephrine (1:100,000) (LE, n= 28). Blood pressure, heart rate, oxygenation and electrocardiogram data were all recorded throughout the procedure. State and trait anxiety levels were measured. RESULTS: Fifty-nine patients were selected for the LE group (n=28), with an average age of 40.3 ± 10.9, or for the PL group (n=31), age 42.2 ± 10.3. No differences were shown in blood pressure, heart rate and pulse oximetry values before, during and after local anesthesia injection between the two groups. State and trait anxiety levels were not different. Arrhythmias observed before dental anesthesia did not change in shape or magnitude after treatment. Complaints of pain during the dental procedure were more frequent within the PL group, which received a higher amount of local anesthesia. CONCLUSION: Lidocaine with epinephrine (1:100,000) provided effective local anesthesia. This treatment did not cause an increase in heart rate or blood pressure and did not cause any arrhythmic changes in patients with cardiac valvular diseases.
  • Total arthroplasty in ankylosed knees: a case series Clinical Sciences

    Camanho, Gilberto Luiz

    Abstract in English:

    OBJECTIVE: To present nine patients with ankylosis in their knees that were submitted to a total arthroplasty to lessen their pain and improve their functional limitation. For these patients, arthrodesis remained a possibility in the event of arthroplasty failure. INTRODUCTION: Ankylosis of the knee is a severe functional limitation that becomes worse when pain is present. Arthrodesis of the knee is a classical indication for such patients, since it resolves the pain; however, the severe functional limitation remains. METHODS: In the present study, we evaluated the clinical course of nine patients who underwent total arthroplasty of the knee, and were followed up for at least five years. RESULTS: The results demonstrate that all of the patients experienced a significant reduction in pain and some improvement in the degree of knee flexion and extension. CONCLUSION: Based on the latest follow-up, there has been no need to perform arthrodesis for any of our patients, showing that a total arthroplasty could be a option for treatment in knee ankylosis.
  • Ultrasonography accurately evaluates the dimension and shape of the pilonidal sinus Clinical Sciences

    Mentes, Oner; Oysul, Asli; Harlak, Ali; Zeybek, Nazif; Kozak, Orhan; Tufan, Turgut

    Abstract in English:

    PURPOSE: To study the benefits of ultrasonography for detecting the borders of pilonidal sinus tissue. The correlation between physical and ultrasonographic examination was used for surgical planning. METHOD: Between April and December 2004, 73 patients were recruited for this study. All patients were examined, and the borders of the sinus tissue were marked on the skin according to palpation before surgery. The surgeon also made a treatment plan considering the diseased tissue and marked a possible incision line. Patients were subsequently examined with ultrasonography. According to the ultrasonographic evaluation, the margins, extensions, and openings of pilonidal sinus tissue were determined and marked on the patient in a different color by a radiologist prior to surgery. The most suitable surgical treatment was decided according to the information obtained by ultrasonography. RESULTS: The average age was 23.03 ± 3.05 (range 18-39) years. We found 81 lesions in 73 patients. Ultrasonographic borders of sinus tissue were similar to the borders marked by the surgeon in 56 patients (76.7%). In the remaining 17 patients (23.3%), ultrasonography detected branches or borders that distinctly exceeded the planned incision line. After ultrasonographic examination, the surgeon changed his incision line in 14 patients and the surgical intervention in 3 patients. CONCLUSION: Palpation and methylene blue injection do not provide appropriate information in many patients. Our study revealed that pre-operative ultrasonography can improve the identification of the sinus tract and its branches when compared to palpation and methylene blue injection.
  • Systemic treatment in severe cases of recurrent aphthous stomatitis: an open trial Clinical Sciences

    Mimura, Maria Angela Martins; Hirota, Silvio Kenji; Sugaya, Norberto Nobuo; Sanches Jr, José Antonio; Migliari, Dante Antonio

    Abstract in English:

    PURPOSE: This study aimed to evaluate the efficacy of the systemic drugs thalidomide, dapsone, colchicine, and pentoxifylline in the treatment of severe manifestations of RAS. METHODS: An open, 4-year clinical trial was carried out for 21 consecutive patients with severe RAS. Initially, patients were given a 2-week course of prednisone to bring them to a baseline status. Simultaneously, one of the four test drugs was assigned to each patient to be taken for a period of 6 months. During the course of the trial, patients were switched to one of the other three drugs whenever side effects or a lack of satisfactory results occurred, and the 6-month limit of the treatment was then reset. RESULTS: The most efficient and best-tolerated drug was thalidomide, which was administered to a total of eight patients and resulted in complete remission in seven (87.5%). Dapsone was prescribed for a total of nine patients, of whom eight (89%) showed improvement in their symptoms, while five showed complete remission. Colchicine was administered to a total of ten patients, with benefits observed in nine (90%), of whom four showed complete remission. Pentoxyfilline was administered to a total of five patients, with benefits observed in three (60%), of whom one patient showed complete remission. CONCLUSION: The therapeutic methods used in this trial provided significant symptom relief. Patients experienced relapses of the lesions; however, this occurred after withdrawal of their medication during the follow-up period.
  • Prevalence of pain on palpation of the inferior pole of the patella among patients with complaints of knee pain Clinical Sciences

    Ramos, Leonardo Addêo; Carvalho, Rogério Teixeira de; Garms, Emerson; Navarro, Marcelo Schmith; Abdalla, Rene Jorge; Cohen, Moisés

    Abstract in English:

    CONTEXT AND OBJECTIVE: Patellar tendinopathy is a common condition in sports. It may occur at any location of the patellar tendon, but the most commonly affected area is the inferior pole of the patella. Among various diagnostic tests, the one most used is palpation of the inferior pole of the patella. The aim of this study was to investigate the prevalence of pain complaints among individuals with pathological knee conditions and to evaluate palpation of the inferior pole of the patella as a diagnostic test for patellar tendinopathy. METHODS: Palpation of the patellar tendon was performed on 318 individuals who presented with knee-related complaints. Palpation was performed with the individual in the supine position and the knee extended. The age, gender, physical activity and labor activity of each individual were recorded at the time the symptoms appeared; the diagnosis was also recorded. RESULTS: Of the total number of individuals evaluated, 124 (39%) felt pain on palpation of the inferior pole of the patella. Of these, only 40 (32.3%) received a diagnosis of patellar tendinopathy. We did not observe any difference with respect to gender and age distribution. When evaluating daily physical activity levels, however, we observed that individuals with pain on palpation of the inferior pole of the patella experienced more intense physical activity. CONCLUSIONS: Palpation of the inferior pole of the patella is a diagnostic procedure with high sensitivity and moderate specificity for diagnosing patellar tendinopathy, especially among individuals who perform activities with high functional demands.
  • Prosthesis for open pleurostomy (POP): management for chronic empyemas Clinical Sciences

    Filomeno, Luiz Tarcísio Brito; Campos, José Ribas Milanez de; Machuca, Tiago Noguchi; Neves-Pereira, João Carlos das; Terra, Ricardo Mingarini

    Abstract in English:

    OBJECTIVES: We developed a prosthesis for open pleurostomy cases where pulmonary decortication is not indicated, or where post-pneumonectomy space infection occurs. The open pleural window procedure not only creates a large hole in the chest wall that is shocking to patients, also results in a permanent deformation of the thorax. prosthesis for open pleurostomy is a self-retained silicone tube that requires the removal of 3 cm of one rib for insertion, and acts as a mature conventional open pleural window. Herein, we report our 13-year experience with this device in the management of different kinds of pleural empyema. METHODS: Forty-four consecutive patients with chronic empyema were treated. The etiology of empyema was diverse: pneumonia, 20; lung resections, 12 (pneumonectomies, 7; lobectomies, 4; non-anatomical, 1); mixed-tuberculous, 6; and mixed-malignant pleural effusion, 6. After debridment of both pleural surfaces, the prosthesis for open pleurostomy was inserted and attached to a small recipient plastic bag. RESULTS: Infection control was achieved in 20/20 (100%) of the parapneumonic empyemas, in 3/4 (75%) of post-lobectomies, in 6/7 (85%) of post-pneumectomies, in 6/6 (100%) of mixed-tuberculous cases, and in 4/6 (83%) of mixed-malignant cases. Lung re-expansion was also successful in 93%, 75%, 33%, and 40% of the groups, respectively CONCLUSIONS: Prosthesis for open pleurostomy insertion is a minimally invasive procedure that can be as effective as conventional open pleural window for management of chronic empyemas. Thus, we propose that the use of prosthesis for open pleurostomy should replace the conventional method.
  • Use of the hospital anxiety and depression scale (HADS) in a cardiac emergency room: chest pain unit Clinical Sciences

    Soares-Filho, Gastão L. F.; Freire, Rafael C.; Biancha, Karla; Pacheco, Ticiana; Volschan, André; Valença, Alexandre M.; Nardi, Antonio E.

    Abstract in English:

    OBJECTIVE: To determine the prevalence of anxiety and depression in patients complaining of chest pain who seek a chest pain unit attendance. INTRODUCTION: Patients arriving at a Chest Pain Unit may present psychiatric disorders not identified, isolated or co-morbid to the main illness, which may interfere in the patient prognosis. METHODOLOGY: Patients were assessed by the "Hospital Anxiety and Depression Scale" as a screening instrument wile following a systematized protocol to rule out the diagnosis of acute coronary syndrome and other potentially fatal diseases. Patients with 8 or more points in the scale were considered "probable case" of anxiety or depression. RESULTS: According to the protocol, 59 (45.4%) of 130 patients studied presented Chest Pain of Determined Cause, and 71 (54.6%) presented Chest Pain of Indefinite Cause. In the former group, in which 43 (33.1%) had acute coronary syndrome, 33.9% were probable anxiety cases and 30.5% depression cases. In the second group, formed by patients without acute coronary syndrome or any clinical conditions involving greater morbidity and mortality risk, 53.5% were probable anxiety cases and 25.4% depression. CONCLUSION: The high anxiety and depression prevalence observed may indicate the need for early and specialized approach to these disorders. When coronary arterial disease is present, this may decrease complications and shorten hospital stay. When psychiatric disorder appears isolated, is possible to reduce unnecessary repeated visits to emergency room and increase patient's quality of life.
  • Effects of cardiopulmonary bypass on propofol pharmacokinetics and bispectral index during coronary surgery Clinical Sciences

    Barbosa, Ricardo Antonio G.; Santos, Silvia Regina C. Jorge; White, Paul F.; Pereira, Valéria A.; Silva Filho, Carlos R.; Malbouisson, Luiz M. S.; Carmona, Maria José C.

    Abstract in English:

    PURPOSE: Cardiopulmonary bypass is known to alter propofol pharmacokinetics in patients undergoing cardiac surgery. However, few studies have evaluated the impact of these alterations on postoperative pharmacodynamics. This study was designed to test the hypothesis that changes in propofol pharmacokinetics increase hypnotic effects after cardiopulmonary bypass. METHODS: Twenty patients scheduled for on-pump coronary artery bypass graft (group, n=10) or off-pump coronary artery bypass graft (group, n=10) coronary artery bypass grafts were anesthetized with sufentanil and a propofol target controlled infusion (2.0 µg/mL). Depth of hypnosis was monitored using the bispectral index. Blood samples were collected from the induction of anesthesia up to 12 hours after the end of propofol infusion, at predetermined intervals. Plasma propofol concentrations were measured using high-performance liquid chromatography, followed by a non-compartmental propofol pharmacokinetic analysis. Data were analyzed using ANOVA, considering p<0.05 as significant. RESULTS: After cardiopulmonary bypass, despite similar plasma propofol concentrations in both groups, bispectral index values were lower in the on-pump coronary artery bypass graft group. Time to extubation after the end of propofol infusion was greater in the on-pump coronary artery bypass graft group (334 ± 117 vs. 216 ± 85 min, p = 0.04). Patients undergoing cardiopulmonary bypass had shorter biological (1.82 ± 0.5 vs. 3.67 ± 1.15h, p < 0.01) and terminal elimination (6.27 ± 1.29 vs. 10.5h ± 2.18, p < 0.01) half-life values, as well as higher total plasma clearance (28.36 ± 11.40 vs.18.29 ± 7.67 mL/kg/min, p = 0.03), compared to patients in the off-pump coronary artery bypass graft group. CONCLUSION: Aside from the increased sensitivity of the brain to anesthetics after cardiopulmonary bypass, changes in propofol pharmacokinetics may contribute to its central nervous system effects.
  • Evidence that the degree of obstructive sleep apnea may not increase myocardial ischemia and arrhythmias in patients with stable coronary artery disease Clinical Sciences

    Araújo, Cristiana Marques de; Solimene, Maria Cecilia; Grupi, Cesar Jose; Genta, Pedro Rodrigues; Lorenzi-Filho, Geraldo; Luz, Protásio Lemos Da

    Abstract in English:

    There is controversy regarding whether obstructive sleep apnea is responsible for triggering myocardial ischemia, arrhythmias and heart rate variability in patients with coronary artery disease. OBJETIVE: The objective of this study was to identify relationships between sleep apnea, myocardial ischemia and cardiac arrhythmia in patients with coronary artery disease. METHODS: Fifty-three patients with stable coronary disease underwent simultaneous polysomnography and electrocardiographic Holter recording. The apnea-hypopnea index (AHI) was defined as the number of apneas/hypopneas per hour of sleep. Patients were divided into a Control group (AHI15, n=23 pts) and an Apnea group (AHI>15, n=30 pts). A subgroup of 13 patients with an AHI>30 (Severe Apnea group) was also studied. We analyzed ischemic episodes (ST-segment depressions >1 mm, > 1 min), heart rate variability and the occurrence of arrhythmias during wakefulness and sleep. RESULTS: Baseline clinical characteristics among the groups were similar except for higher blood pressure in the Apnea groups (p<0.05). Myocardial ischemia was recorded in 39 (73.6%) patients. The number and duration of ischemic episodes significantly decreased during sleep in all groups; during wakefulness, patients with severe apnea exhibited fewer and shorter episodes in comparison with the controls. There were no significant differences in heart rate variability or in the occurrence of arrhythmias among the groups. Malignant ventricular arrhythmias, atrial fibrillation/flutter, bradycardia and high-degree atrioventricular blocks were not detected. CONCLUSION: Obstructive sleep apnea was not related to myocardial ischemia, heart rate variability or arrhythmias in patients with stable coronary artery disease and did not alter the circadian pattern of myocardial ischemia.
  • Spatial memory perfomance of wistar rats exposed to mobile phone Basic Research

    Narayanan, Sareesh Naduvil; Kumar, Raju Suresh; Potu, Bhagath Kumar; Nayak, Satheesha; Mailankot, Maneesh

    Abstract in English:

    INTRODUCTION: With the tremendous increase in number of mobile phone users world wide, the possible risks of this technology have become a serious concern. OBJECTIVE: We tested the effects of mobile phone exposure on spatial memory performance. MATERIALS AND METHODS: Male Wistar rats (10-12 weeks old) were exposed to 50 missed calls/day for 4 weeks from a GSM (900/1800MHz) mobile phone in vibratory mode (no ring tone). After the experimental period, the animals were tested for spatial memory performance using the Morris water maze test. RESULTS: Both phone exposed and control animals showed a significant decrease in escape time with training. Phone exposed animals had significantly (~3 times) higher mean latency to reach the target quadrant and spent significantly (~2 times) less time in the target quadrant than age- and sex-matched controls. CONCLUSION: Mobile phone exposure affected the acquisition of learned responses in Wistar rats. This in turn points to the poor spatial navigation and the object place configurations of the phone-exposed animals.
  • The effects of palm oil tocotrienol-rich fraction supplementation on biochemical parameters, oxidative stress and the vascular wall of streptozotocin-induced diabetic rats Basic Research

    Budin, Siti Balkis; Othman, Faizah; Louis, Santhana Raj; Bakar, Mokhtar Abu; Das, Srijit; Mohamed, Jamaludin

    Abstract in English:

    OBJECTIVE: This study examined the effects of palm oil tocotrienol-rich fractions on streptozotocin-induced diabetic rats. METHODS: Animals were divided into three groups: (i) normal non-diabetic (NDM), (ii) diabetic treated (tocotrienol-rich fractions - TRF) and (iii) diabetic untreated (non-TRF). The treatment group received oral administration of tocotrienol-rich fractions (200 mg/kg body weight) daily for eight weeks. The normal non-diabetic and the diabetic untreated groups were fed standard rat feed. Blood glucose and lipid profiles, oxidative stress markers and morphological changes of the thoracic aorta were evaluated. RESULTS: Tocotrienol-rich fractions treatment reduced serum glucose and glycated hemoglobin concentrations. The tocotrienol-rich fractions group also showed significantly lower levels of plasma total cholesterol, low-density lipoprotein cholesterol, and triglyceride, as compared to the untreated group. The tocotrienol-rich fractions group had higher levels of high-density lipoprotein cholesterol, as compared to the untreated group. Superoxide dismutase activity and levels of vitamin C in plasma were increased in tocotrienol-rich fractions-treated rats. The levels of plasma and aorta malondealdehyde + 4-hydroxynonenal (MDA + 4-HNE) and oxidative DNA damage were significant following tocotrienol-rich fractions treatment. Electron microscopic examination showed that the normal morphology of the thoracic aorta was disrupted in STZ-diabetic rats. Tocotrienol-rich fractions supplementation resulted in a protective effect on the vessel wall. CONCLUSION: These results show that tocotrienol-rich fractions lowers the blood glucose level and improves dyslipidemia. Levels of oxidative stress markers were also reduced by administration of tocotrienol-rich fractions. Vessel wall integrity was maintained due to the positive effects mediated by tocotrienol-rich fractions.
  • Selective cyclooxygenase-2 inhibition protects against myocardial damage in experimental acute ischemia Basic Research

    Carnieto Jr., Alberto; Dourado, Paulo Magno Martins; Luz, Protásio Lemos da; Chagas, Antonio Carlos Palandri

    Abstract in English:

    BACKGROUND: Acute myocardial infarction is associated with tissue inflammation. Early coronary reperfusion clearly improves the outcome but may help propagate the inflammatory response and enhance tissue damage. Cyclooxygenase-2 is an enzyme that catalyzes the initial step in the formation of inflammatory prostaglandins from arachidonic acid. Cyclooxygenase-2 levels are increased when ischemic cardiac events occur. The overall function of COX-2 in the inflammatory process generated by myocardial ischemic damage has not yet been elucidated. GOAL: The objective of this study was to determine whether a selective cyclooxygenase-2 inhibitor (rofecoxib) could alter the evolution of acute myocardial infarction after reperfusion. METHODS AND RESULTS: This study was performed with 48 mongrel dogs divided into two groups: controls and those treated with the drug. All animals were prepared for left anterior descending coronary artery occlusion. The dogs then underwent 180 minutes of coronary occlusion, followed by 30 minutes of reperfusion. Blood samples were collected from the venous sinus immediately before coronary occlusion and after 30 minutes of reperfusion for measurements of CPK-MB, CPK-MBm and troponin I. During the experiment we observed the mean blood pressure, heart rate and coronary flow. The coronary flow and heart rate did not change, but in the control group, there was blood pressure instability, in addition to maximal levels of CPK-MB post-infarction. The same results were observed for CPK-MBm and troponin I. CONCLUSION: In a canine model of myocardial ischemia-reperfusion, selective inhibition of Cyclooxygenase-2 with rofecoxib was not associated with early detrimental effects on the hemodynamic profile or the gross extent of infarction; in fact, it may be beneficial by limiting cell necrosis.
  • A brief review of chronic exercise intervention to prevent autonomic nervous system changes during the aging process Review Articles

    Wichi, Rogério Brandão; De Angelis, Kátia; Jones, Lia; Irigoyen, Maria Claudia

    Abstract in English:

    The aging process is associated with alterations in the cardiovascular and autonomic nervous systems. Autonomic changes related to aging involve parasympathetic and sympathetic alterations leading to a higher incidence of cardiovascular disease morbidity and mortality. Several studies have suggested that physical exercise is effective in preventing deleterious changes. Chronic exercise in geriatrics seems to be associated with improvement in the cardiovascular system and seems to promote a healthy lifestyle. In this review, we address the major effects of aging on the autonomic nervous system in the context of cardiovascular control. We examine the use of chronic exercise to prevent cardiovascular changes during the aging process.
  • Resistance to vitamin d treatment as an indication of celiac disease in a patient with primary hypoparathyroidism Letters To The Editors

    Marcondes, José Antonio Miguel; Seferian Junior, Pedro; Mitteldorf, Cristina Aparecida Proques da Silveira
  • An anomalous muscle in the forearm extensor compartment Letters To The Editors

    Nayak, Soubhagya R.; Vadgaonkar, Rajanigandha; Krishnamurthy, Ashwin; Prabhu, Latha V.
  • MR imaging features of peritoneal adenomatoid mesothelioma: a case report Letters To The Editors

    Lins, Cynthia Maria Coelho; Elias Jr, Jorge; Cunha, Adilson Ferreira; Muglia, Valdair Francisco; Monteiro, Carlos Ribeiro; Valeri, Fábio V.; Feres, Omar
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