Graft of small patch of partial thickness in equine wound

Background: Cutaneous wounds in locomotor limbs represent one of the most frequent disorders in equine medicine. Wounds in equines are distinguished from those in other species by unique characteristics, including different healing rates among breeds, wound location and high propensity to formation of exuberant granulation tissue during the healing process. The wound healing process that cannot be sutured can be accelerated by the use of skin grafts, lowering the treatment cost. The objective of this report was to divulgate the success upon treatment of an extensive lacerated wound in the metatarsal region of a horse using autologous skin grafts.Case: A 3-year-old, female, American quarter horse weighting 450 kg was brought to veterinary hospital with lower limb injury. According to the owner’s report, the animal had one of its limbs stuck in a plain wire fence. A wound was observed in the metatarsal region during physical examination, the lesion caused an extensive skin laceration that showed the dorsal surface of the metatarsal bone and the digital extensor tendon. After injury assessment, wound debridement was carried out by surgery intervention followed by antisepsis and application of autologous plasma every two days as post-surgical care and wound preparation to receive the graft. Forty-five days after the first intervention, grafts were collected from the neck and implanted in the wound. The procedure achieved 70% of success. After approximately 75 days, transplantation was performed in other regions of the wound using the same technique. The duration of treatment at the Veterinary Hospital of the Universidade Paranaense (UNIPAR) was eight months, and then the animal returned home, where dressings were applied for two months to avoid the risk of contamination and until complete recovery.Discussion: The debridement of the wound and edges approximation were of great value in order to begin the process of wound granulation.[...]

Graft of small patch of partial thickness in equine wound

Background: Cutaneous wounds in locomotor limbs represent one of the most frequent disorders in equine medicine. Wounds in equines are distinguished from those in other species by unique characteristics, including different healing rates among breeds, wound location and high propensity to formation of exuberant granulation tissue during the healing process. The wound healing process that cannot be sutured can be accelerated by the use of skin grafts, lowering the treatment cost. The objective of this report was to divulgate the success upon treatment of an extensive lacerated wound in the metatarsal region of a horse using autologous skin grafts.Case: A 3-year-old, female, American quarter horse weighting 450 kg was brought to veterinary hospital with lower limb injury. According to the owners report, the animal had one of its limbs stuck in a plain wire fence. A wound was observed in the metatarsal region during physical examination, the lesion caused an extensive skin laceration that showed the dorsal surface of the metatarsal bone and the digital extensor tendon. After injury assessment, wound debridement was carried out by surgery intervention followed by antisepsis and application of autologous plasma every two days as post-surgical care and wound preparation to receive the graft. Forty-five days after the first intervention, grafts were collected from the neck and implanted in the wound. The procedure achieved 70% of success. After approximately 75 days, transplantation was performed in other regions of the wound using the same technique. The duration of treatment at the Veterinary Hospital of the Universidade Paranaense (UNIPAR) was eight months, and then the animal returned home, where dressings were applied for two months to avoid the risk of contamination and until complete recovery.Discussion: The debridement of the wound and edges approximation were of great value in order to begin the process of wound granulation.[...](AU)

Equine Sporotrichosis and iatrogenic hypothyroidism / Esporotricose equina e hipotireoidismo iatrogênico

Background: Sporotrichosis is a subacute or chronic granulomatous fungal infection that affects the dermis and subcutaneous tissue. Its etiology is related to a complex of Sporothrix spp. species of worldwide distribution. Usually, sporotrichosis results from traumatic inoculation of Sporothrix spp. into the dermis, affecting humans and other mammals, but a greater number of cases have been reported in felines, a fact increasingly important in the zoonotic transmission of diseased animals to man. In horses, there may be multiple ulcerated wounds covered with scabs and slightly elevated plaques or nodules that occur along lymphatic chains in limbs and can be unique and located. Iodides are considered drugs of choice for the treatment of sporotrichosis in horses. The main side effect of prolonged use of these substances is iodism and thyroid dysfunction. The aim of this study was to report a clinical case of sporotrichosis in an equine treated in the state of Paraná, southern Brazil, which showed secondary iatrogenic hypothyroidism with prolonged use of sodium and potassium iodide. Case: A female, 3-year-old, Quarter Horse, with 400 kg of liveweight presented at clinical examination of the cutaneous tissue elevated lesions of nodular aspect, with 2 to 4 cm in diameter, absence of itching and some nodules presenting alopecia areas in the chest and abdominal region, and in the [...](AU)

Equine Sporotrichosis and iatrogenic hypothyroidism / Esporotricose equina e hipotireoidismo iatrogênico

Background: Sporotrichosis is a subacute or chronic granulomatous fungal infection that affects the dermis and subcutaneous tissue. Its etiology is related to a complex of Sporothrix spp. species of worldwide distribution. Usually, sporotrichosis results from traumatic inoculation of Sporothrix spp. into the dermis, affecting humans and other mammals, but a greater number of cases have been reported in felines, a fact increasingly important in the zoonotic transmission of diseased animals to man. In horses, there may be multiple ulcerated wounds covered with scabs and slightly elevated plaques or nodules that occur along lymphatic chains in limbs and can be unique and located. Iodides are considered drugs of choice for the treatment of sporotrichosis in horses. The main side effect of prolonged use of these substances is iodism and thyroid dysfunction. The aim of this study was to report a clinical case of sporotrichosis in an equine treated in the state of Paraná, southern Brazil, which showed secondary iatrogenic hypothyroidism with prolonged use of sodium and potassium iodide. Case: A female, 3-year-old, Quarter Horse, with 400 kg of liveweight presented at clinical examination of the cutaneous tissue elevated lesions of nodular aspect, with 2 to 4 cm in diameter, absence of itching and some nodules presenting alopecia areas in the chest and abdominal region, and in the [...]

Immobilization with modified Thomas splint and synthetic casting for long bone fracture correction in large animals / Imobilização com muleta de Thomas modificada e gesso sintético para reparação de fraturas de ossos longos em grandes animais

Background: Several techniques have been used for the treatment of fractures in large animals, once these animals are frequently subject to trauma that interrupts bone continuity, especially in long bones. The choice for the technique depends on the configuration of the fracture, damage to the adjacent tissue, and presence or absence of bone exposure. The success of the modified Thomas splint, associated to synthetic casting has been reported in several studies. However, there still are restrictions to the use of this technique. Thus, the objective of the present study is to report the use of immobilization by the modified Thomas splint, coupled with synthetic casting, for the treatment of fractures in long bones of bovine and equine animals.Cases: The five animals were treated at the Veterinary Hospital of the Universidade Paranaense, being four bovines and one equine, all presenting fractures in long bones, resulting from accidental trauma. The equine, weighting 300 kg, presented fracture in the third metacarpal bone, previously submitted to immobilization through external fixation type II. Three bovines, weighting 50, 200, and 500 kg, presented fractures in the metacarpals, with the smallest presenting exposed fracture, another bovine, weighting 300 kg, presented fractures in the radius and ulna. The animals were examined and submitted to sedation and anesthesia for manual...(AU)

As fraturas de ossos longos ocorrem com relativa frequência em animais de grande porte [9] acarretando significativas perdas econômicas para a pecuária nacional [10], já que os elevados custos implicados no tratamento refletem na opção pela eutanásia [9]. No entanto, animais de alto valor econômico, estimulam o investimento em pesquisas e a utilização de efetivas técnicas para a correção de fraturas [10]. Nos últimos anos várias técnicas têm sido utilizadas no tratamento de fraturas em animais de grande porte, no entanto, ainda persiste a falta de dispositivos de fixação adequados e desenvolvidos especificamente para esses animais [3]. Relata-se o uso de gesso até o carpo/tarso ou por toda a extensão do membro [1], aparelho modificado de Thomas associado ou não à tala de gesso [6], utilização de parafusos, pinos intramedulares e placas ortopédicas [7], haste intramedular bloqueada [11] e fixação externa [4]. O sucesso do uso da muleta de Thomas modificada, associada ao gesso, tem sido relatado por diversos autores e, muitas vezes, é a opção de escolha em comparação com técnicas de fixação interna. Com base nisto, o presente trabalho tem como objetivo relatar cinco casos das espécies bovina e equina que apresentavam fratura decorrente de trauma, corrigidas com a utilização de muleta de Thomas modificada e gesso sintético, enfatizando a empregabilidade da técnica...(AU)

Ganho de peso e características de carcaça de bovinos nelore e meio sangue angus-nelore em regime de suplementação a pasto / Weight gain and carcass characteristics of nellore and crossbreed angus-nellore cattle on grazing supplementation scheme / Aumento de peso y características de esqueleto de bovinos nelore y media sangre angus-nelore en régimen de suplementos a pasto

A pecuária de corte brasileira tem sido marcada por intensas transformações, resultantes da aplicação de técnicas modernas de produção, da utilização dos cruzamentos entre raças, e das exigências do mercado consumidor. O desempenho do período pré-desmama é importante por se tratar do primeiro resultado de produtividade animal e a classificação e tipificação das carcaças possibilitam enquadrá-las em diferentes classes e, assim, direcioná-las a diferentes mercados. O objetivo deste trabalho foi comparar o desempenho pré-desmama e características de carcaças entre dois grupos genéticos: Nelore (NE), e ½ sangue Angus-Nelore (F1), os quais foram abatidos sem castração e suplementados a pasto do nascimento ao abate. Foram tomados, ao acaso, 36 animais sendo 18 machos da raça Nelore (NE) e 18 machos oriundos do cruzamento industrial entre Nelore e Angus, machos (F1), sendo todos submetidos ao mesmo manejo e abatidos sem castração, com idade aproximada de 20 meses. Durante o processo de abate, as carcaças foram classificadas e tipificadas. O grupo F1 foi superior ao grupo NE com diferença significativa referente ao peso ao nascer (p=0,0046), peso ajustado aos 205 dias (p=0,0002), peso ao desmame (p=0,0005), ganho de peso diário entre o nascimento e os 205 dias (p=0,001). Quanto às características de carcaças não houve diferença estatística entre os grupos (p>0,05), sendo que, ambos atingiram a exigência frigorífica para espessura de gordura. Observou-se uma superioridade nos animais F1 quanto ao desempenho pré-desmama, e nota-se a possibilidade de terminar animais inteiros a pasto, com acabamento de carcaça mínimo, desde que bem alimentados.(AU)

The Brazilian beef cattle industry has been marked by dramatic changes resulting from the application of modern production techniques, use of crossbreeding and consumer market requirements. The performance of the pre-weaning period is important because it is the first result of animal productivity, and the evaluation and classification of carcasses enable their categorization into different classes, and thus, their directing to different markets. The objective of this study was to compare the pre-weaning performance and carcass traits between two genetic groups: Nellore (NE) and Angus-Nellore crossbreed (F1), which were slaughtered without castration, receiving grazing supplementation from birth to slaughter. Thirty-six animals were randomly selected, 18 Nelore (NE) and 18 Angus-Nellore crossbreed (F1) animals, all males, submitted to the same management system and slaughtered without castration, with approximate age of 20 months. During the slaughtering process, carcasses were classified and typified. The F1 group was superior to the NE group with significant differences related to birth weight (p = 0.0046), weight adjusted to 205 days (p = 0.0002), weaning weight (p = 0.0005), daily weight gain between birth and 205 days (p = 0.001). Regarding carcass traits, there was no statistical difference between groups (p> 0.05), and both reached the requirement for fat thickness. F1 animals were superior in relation to pre-weaning performance, and there is possibility to slaughter whole animals on pasture, with minimal carcass finishing if well fed.(AU)

La pecuaria de corte brasileña ha sido marcada por intensas transformaciones, resultantes de la aplicación de técnicas modernas de producción, de utilización de los cruzamientos entre razas, y de exigencias del mercado consumidor. El desempeño del período pre destete es importante por tratarse del primer resultado de productividad animal, la clasificación y tipificación de los esqueletos posibilitan encuadrarlos en diferentes clases y, así, dirigirlos a diferentes mercados. El objetivo de esa investigación ha sido comparar el desempeño pre destete y características de esqueletos entre dos grupos genéticos: Nelore (NE), y ½ sangre Angus-Nelore (F1), los cuales fueron abatidos sin castración y suplementados a pasto desde el nacimiento al abate. Fueron tomados, al azar, 36 animales siendo 18 machos de la raza Nelore (NE) y 18 machos oriundos del cruzamiento industrial entre Nelore y Angus, machos (F1), siendo todos sometidos al mismo manejo y abatidos sin castración, con edad aproximada a 20 meses. Durante el proceso de abate, los esqueletos fueron clasificados y tipificados. El grupo F1 fue superior al grupo NE con diferencia significativa referente al peso al nascer (p=0,0046), peso ajustado a los 205 días (p=0,0002), peso al destete (p=0,0005), aumento de peso diario entre el nacimiento y los 205 días (p=0,001). Sobre las características de esqueletos no hubo diferencia estadística entre los grupos (p>0,05), siendo que, ambos alcanzaron la exigencia frigorífica para espesor de grasa. Se observó una superioridad en los animales F1 en el desempeño pre destete, y se nota la posibilidad de terminar animales enteros a pasto, con terminación de esqueleto mínimo, desde que bien alimentados.(AU)

Immobilization with modified Thomas splint and synthetic casting for long bone fracture correction in large animals / Imobilização com muleta de Thomas modificada e gesso sintético para reparação de fraturas de ossos longos em grandes animais

Background: Several techniques have been used for the treatment of fractures in large animals, once these animals are frequently subject to trauma that interrupts bone continuity, especially in long bones. The choice for the technique depends on the configuration of the fracture, damage to the adjacent tissue, and presence or absence of bone exposure. The success of the modified Thomas splint, associated to synthetic casting has been reported in several studies. However, there still are restrictions to the use of this technique. Thus, the objective of the present study is to report the use of immobilization by the modified Thomas splint, coupled with synthetic casting, for the treatment of fractures in long bones of bovine and equine animals.Cases: The five animals were treated at the Veterinary Hospital of the Universidade Paranaense, being four bovines and one equine, all presenting fractures in long bones, resulting from accidental trauma. The equine, weighting 300 kg, presented fracture in the third metacarpal bone, previously submitted to immobilization through external fixation type II. Three bovines, weighting 50, 200, and 500 kg, presented fractures in the metacarpals, with the smallest presenting exposed fracture, another bovine, weighting 300 kg, presented fractures in the radius and ulna. The animals were examined and submitted to sedation and anesthesia for manual...

As fraturas de ossos longos ocorrem com relativa frequência em animais de grande porte [9] acarretando significativas perdas econômicas para a pecuária nacional [10], já que os elevados custos implicados no tratamento refletem na opção pela eutanásia [9]. No entanto, animais de alto valor econômico, estimulam o investimento em pesquisas e a utilização de efetivas técnicas para a correção de fraturas [10]. Nos últimos anos várias técnicas têm sido utilizadas no tratamento de fraturas em animais de grande porte, no entanto, ainda persiste a falta de dispositivos de fixação adequados e desenvolvidos especificamente para esses animais [3]. Relata-se o uso de gesso até o carpo/tarso ou por toda a extensão do membro [1], aparelho modificado de Thomas associado ou não à tala de gesso [6], utilização de parafusos, pinos intramedulares e placas ortopédicas [7], haste intramedular bloqueada [11] e fixação externa [4]. O sucesso do uso da muleta de Thomas modificada, associada ao gesso, tem sido relatado por diversos autores e, muitas vezes, é a opção de escolha em comparação com técnicas de fixação interna. Com base nisto, o presente trabalho tem como objetivo relatar cinco casos das espécies bovina e equina que apresentavam fratura decorrente de trauma, corrigidas com a utilização de muleta de Thomas modificada e gesso sintético, enfatizando a empregabilidade da técnica...

Spontaneous poisoning by Senna occidentalis in a holstein heifer in the state of Paraná, Brazil / Intoxicação espontânea por Senna occidentalis em bovino no estado do Paraná, Brasil

Background: Senna occidentalis, commonly known as coffee senna or coffee weed, is the species of the genus Senna with the most reports of poisoning in bovines. The animals are poisoned by ingesting the plant or its parts, being the seeds the most toxic part, and the poisoning may occur in bursts or isolated, causing myopathy and causing significant mortality in bovines, especially in the southern regions of Brazil. The main clinical signs consist of muscle weakness and tremor, difficulty in walking, incoordination, permanent sternal decubitus, myoglobinuria and death, and the lesions found are mainly located in skeletal muscle. Due to the small number of cases of spontaneous poisoning reported, and the severity of such, the objective was to report epidemiological, clinical, and pathological aspects, observed in an isolated case of spontaneous poisoning by S. occidentalis in a Holstein heifer in the State of Paraná, southern Brazil.Case: A 20-month-old Holstein heifer presented clinical signs suggestive for muscular degeneration, such as permanent sternal decubitus, muscle tremors and dark colored urine. The presence of the plant in the farm where the animal was, together with the macroscopic and microscopic changes posteriorly observed, accounted for the diagnosis. The treatment used was not effective and the animal died three days after the first clinical manifestations...(AU)

Cerca de 200 espécies de plantas do gênero Senna estão presentes no continente americano [9]. A maioria das intoxicações, em bovinos, são decorrentes da ingestão de S. occidentalis [3], também relatadas em suínos domésticos [11], javalis [17] e equinos [1]. A intoxicação ocorre pela ingestão da planta ou partes dela, sendo as sementes aparte mais tóxica [19]. As principais consequências são miopatia e cardiomiopatia degenerativas [16] acarretando significativa mortalidade em bovinos, principalmente na região sul do Brasil [2]. A ingestão pode ocorrer espontaneamente, através de pastejo, ou acidentalmente, pela contaminação de concentrado com partes da planta [16], intoxicando animais isoladamente ou em forma de surtos, forma mais comum, podendo acometer até 60% do rebanho [2]. Os principais sinais clínicos consistem em fraqueza e tremor muscular, dificuldade de locomoção, incoordenação, decúbito esternal permanente, mioglobinúria e morte, e as lesões encontradas são localizadas, principalmente, na musculatura esquelética onde, macroscopicamente, observa-se áreas pálidas e áreas normais intercaladas e, microscopicamente, miopatia tóxica degenerativa [1,19].Devido ao baixo número de relatos de intoxicação espontânea e à gravidade desta patologia, objetivou-se relatar os aspectos epidemiológicos, clínicos e patológicos observados em um caso isolado de intoxicação espontânea...(AU)

Spontaneous poisoning by Senna occidentalis in a holstein heifer in the state of Paraná, Brazil / Intoxicação espontânea por Senna occidentalis em bovino no estado do Paraná, Brasil

Background: Senna occidentalis, commonly known as coffee senna or coffee weed, is the species of the genus Senna with the most reports of poisoning in bovines. The animals are poisoned by ingesting the plant or its parts, being the seeds the most toxic part, and the poisoning may occur in bursts or isolated, causing myopathy and causing significant mortality in bovines, especially in the southern regions of Brazil. The main clinical signs consist of muscle weakness and tremor, difficulty in walking, incoordination, permanent sternal decubitus, myoglobinuria and death, and the lesions found are mainly located in skeletal muscle. Due to the small number of cases of spontaneous poisoning reported, and the severity of such, the objective was to report epidemiological, clinical, and pathological aspects, observed in an isolated case of spontaneous poisoning by S. occidentalis in a Holstein heifer in the State of Paraná, southern Brazil.Case: A 20-month-old Holstein heifer presented clinical signs suggestive for muscular degeneration, such as permanent sternal decubitus, muscle tremors and dark colored urine. The presence of the plant in the farm where the animal was, together with the macroscopic and microscopic changes posteriorly observed, accounted for the diagnosis. The treatment used was not effective and the animal died three days after the first clinical manifestations...

Cerca de 200 espécies de plantas do gênero Senna estão presentes no continente americano [9]. A maioria das intoxicações, em bovinos, são decorrentes da ingestão de S. occidentalis [3], também relatadas em suínos domésticos [11], javalis [17] e equinos [1]. A intoxicação ocorre pela ingestão da planta ou partes dela, sendo as sementes aparte mais tóxica [19]. As principais consequências são miopatia e cardiomiopatia degenerativas [16] acarretando significativa mortalidade em bovinos, principalmente na região sul do Brasil [2]. A ingestão pode ocorrer espontaneamente, através de pastejo, ou acidentalmente, pela contaminação de concentrado com partes da planta [16], intoxicando animais isoladamente ou em forma de surtos, forma mais comum, podendo acometer até 60% do rebanho [2]. Os principais sinais clínicos consistem em fraqueza e tremor muscular, dificuldade de locomoção, incoordenação, decúbito esternal permanente, mioglobinúria e morte, e as lesões encontradas são localizadas, principalmente, na musculatura esquelética onde, macroscopicamente, observa-se áreas pálidas e áreas normais intercaladas e, microscopicamente, miopatia tóxica degenerativa [1,19].Devido ao baixo número de relatos de intoxicação espontânea e à gravidade desta patologia, objetivou-se relatar os aspectos epidemiológicos, clínicos e patológicos observados em um caso isolado de intoxicação espontânea...

Aerofagia em equinos: revisão de literatura / Aerofagia en equinos: revisión de literatura / Windsucking in horses: a literature review

São observados em diversos cavalos, alojados em baias, tendência a executarem uma variedade de atividades aparentemente sem função e comportamentos repetitivos, denominados estereotipias. Destes, a aerofagia é um vício geralmente adquirido, relativamente comum em equinos, sem distinção de raça e sexo, no qual o animal, apoiando os dentes incisivos em um objeto fixo, realiza um movimento de arqueamento e flexão do pescoço, conseguindo engolir certa quantidade de ar. Na aerofagia com o tempo ocorre desgaste excessivo dos dentes incisivos, perda de peso, hipertrofia dos músculos ventrais do pescoço, especialmente do músculo esternocefálico, cólicas por ulceração gástrica, encarceiramento do forame epiplóico e meteorismos ocasionais além da desvalorização do animal. Projetar adequadamente as baias optando por evitar superfícies de apoio, uso de eletrochoque, utilização de colar eletrônico para adestramento de cães, uso de colar de pescoço para evitar o movimento de deglutição, colocar o animal em companhia de outros em piquetes, aumentar o número de exercícios e fornecer maior quantidade de feno ou gramíneas verdes, são métodos que ajudam na prevenção dos episódios. Diante do insucesso de técnicas conservativas, três procedimentos cirúrgicos são descritos para o controle da aerofagia. São descritas também diversas modalidades terapêuticas, que podem reduzir a incidência dos episódios, embora melhores resultados resultem de cuidados profiláticos, antes dos vícios se estabelecerem.(AU)

In several horses housed in stalls, a tendency to perform a variety of apparently functionless activities and repetitive behaviors called stereotypies can be observed. Among these, windsucking is an addiction usually acquired that is relatively common in horses, regardless of breed or gender, in which the animal, holding its incisor teeth onto a fixed object, performs the movement of bending and flexing the neck, managing to swallow a certain amount of air. With time, windsucking causes excessive wear of the incisor teeth, weight loss, hypertrophy of the ventral neck muscles, especially the esternocephalic muscle, cramps due to gastric ulceration, trapping of the epiploic foramen and occasional meteorisms, as well as devaluating the animal. Properly designing the stalls, opting to avoid supporting surfaces, the use of electroshock, the use of electronic collar for dog training, the use of neck collar to prevent swallowing movements, placing the animal with others in paddocks, increasing the number of exercises and providing greater amount of hay or green grass are methods that help preventing these episodes. Given the failure of conservative techniques, three surgical procedures are described for the control of windsucking. Several therapeutic modalities are also described, which can reduce the incidence of the episodes, although better results arise from prophylactic care, before these addictions are established.(AU)

Se ha observado en varios caballos alojados en establos, tendencia a ejecutaren variedad de actividades aparentemente sin función y comportamientos repetitivos, llamados estereotipos. De éstos, la aerofagia es un vicio generalmente adquirido, relativamente común en equinos, independientemente de la raza y sexo, en que el animal apoyando los dientes incisivos en un objeto fijo, realiza un movimiento de arqueamiento y flexión del cuello, consiguiendo tragar cierta cantidad de aire. En aerofagia, con el tiempo, ocurre desgaste excesivo de los dientes incisivos, pérdida de peso, hipertrofia de los músculos del cuello ventral, especialmente del músculo externo cefálico, cólicos por ulceración gástrica, encarcelamiento del foramen epiploico y meteorismos ocasionales, además de la desvalorización del animal. Proyectar adecuadamente los establos, optando por evitar superficies de apoyo, uso de electroshock, uso de collar electrónico para adiestramiento de perros, uso de collar cervical para evitar el movimiento de deglución, poner el animal en compañía de otros en potreros, aumentar el número de ejercicios y proporcionar una mayor cantidad de heno o gramíneas verdes, son métodos que ayudan en la prevención de los episodios. Dado el fracaso de las técnicas conservadoras, tres procedimientos quirúrgicos se describen para el control de aerofagia. También se describen varias modalidades terapéuticas que pueden reducir la incidencia de episodios, aunque los mejores resultados surgen de la atención profiláctica y antes que se establezcan los vicios.(AU)