Adormecimento psíquico e despertar do inconsciente na adolescência: uma aposta na palavra / Le sommeil psychique et l'éveil de l'inconscient à l'adolescence: un pari sur la parole / Psychic numbness and awakening of the unconscious in adolescence: betting on the word

Este artigo apresenta uma reflexão sobre os efeitos do contexto da cultura digital para a adolescência. Abordamos a adolescência na teoria psicanalítica desde as concepções freudianas até as elaborações contemporâneas. Retomamos a infância como fase constitutiva do sujeito e suas implicações para a adolescência para destacar os impasses experienciados pelos adolescentes na cultura digital. Destacamos os conceitos de saber, Outro e objeto como articulatórios para a compreensão da adolescência na contemporaneidade. Consideramos que o estatuto do saber sofreu transformações decorrentes da aliança entre o capitalismo e a digitalização e que essas transformações trazem implicações para o laço social, configurando o que chamamos de adormecimento psíquico. Por fim, apontamos a conversação de orientação psicanalítica como uma possibilidade no enfrentamento dos desafios que a cultura digital apresenta

Cet article présente une réflexion sur les effets du contexte de la culture numérique sur l'adolescence. Nous analysons l'adolescence dans la théorie psychanalytique à partir des conceptions freudiennes jusqu'aux élaborations contemporaines. Nous revenons sur l'enfance en tant que phase constitutive du sujet et ses implications pour l'adolescence afin de mettre en évidence les impasses vécues par les adolescents dans la culture numérique. Nous mettrons en évidence les concepts de connaissance, d'Autre et d'objet comme des articulations fondamentales pour la compréhension de l'adolescence à l'époque contemporaine. Nous considérons que le statut du savoir a subi des transformations résultant de l'alliance entre capitalisme et numérisation et que ces transformations ont des implications sur le lien social, configurant ce que nous appelons le sommeil psychique. Enfin, nous indiquons la conversation psychanalytique comme une possibilité pour faire face aux défis que présente la culture numérique.

This article presents a reflection on the effects of digital culture on adolescence. We analyze adolescence in psychoanalytic theory from Freudian conceptions to contemporary elaborations. We return to childhood as a constitutive phase of the subject and its implications for adolescence in order to highlight the impasses experienced by adolescents in the digital culture. We highlight the concepts of knowledge, Other and object as articulations for the understanding of adolescence nowadays. We consider that the status of knowledge has undergone transformations resulting from the alliance between capitalism and digitalization and that these transformations have implications for the social bond, configuring what we call psychic numbness. Finally, we point out the psychoanalytic conversation as a possibility in facing the challenges that digital culture presents.

Evaluación subjetiva de la hipoestesia subclavicular luego de una reducción abierta y fijación interna de fracturas de clavícula / Subjective evaluation of subclavicular hypoesthesia after open reduction and internal fixation of clavicle fractures

Introducción: Las fracturas de clavícula representan el 4% de las fracturas del adulto; el 80% son mediodiafisarias. Se ha de-mostrado que el tratamiento quirúrgico disminuye el riesgo de seudoartrosis, consolidación viciosa y dolor residual, aunque no está exento de complicaciones, como la hipoestesia regional (12-29%), entre otras. Objetivo: Evaluar la incidencia de hipoestesia subclavicular luego de una reducción abierta y fijación interna para una fractura de clavícula, si afecta la calidad de vida del paciente y cómo la afecta. Materiales y Métodos: Se realizó un estudio transversal analítico prospectivo de pacientes con una fractura mediodiafisaria desplazada de clavícula tratados con reducción abierta y fijación interna entre 2018 y 2021. Se utilizó un cuestionario elaborado por el equipo, que consistió en 6 preguntas para responder de forma anónima. Se evaluó la presencia de hipoestesia subclavicular, dolor regional y afectación de la vida cotidiana. Resultados: Se evaluó a 29 pacientes con un seguimiento posoperatorio mínimo de un año, operados mediante un abordaje longitudinal. Veintidós (76%) tenían alteración de la sensibilidad y siete (24%) negaron este síntoma. La hipoestesia subclavicular afectó la calidad de vida de manera leve o nula del 97% de los pacientes. Conclusión: Es importante advertirle al paciente antes de la cirugía sobre la posibilidad de hipoestesia cutánea como complicación posoperatoria, debido a su alta frecuencia, aunque es poco probable que dicha complicación afecte la calidad de vida. Nivel de Evidencia: IV

Introduction: Clavicle fractures account for 4% of adult fractures, with mid-shaft fractures accounting for 80%. Although surgical treatment reduces the risk of pseudarthrosis, malunion, and residual pain, it is not without complications such as regional hypoesthesia (12-29%). Objective: To determine the prevalence of subclavicular hypoesthesia following open reduction and internal fixation for clavicle fracture, as well as if and how it impacts the patient's quality of life. Materials and Methods: A prospective cross-sectional analytical study of patients with displaced clavicle midshaft fractures treated with ORIF between 2018-2021 was performed. The research team used a questionnaire with six items that were completed anonymously. The presence of infraclavicular hypoesthesia, regional pain, and daily life interference was assessed. Results: Twenty-nine patients treated surgically with a longitudinal approach and with a minimum postoperative follow-up of one year were evaluated. Twenty-two patients (76%) had altered sensitivity, whereas seven (24%) denied the existence of the symptom. In 97% of individuals with subclavicular hypoesthesia, quality of life was impaired minimally or not at all. Conclusions: Before undergoing surgery, it is important to inform the patient about the risk of cutaneous numbness as a postoperative consequence due to its high frequency but improbable impact on daily activities. Level of Evidence: IV

Anesthetic management in neurological disorders: is combined spinal-epidural a suitable option? Case report / Manejo anestésico en trastornos neurológicos: ¿es la anestesia espinal-epidural una alternativa apropiada? Reporte de caso

Abstract Tuberous sclerosis (TSC) is a rare disease with multi-systemic involvement, predominantly neurological. Little evidence exists about the anesthetic management of patients with this disorder, particularly in pregnant women. This article discusses a case of a patient with TSC admitted to our hospital for the delivery of a twin gestation. Twenty-four hours after surgery, the patient presented left-side facial-brachial hypoesthesia and headache. A brain CT revealed a right frontal cortical bleeding tumor, which was diagnosed as glioblastoma multiforme. The patient was discharged 15 days after admission and a neurosurgical approach was suggested.

Resumen La esclerosis tuberosa es una enfermedad poco frecuente asociada con compromiso multisistémico, principalmente neurológico. Es poca la evidencia sobre el manejo anestésico de los pacientes con este trastorno, en particular las mujeres embarazadas. En este artículo presentamos el caso de una paciente con esclerosis tuberosa ingresada en nuestro hospital para el parto de una gestación gemelar. Veinticuatro horas después de la cirugía, la paciente presentó hipoestesia facial y braquial izquierda y cefalea. La tomografía cerebral mostró un tumor cortical sangrante en el lóbulo frontal derecho, diagnosticado como glioblastoma multiforme. La paciente fue dada de alta 15 días después de su ingreso y, con recomendación de manejo por neurocirugía.

Late recurrence of Burkitt's lymphoma in the jaw: numb chin syndrome as the only symptom

The Numb Chin Syndrome (NCS) is defined as facial and oral numbness restricted to the mental nerve's distribution involving the lower lip, skin of the chin, or gingiva of the lower anterior teeth. Hypoesthesia can occur unilaterally or bilaterally. Although this syndrome is rare, its importance is related to the fact that it represents the clinical manifestations of malignant diseases. Breast cancer and non-Hodgkin lymphoma are the most common cause of NCS. The patient, a 58-year-old woman, treated for a Burkitt Lymphoma (BL) nine years ago, described a two-week history of change in sensitivity and pain in the chin region, without relief with the use of analgesics. She had no headache, speech disturbance, dysphagia, visual disturbance, or other neurological symptoms. No surgical intervention has been performed recently. The intraoral examination revealed a healthy oral mucosa and a small area adjacent to the right mental nerve region that was uncomfortable to palpation. No changes were found in the bone trabeculae at cone-beam computed tomography. The contrasted magnetic resonance features made it possible to identify a change in the mandibular body extending to the entire right side, coinciding with the patient's complaint, indicating a probable mandibular medullary invasion. The patient was submitted to a biopsy to rule out a possible recurrence of BL. The microscopic findings were consistent with the diagnosis of BL. The present report described a very unusual presentation of late recurrent BL nine years after the first treatment, which manifested as an NCS.

Hipocalemia sintomática asociada al uso de Llantén ("Plantago major") / Symptomatic hypokalemia associated with use of Llantén ("Plantago major")

RESUMEN Introducción: El uso de plantas medicinales se asocia a la creencia de ausencia de efectos adversos. Objetivo: Reportar una posible asociación entre el uso de Plantago major e hipocalemia Presentación de caso: Paciente mujer de 38 años que acudió con entumecimiento y debilidad en extremidades debido a hipocalemia (2.94 meq/l) asociada al uso de Plantago major (Llantén), una planta medicinal de uso generalizado en Perú y de distribución global. El potasio se normalizó y los síntomas disminuyeron después de descontinuar el Llantén. Conclusión: El empleo de plantas medicinales de uso común debe tener en cuenta siempre posibles efectos adversos (AU)

ABSTRACT Introduction: The use of medicinal plants is associated with the belief of the absence of adverse effects. Objective: To report a possible association between the use of Plantago major and hypokalemia Case presentation: Thirty-eight-year-old female patient with numbness and weakness in her limbs due to hypokalemia (2.94 meq/l) associated with the use of Llantén (Plantago major), a medicinal plant of widespread use and global distribution. Potassium was normalized and symptoms subsided after discontinuation of Llantén. Conclusion: Possible adverse effects of the use of commonly used medicinal plants must always be considered(AU)

A Comparison between Oblique and Vertical Incisions on the Hamstring Tendon Harvesting in Anterior Cruciate Ligament Reconstruction and Infrapatellar Branch Injury of the Saphenous Nerve / Uma comparação entre incisões oblíquas e verticais na coleta do tendão dos isquiotibiais na reconstrução do LCA e na lesão do ramo infrapatelar do nervo safeno

Abstract Objective The present study aimed to compare the oblique and vertical incisions in hamstring tendon harvesting in anterior cruciate ligament (ACL) reconstruction and in infrapatellar branch injury of the saphenous nerve. Methods The present study was conducted at a tertiary referral center for 12 months. Patients with an indication of reconstruction of ACL tear were included in the study, who were then randomized into two groups (vertical [VG] and oblique [OG] groups). After excluding a few cases, 92 patients were eligible for further analysis (VG: n= 44; OG: n = 48). They were followed-up for 9 months after the surgery, and loss of sensation over the knee and over the proximal aspect of the operated leg was recorded. Results The mean lengths of the incisions were 27 mm and 38 mm for the OG and VG groups, respectively. The total rate of hypoesthesia was 40% (27 patients). A total of 12 (25%) and 25 patients (56.8%) on the OG and VG groups, respectively, reported hypoesthesia symptoms. The presence of hypoesthesia in patients in the VG group was two times higher than in the OG group. No statistical correlation was observed between the nerve injury and age, gender, education, and delay from injury to reconstruction. Conclusion Oblique incision, which showed lower risk of nerve damage, might be more recommended for graft harvesting. Patients who underwent reconstruction of the ACL in the OG group had a lower incidence of peri-incisional hypoesthesia when compared to those in the VG group.

Resumo Objetivo O presente estudo teve como objetivo comparar as incisões oblíquas e verticais na coleta dos tendões dos isquiotibiais na reconstrução do ligamento cruzado anterior (LCA) e na lesão do ramo infrapatelar do nervo safeno. Métodos O presente estudo foi realizado em um centro de referência terciário por 12 meses. Pacientes com indicação de reconstrução de uma ruptura do LCA foram incluídos no estudo, os quais foram randomizados em dois grupos (vertical [GV] e oblíquo [GO]). Após a exclusão de alguns casos, 92 pacientes foram elegíveis para análise posterior (GV: n= 44; GO: n = 48). Eles foram acompanhados por 9 meses após a cirurgia, e a perda de sensibilidade sobre o joelho e sobre o aspecto proximal da perna operada foi registrado. Resultados Os comprimentos médios da incisão foram de 27 mm e 38 mm para os grupos GO e GV, respectivamente. A taxa total de hipoestesia foi de 40% (27 pacientes). Um total de 12 (25%) e de 25 pacientes (56,8%) dos grupos GO e GV, respectivamente, relataram sintomas de hipoestesia. A presença de hipoestesia em pacientes no grupo GV foi duas vezes maior do que no grupo GO. Não foi observada correlação estatística entre a lesão do nervo e idade, gênero, escolaridade e demora entre a lesão e a reconstrução. Conclusão A incisão oblíqua, que apresentou menor risco de lesão nervosa, pode ser mais recomendada para a coleta do enxerto. Pacientes submetidos à reconstrução do LCA no grupo GO tiveram menor incidência de hipoestesia peri-incisional quando comparados aos pacientes do grupo GV.

Exodontia de pré-molar incluso em íntimo contato com o nervo mentoniano: relato de caso / Unerupted premolar extraction in close contact with the mental nerve: case report

Ocasionalmente, as unidades dentárias sofrem alterações em sua região de desenvolvimento natural, impossibilitando a erupção ou irrompimento em posições funcionais. Objetivo: O presente trabalho tem como objetivo relatar o procedimento ambulatorial de exodontia de pré-molar impactado em íntimo contato com o nervo mentual, observando os riscos presentes. Relato de Caso: Paciente do gênero feminino, faioderma, 30 anos de idade, procurou o serviço de Cirurgia e Traumatologia Bucomaxilofacial da OSID/UFBA para exodontia da unidade 35 inclusa, com finalidade ortodôntica, após insucesso de tracionamento prévio. O plano de tratamento incluiu exodontia do elemento 35 sob anestesia local. No pós-operatório de sete dias, foi referida presença de hipoestesiaemregião de mento e lábioesquerdo, sendo esta sintomatologia ausente após o vigésimo primeiro dia de acompanhamento. No momento, em acompanhamento de 04 meses de pós-operatório, a paciente encontra-se sem sinais e sintomas de hipoestesia em hemiface afetada, bem como retorno ao tratamento ortodôntico. Conclusão: A técnica cirúrgica minimamente invasiva é imprescindível para obtenção de bons resultados com o mínimo de repercussão para o paciente, ainda que o trauma cirúrgico devido ao afastamento do nervo mentoniano possa provocar alteração de sensibilidade pós-operatória temporária. Este caso pode contribuir para a literatura mínima disponível sobre os segundos pré-molares impactados, oferecendo uma opção de abordagem em seu plano de tratamento, de forma a evitar lesões ao nervo mentoniano e persistência de hipoestesia no pós-operatório(AU)

Occasionally, dental units undergo changes in their region of natural development, making it impossible to erupt in functional positions. Objective: The present study aims to report the outpatient procedure of impacted premolar extraction in close contact with the mental nerve, observing the present risks. Case Report: Female patient, faioderm, 30 years old, sought the Service of Oral and Maxillofacial Surgery of OSID/UFBA for extraction of included unit 35, with orthodontic purpose, after failure of previous orthodontic traction. Conclusion: The minimally invasive surgical technique is essential to obtain good results with minimal repercussion for the patient, although the surgical trauma due to the separation of mental nerve may cause a change in the temporary postoperative sensitivity. This case may contribute to the minimal literature available about impacted second premolars, offering an option of approach in its treatment plan, in order to avoid lesions to the mental nerve and persistence of postoperative hypoesthesia(AU)

Fístula arteriovenosa dural espinal: a propósito de un caso / Spinal dural arteriovenous fistula: a case report

Las fístulas arteriovenosas durales medulares son malformaciones vasculares adquiridas que constituyen una causa muy infrecuente de mielopatía progresiva (5-10 casos por millón de habitantes por año). La resonancia magnética es el estudio por imágenes de elección para su diagnóstico. A continuación presentamos el caso de una paciente femenina de 89 años, que consultó a la guardia de nuestra institución por un cuadro de paraparesia moderada asociada a parestesias e incontinencia urinaria posterior a esfuerzo físico. Se le diagnosticó una fístula arteriovenosa dural medular como causante de su cuadro. (AU)

Spinal dural arteriovenous fistulas (SDAVF) are acquired spinal vascular malformations and a rare cause of progressive myelopathy (5-10 new cases per year and per 1 million inhabitants). Magnetic resonance imaging is the diagnosis modality of choice. We present a case of a 89-year-old female patient who consulted the emergency department of our institution because of paraparesis and lower extremities paresthesias associated with urinary incontinence post physical effort. With the final diagnosis of spinal dural arteriovenous fistula, as a cause of the clinical symptoms. (AU)

The challenging approach to a combined neurotrophic and exposure corneal ulcer / Abordagem desafiante de uma úlcera de córnea neurotrófica e por exposição

ABSTRACT This study aims to describe a challenging clinical case of a patient with a neurotrophic and exposure corneal ulcer. A 75-year-old male patient, with history of right eye (RE) limbic stem-cell insuficiency due to complications of recurrent herpetic keratitis, underwent successful limbic stem-cell transplantation in 2008. In 2010, an uneventful penetrating keratoplasty was performed. After a cataract phacoemulsification surgery with intraocular lens implantation done in 2011, best corrected visual acuity was 20/20, and remained stable until 2015. In July 2015, the patient developed right facial nerve palsy and two months later, presented with an extensive central corneal ulcer, with a significant thinning of central stroma, without infection signs, but with an imminent risk of perforation. Treatment with topical ofloxacin and intensive ocular lubrification was started in association with permanent ocular oclusion. Due to lack of any clinical improvement, treatment with RGTA [Poli (carboximetilglucose) sulfate, dextrano T40] (Cacicol®, Thea) was started. After two weeks of treatment, a complete reepithelization and partial stromal filling was observed. Continued monitoring and treatment with artificial tears was maintained, with no recurrence observed. There is an unmet need for a medical therapy that could help corneal neurotrophic ulcers to heal. The presented clinical case shows that the approach of targeting extracellular matrix can be effective in the reepithelialization of neurotrophic and exposure corneal ulcer that do not respond to conventional treatments.

RESUMO Este trabalho relata um caso clínico desafiante de doente com uma úlcera de córnea neurotrófica e de exposição. Doente do sexo masculino, de 75 anos, com antecedentes de queratites herpéticas de repetição no olho direito (OD), complicadas com o desenvolvimento de uma insuficiência límbica, foi submetido com sucesso a transplante de células límbicas em 2008. Em 2010 foi submetido a queratoplastia penetrante e em 2011, após realização de cirurgia de catarata, apresentava uma melhor acuidade visual corrigida (MAVC) de 20/20. A MAVC manteve-se estável até Julho de 2015, altura em que desenvolveu paresia facial periférica à direita. Dois meses depois, o doente desenvolveu uma úlcera de córnea central extensa, com adelgaçamento significativo do estroma central, sem sinais de infeção, mas com risco iminente de perfuração. Foi iniciado tratamento tópico com ofloxacina, lubrificação intensiva e oclusão ocular contínua. Por ausência de melhoria clínica, foi iniciado tratamento tópico com um RGTA [Poli (carboximetilglucose) sulfato, dextrano T40] (Cacicol®, Thea). Após duas semanas de tratamento, observou-se uma reepitelização completa e regeneração parcial do estroma. Foi mantida monitorização regular e tratamento com lágrimas artificiais, sem recidiva do quadro clínico. Há uma grande necessidade de tratamentos médicos que possam ajudar na regeneração de úlceras de córnea neurotróficas e de exposição. O caso clínico apresentado sugere que os fármacos que têm por alvo a matrix extracelular poderão ser eficazes na reepitelização de úlceras de córnea neurotróficas e de exposição que não respondem ao tratamento convencional.

Brachial Plexus Injuries with Ulnar Musculocutaneous Transfer: 78 Cases Study Focused on Possible Postoperative Complications

Objective To analyze 78 cases of brachial plexus injury submitted to the Oberlin technique between 2003 and 2012. The potential complications of this technique were analyzed, especially motor damage or hypoesthesia of the hand. Method Medical records from patients with brachial plexus injuries at the levels of the C5-C6 and C5-C6-C7 vertebrae were retrospectively analyzed. Cases submitted to the Oberlin procedure with or without concomitant brachial plexus procedures between 2003 and 2012 were evaluated. The minimum follow-up period was of 1 year. In addition to the clinical examination, electromyography and magnetic resonance imaging (MRI) of the brachial plexus were used to diagnose and locate the nerve damage. Results A total of 78 surgical patients met the inclusion criteria. Postoperative neurological changes, mostly transient, were observed in 18 patients. Hypoesthesia in the ulnar side of the handwas observed in seven cases; neuropathic pain in five cases; allodynia in four cases, and hand motor loss in two cases. Conclusion Based on the results of the present case series, we conclude that there are few sequelae in the donor nerve territory compared with the benefit of the Oberlin technique on the recovery of elbow flexion after brachial plexus injuries.

Histiocitosis de células de Langerhans con compromiso vertebral / Langerhans cell histiocytosis with vertebral involvement

Resumen: Introducción: La histiocitosis de células de Langerhans (HCL) es un trastorno histiocítico raro y su incidencia exacta se mantiene desconocida; se ha diagnosticado en todos los grupos de edad, pero es más común en los primeros 3 años de vida. Se caracteriza por lesiones únicas o múltiples de tipo osteolítico causadas por proliferación clonal de células histológicamente similares a las células de Langerhans; su presentación clínica es heterogénea. Caso clínico: Presentamos el caso de una paciente de sexo femenino de 7 años, con dificultad para la marcha y debilidad progresiva en los miembros inferiores de 5 días de evolución. A la exploración física presenta hallazgos concordantes con síndrome piramidal e hipoes­ tesias de miembros inferiores. Se realizó resonancia magnética (RM) de columna y tomografía computarizada de cráneo simple, que descartó patología intracraneal . En la RM de columna se detectó vertebra plana con extensión epidural y para­ vertebral, por lo que se inició manejo con esteroides y se indicó descompresión quirúrgica. Se realizó resección parcial y biopsia de la lesión. Debido a los hallazgos histológicos y la presencia de marcadores positivos para CD1a y CD207, se confirmó el diagnóstico de HCL. Conclusiones: La HCL es una enfermedad poco frecuente y de difícil diagnóstico por su presentación heterogénea. El granuloma eosinofílico y la vértebra plana como hallazgos imagenológicos pueden orientar el diagnóstico, aunque siempre se debe confirmar histológicamente.

Abstract: Background: Langerhans cell histiocytosis (LCH) is a rare disease, more common in the first three years of lite. lt is characterized by single ar multiple osteolytic lesions due to clonal proliferation of cells histologically similar to Langerhans cells; its clínical presentation is heterogeneous. Case report: 7-year-old female patient with 5 days of progressive lower extremity weakness and difficulty to walk. Physical exam findings were consistent with pyramidal syndrome and lower extremities hypoesthesia. Magnetic resonance imaging (MRI) of spine and cranial computed tomography (CT) were performed. lntracranial pathology was ruled out. The MRI findings showed vertebra plana with epidural and paravertebral involvement, so treatment with steroids and surgical decompression initiated. Partíal resection and biopsy of the lesion was performed. Due to histological findings and positive CD1a and CD207 markers, diagnosis of LCH was confirmed. Conclusions: LCH is an uncommon disease with a challenging diagnosis due to its heterogeneous clinical presentation. Eosinophilic granuloma and vertebra plana as imaging findings may guide the diagnosis. However, it should always be confirmed with histological evidence.

Utilização de lente de contato escleral na abordagem terapêutica da úlcera neurotrófica corneana / Use of scleral contact lens in the therapeutic approach of corneal neurotrophic ulcer

Resumo Neste artigo descrevemos como conduzimos com sucesso um caso de úlcera neurotrófica não responsivo à terapia convencional com o uso de lente de contato escleral e as vantagens desta terapêutica.

Abstract In this paper we describe how we successfully conducted a case of neurotrophic ulcer not responsive to conventional therapy using scleral contact lens and the advantages of this therapy.

Lepra neural pura de 18 años de evolución / 18 years of pure neuritic leprosy

La lepra puede presentar dificultades diagnósticas, especialmente en la forma neural primaria. Un hombre de 38 años, exsoldado y trabajador rural, presentó durante más de 10 años hiperestesia supraclavicular y supraescapular izquierdas y anestesia progresiva escapular y en guante de la mano y brazo izquierdos, con reabsorción ósea de las falanges distales del primero y segundo dedos de la misma mano, cambios que le dificultaban realizar sus labores; no tenía lesiones cutáneas de lepra. El nervio cubital izquierdo presentaba engrosamiento epitroclear, por lo que se sospechó lepra neural pura. Las baciloscopias de moco, pabellones auriculares y codos fueron negativas, al igual que los anticuerpos IgM contra el glicolípido fenólico 1; dos biopsias de piel de zonas anestésicas fueron normales también. La electromiografía evidenció disminución notoria de los potenciales sensitivos de los nervios cubital, radial y mediano izquierdos, lo cual favoreció el diagnóstico de lepra neural primaria. Se inició tratamiento para lepra multibacilar por tener afección de más de un tronco nervioso, dos meses después comenzó a presentar mejoría notoria de los síntomas y logró reanudar sus actividades comunes y laborales. La lepra neural primaria cursa con zonas de hipoestesia y anestesia cutánea y engrosamiento neural troncular, puede permanecer sin diagnóstico durante años. La electromiografía, que demuestra disminución de los potenciales sensitivos, es una ayuda diagnóstica considerable, mientras la biopsia de piel anestésica ayuda al diagnóstico solo en la tercera parte de los casos. La sospecha clínica razonable es suficiente para iniciar tratamiento antileproso, cuando no se dispone de otros medios diagnósticos.

Leprosy can be difficult to diagnose, in particular the pure neuritic leprosy type. A 38-year-old male, former soldier and rural worker, presented with a 10-year history of supraclavicular and suprascapular hyperesthesia of the left side and progressive scapular left arm anesthesia, including the hand, associated with bone resorption in distal phalanges of the first and second finger. No typical leprosy skin changes were present. An examination of the skin revealed epitrochlear thickening of the left side cubital nerve, therefore primary neural leprosy was suspected. Skin smears from the routine sites were normal, as were two skin biopsies and the serologic assay specific for M leprae to detect phenolic glycolipid-1. Electromyography revealed an important reduction in the sensory action potential of the ulnar, radial and medial nerves, which favored the primary neural leprosy diagnosis. After two months of multibacillar leprosy treatment, the symptoms started to disappear and the patient could recommence his old job. Pure neuritic leprosy presents with skin areas of hypesthesia and anesthaesia associated with nerve thickening. It is a disease that is commonly misdiagnosed for several years before the correct diagnosis is made and effective treatment is started. Electromyography can be a helpful tool in the diagnosis, typically showing reduced sensory action potential, while a biopsy of anesthetic skin is only helpful in one-third of cases. Reasonable clinical suspicion is sufficient to initiate antileprosy treatment when no other diagnostic methods are available.

Avaliação de sensibilidade objetiva versus sensibilidade subjetiva após fraturas de zigoma / Sensitivity assessment objective versus objective after fracture of zygoma

Introdução: Cirurgiões bucomaxilofaciais frequentemente tratam fraturas do complexo zigomaticofacial e, com isso, os sinais e sintomas auxiliam o profissional a estabelecer o diagnóstico e a conduta frente a cada caso. A presença de alteração de sensibilidade é um sintoma frequente neste tipo de trauma. Objetivo: Avaliar comparativamente a presença e as alterações de sensibilidade subjetiva e sensibilidade objetiva após fraturas de zigoma. Metodologia: Foram selecionados 14 pacientes com fraturas unilaterais de zigoma. A sensibilidade subjetiva foi avaliada por meio de um questionário e a sensibilidade objetiva, mensurada por meio do monofilamento de Semmes-Weinstein. Resultado: Os resultados mostraram alteração de sensibilidade em 13 pacientes (92,84%); destes, oito pacientes (57,13%) apresentaram alterações de ordem subjetiva e dez (71,42%), de ordem objetiva. Alterações concomitantes de sensibilidade subjetiva e sensibilidade objetiva foram encontradas em cinco pacientes (35,71%). Afetados exclusivamente por um tipo de alteração de sensibilidade somaram oito pacientes (57,13%); destes, cinco pacientes (35,71%) apresentaram somente alterações objetivas e três pacientes (21,42%), apenas alterações subjetivas. A única queixa de sensibilidade subjetiva encontrada foi a hipoestesia, com sete casos (50%). Conclusão: As alterações de sensibilidade são frequentemente encontradas após fraturas de zigoma, existindo uma forte correlação entre a perda da percepção subjetiva e a perda da sensibilidade objetiva; porém, ocorre predominância de alterações de ordem objetiva.

Introduction: Maxillofacial surgeons often treat zygomatic facial complex fractures, therefore, signs and symptoms of these fractures help establish the diagnosis and the procedure for every case. The presence of sensibility alteration is a common symptom in this type of trauma. Objective: This study evaluated comparatively the presence and changes of subjective and objective sensitivity after zygomatic fractures. Methodology: Fourteen patients were selected with unilateral fractures of zygomatic. Subjective sensitivity was evaluated through a questionnaire and objective sensitivity measured by the Semmes-Weinstein monofilament. Result: The results shows sensibility alteration was found in 13 patients (92.84%), of these, 8 patients (57.13%) had changes of subjective order and 10 (71.42%) of objective order. Concomitant changes in subjective and objective sensitivity were found in 5 patients (35.71%). Patients affected only by one type of sensibility alteration totaled 8 patients (57.13%); of these, 5 patients (35.71%) had only objective alterations and 3 patients (21.42%) only subjective sensitivity alterations. The only complaint of subjective sensitivity was hypoesthesia in 7 cases (50%). Conclusion: The sensitivity changes are often found after zygomatic fractures there is a strong correlation between the loss of subjective perception and objective, however, especially the changes in the objective order.

Conceptos actuales de patología anorrectal funcional / Current concepts in functional anorectal disorders

The purpose of the present article is to highlight relevant aspects of anorectal pathology, mainly fiber resistant constipation, fecal incontinence and fecal soiling. A high percentage of patients with fiber resistant constipation correspond to dyssynergic defecation cases. In addition, most patients with dyssinergia and slow colonic transit return to normal after correction of the dyssyinergic condition. For these reasons, the current recommendation is to consider the evaluation of dyssynergic defecation as the initial diagnostic approach in patients with laxative-resistant constipation. Rectal hyposensitivity is an important pathophysiological mechanism involved in both constipation and fecal incontinence. About 80% of fecal incontinence cases present multiple pathological mechanisms, including sphincter insufficiency, rectal hyposensitivity, poor rectal emptying and impaired rectal compliance. Soling and seepage are usually in the context of poor rectal emptying and not in the context of sphincter insufficiency.

El siguiente artículo pretende destacar aspectos relevantes en patología anorrectal funcional, principalmente constipación resistente a fibra, incontinencia fecal y ensuciamiento. Entre los pacientes con constipación resistente a fibra, un alto porcentaje corresponde a defecación disinérgica. Además, la mayoría de los pacientes con defecación disinérgica y tránsito colónico enlentecido normalizan el tránsito tras mejoría de la disinergia. Por estos motivos, la recomendación actual es la evaluación de defecación disinérgica como primera estrategia diagnóstica en los pacientes con constipación refractaria a laxantes. La hiposensibilidad rectal es un mecanismo importante en casos de constipación e incontinencia fecal. Alrededor de 80% de los casos de incontinencia fecal tienen múltiples mecanismos descritos, incluyendo insuficiencia esfinteriana, hiposensibilidad rectal, mal vaciamiento rectal y alteraciones de la complianza rectal. El ensuciamiento suele estar en el contexto de mal vaciamiento rectal y no en el contexto de insuficiencia esfinteriana.

Desempenho sensório-motor na paresia aferente em paciente após acidente vascular encefálico crônico: relato de caso / Sensorimotor performance in afferent paresis in chronic stroke patient: case report

Introdução: Lesões no giro cerebral pós-central podem causar o fenômeno de paresia aferente. Objetivo: Descrever o desempenho sensório-motor de uma paciente com paresia aferente pós-acidente vascular encefálico (AVE) crônico. Métodos: Paciente do sexo feminino, 39 anos, com diagnóstico de hemorragia subaracnoide aguda por rompimento de aneurisma em artéria cerebral média direita foi submetida a protocolo de desempenho físico de Fugl-Meyer, avaliação sensorial de Nottingham, teste dos sinos, testes de sequência motora e dez testes funcionais, sendo os dois últimos executados com e sem privação visual. Resultados: A paciente apresentou comprometimento motor leve, hipoestesia tátil e ausência de propriocepção em punho e mão, astereognosia e dificuldade na resolução de tarefas motoras durante a privação visual. Conclusão: A paciente com sequelas crônicas pós-AVE apresentou déficits sensoriais e lentidão ou incapacidade de realização das tarefas motoras manuais na ausência da orientação visual, caracterizando, assim, a paresia aferente.

Introduction: Lesions on the postcentral gyrus may cause the phenomenon denominated afferent paresis. Objective: To describe sensorimotor performance of a patient with afferent paresis after chronic stroke. Methods: Female patient, 39 years with a diagnosis of acute subarachnoid hemorrhage caused by rupture of an aneurysm in the right middle cerebral artery underwent physiotherapy assessment. She was subjected to the Fugl-Meyer assessment, Nottingham sensory assessment, the bells test, the motor sequences and ten functional tests, the last two were performed with and without visual deprivation. Results: The patient had mild motor dysfunction, tactile hypoesthesia and absence of proprioception in the wrist and hand, astereognosis and difficulty in resolving motor tasks during visual deprivation. Conclusion: The chronic post-stroke patient exhibited significant sensory deficits in the contralesional upper extremity and slowness or inability to perform motor tasks only in the absence of visual guidance, thus characterizing the afferent paresis.

Avaliação da eficácia do uso dos monofilamentos de Semmes-Weinstein para avaliação da sensibilidade abdominal / Evaluation of the effectiveness of Semmes­Weinstein monofilaments in assessing abdominal sensitivity

OBJETIVO: O objetivo deste estudo é avaliar se o método de Semmes-Weinstein tem resultados consistentes e verificar se existem diferenças de sensibilidade entre as regiões da parede abdominal. MÉTODOS: Os monofilamentos de Semmes-Weinstein foram utilizados para avaliar a sensibilidade da pele à pressão abdominal em 20 voluntárias. A pele abdominal foi dividida em nove regiões. A avaliação da sensibilidade cutânea à pressão foi realizada três vezes em cada área, com um intervalo de uma semana entre as medidas. RESULTADOS: Analisando-se as três medidas em cada área, isoladamente, não houve diferenças significativas no limiar pressórico. No entanto, o método de Semmes-Weinstein mostrou diferença estatisticamente significativa entre os valores pressóricos obtidos de cada região abdominal. CONCLUSÕES: Os monofilamentos de Semmes-Weinstein são consistentes para avaliar a sensibilidade da pele abdominal à pressão. Notou-se que o método de Semmes-Weinstein mostrou diferença estatisticamente significativa entre as diferentes áreas da região abdominal. Utilizando-se a metodologia do presente estudo, foi possível estabelecer um protocolo para reduzir o aspecto subjetivo, medindo a sensibilidade à pressão.

OBJECTIVE: The aim of this study is to evaluate whether Semmes-Weinstein monofilaments could be used to reliably assess the sensitivities of different abdominal wall regions. METHODS: Semmes-Weinstein monofilaments were used to evaluate skin sensitivity to abdominal pressure in 20 volunteers. The abdominal skin was divided into nine regions. The assessment of skin sensitivity to pressure was carried out three times in each area, with 1 week intervals between measurements. RESULTS: No significant differences in the pressure threshold were observed when the three measurements in each region were analyzed separately. However, with the Semmes-Weinstein monofilament technique, a statistically significant difference was observed between the values of pressure obtained in each abdominal region. CONCLUSIONS: Semmes-Weinstein monofilaments are a reliable tool in evaluating abdominal skin sensitivity to pressure. A statistically significant difference was observed between the different areas of the abdominal region with this technique. With the method reported in this study, it was possible to establish a protocol to reduce subjectivity and measure the skin sensitivity to pressure.