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2.
J Neurol Sci ; 408: 116550, 2020 Jan 15.
Artigo em Inglês | MEDLINE | ID: mdl-31677559

RESUMO

OBJECTIVE: Vestibular migraine (VM) is the most common neurologic cause of vertigo among adults. However, there are no specifically studied or approved rescue therapies for acute VM attacks. This study describes how external trigeminal nerve stimulation (eTNS) using the Cefaly® (CEFALY Technology, Seraing, Belgium) device relieves acute VM episodes. METHODS: Single-center, retrospective review of 19 patients with acute VM attacks (seen between May 2018 and June 2019) treated with 20-min eTNS. Prior to treatment, patients graded the severity of their vertigo/headache using a 10-point visual analog scale (VAS) with 0 representing no vertigo/headache, and 10 representing the worst imaginable vertigo/headache. After eTNS, patients graded their vertigo/headache using the same VAS 15 min. In addition, bedside neuro-otologic examination was performed before and after treatment. RESULTS: 19/19 patients reported improvement in vertigo severity. Mean vertigo severity was 6.6 (±2.1; median 7) before eTNS, and 2.7 (±2.6; median 3) following treatment; mean improvement in vertigo was 61.3% (±32.6; median 50.0%). During VM episodes, 14/19 experienced headache. Mean headache severity was 4.8 (±2.4; median 4.5) before eTNS, and was 1.4 (±2.4; median 0) following treatment; mean improvement in headache was 77.2% (±32.7; median 100.0%). Neuro-otologic examination was normal during VM attacks in all except Patient 7 who had spontaneous upbeat nystagmus which resolved after eTNS. Other improvements include improvement of eye pressure, head pressure, and chronic facial pain. No intolerable side effects were reported. CONCLUSION: This study provides preliminary evidence that eTNS is a novel, non-invasive, safe and effective treatment for acute VM attacks.

3.
Neurology ; 93(18): e1715-e1719, 2019 10 29.
Artigo em Inglês | MEDLINE | ID: mdl-31554650

RESUMO

OBJECTIVE: To report on the benefits of noninvasive vagus nerve stimulation (nVNS) on acute vestibular migraine (VM) treatment. METHODS: This was a retrospective chart review of patients with VM treated with nVNS in a single tertiary referral center between November 2017 and January 2019. Eighteen patients (16 women) were identified (mean age 45.7 [±14.8] years); 14 were treated for a VM attack and 4 for bothersome interictal dizziness consistent with persistent perceptual postural dizziness (PPPD). Patients graded the severity of vestibular symptoms and headache using an 11-point visual analog scale (VAS; 0 = no symptoms, 10 = worst ever symptoms) before and 15 minutes after nVNS. RESULTS: In those with acute VM, vertigo improved in 13/14 (complete resolution in 2, at least 50% improvement in 5). The mean vertigo intensity before nVNS was 5.2 (±1.6; median 6), and 3.1 (±2.2; median 3) following stimulation; mean reduction in vertigo intensity was 46.9% (±31.5; median 45%). Five experienced headache with the VM attack; all reported improvement following nVNS. Mean headache severity was 6 (±1.4; median 6) prior to treatment and 2.4 (±1.5; median 3) following nVNS; mean reduction in headache intensity was 63.3% (±21.7; median 50). All 4 treated with nVNS for interictal PPPD reported no benefit. CONCLUSION: Our study provides preliminary evidence that nVNS may provide rapid relief of vertigo and headache in acute VM, and supports further randomized, sham-controlled studies into nVNS in VM. CLASSIFICATION OF EVIDENCE: This study provides Class IV evidence that for patients with acute VM, nVNS rapidly relieves vertigo and headache.


Assuntos
Cefaleia/terapia , Transtornos de Enxaqueca/terapia , Estimulação Elétrica Nervosa Transcutânea/métodos , Estimulação do Nervo Vago/métodos , Vertigem/terapia , Doença Aguda , Adulto , Idoso , Feminino , Cefaleia/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Transtornos de Enxaqueca/fisiopatologia , Estudos Retrospectivos , Resultado do Tratamento , Vertigem/fisiopatologia , Doenças Vestibulares/fisiopatologia , Doenças Vestibulares/terapia , Adulto Jovem
4.
J Neuroophthalmol ; 39(2): 208-219, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-31094996

RESUMO

BACKGROUND: Vestibular migraine (VM) is the most common neurologic cause of vertigo in adults and results in significant utilization of health care resources, but remains under-recognized and underdiagnosed. EVIDENCE ACQUISITION: Review of literature in PubMed using the following terms: vestibular migraine, migraine-associated vertigo, vertiginous migraine, benign recurrent vertigo, migraine-associated dizziness, migraine, migraine treatment, Meniere disease (MD), vertebrobasilar ischemia (VBI), posterior circulation stroke, benign paroxysmal positional vertigo, and episodic-ataxia Type 2 (EA2). RESULTS: VM can manifest with a variety of vestibular symptoms, including spontaneous vertigo, triggered vertigo, positional vertigo, and head-motion dizziness. Patients may report more than 1 vestibular symptom. Episodes of vertigo are often, but not always, accompanied by headache. Auditory symptoms are frequently associated with VM attacks and may mimic the manifestations of MD. Other migrainous features that accompany VM attacks include photophobia, phonophobia, osmophobia, and visual aura. Interictally, patients may suffer from persistent dizziness or isolated paroxysmal vestibular symptoms. Mood disorders (particularly anxiety) are often found in VM. Abnormal neuro-otologic findings are not uncommon in patients with VM. Differential diagnoses for VM include MD, VBI, EA2, and migraine with brainstem aura. For rescue treatment, triptans, vestibular suppressants, and/or antiemetic agents may be considered. Pharmacologic migraine preventives (antiepileptics, beta-blockers, and antidepressants) are often useful. CONCLUSIONS: The keys to correctly diagnosing VM is identifying a relationship between vestibular symptoms and migrainous features and being aware of the heterogeneity of manifestations of this enigmatic, but treatable, condition. The principles of treatment of VM include rescue therapy, lifestyle modification, nonpharmacologic migraine preventives, pharmacologic migraine prophylaxis, and treatment of comorbidities.

5.
Mult Scler Relat Disord ; 31: 72-73, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30947064

RESUMO

A 17-year-old girl with relapsing-remitting multiple sclerosis (MS) was referred for a 2-year history of visual blurriness. Her bedside examination was remarkable for gait unsteadiness only. Optical coherence tomography was performed as part of her workup. Unexpectedly, Spectralis© video imaging revealed left torsional nystagmus that was not apparent on bedside examination. Review of previous brain magnetic resonance images (MRI) revealed left ocular deviation, as well as a left dorsolateral medullary MS plaque, which was the cause of her torsional nystagmus. We highlight how Spectralis© scanning confocal laser ophthalmoscopy allows video imaging that can capture torsional ocular movements.


Assuntos
Esclerose Múltipla Recidivante-Remitente/diagnóstico por imagem , Nistagmo Patológico/diagnóstico por imagem , Adolescente , Feminino , Humanos , Bulbo/diagnóstico por imagem , Bulbo/patologia , Esclerose Múltipla Recidivante-Remitente/complicações , Esclerose Múltipla Recidivante-Remitente/patologia , Nistagmo Patológico/etiologia , Nistagmo Patológico/patologia , Tomografia de Coerência Óptica
6.
J Neurol Sci ; 399: 1-2, 2019 Apr 15.
Artigo em Inglês | MEDLINE | ID: mdl-30735883
7.
Headache ; 59(5): 727-740, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-30737783

RESUMO

OBJECTIVE: To assess the ictal symptoms, interictal symptoms, psychiatric comorbidities, and interictal neuro-otologic examination findings in vestibular migraine (VM). METHODS: Retrospective chart review of 491 patients seen from August 2014 until March 2018 at a tertiary neurology referral center for vestibular disorders to identify patients fulfilling the 2012 VM criteria. RESULTS: One hundred and thirty-one patients (105 women) were identified. Mean age of VM onset was 44.3 (±13.7) years. Preceding the onset of vestibular symptoms, most had migraine (57.3%) and motion sickness (61.1%). It was common to have a family history of migraine (50.8%) and episodic vestibular symptoms (28.1%). Common ictal symptoms were triggered (visually induced and head-motion) and spontaneous vertigo, accompanied by photophobia and phonophobia (118/131 [90.1%] patients), nausea (105/131 [80.2%] patients), aural symptoms (79/131 [60.3%] patients), and headache (65/131 [49.6%] patients). Interictally, many experienced visually induced (116/131 [88.6%] patients), head-motion (86/131 [65.6%] patients), and persistent (67/131 [51.1%] patients) dizziness. Psychiatric comorbidities include anxiety (92/131 [70.2%] patients), depression (53/131 [40.5%] patients), insomnia (38/131 [29.0%] patients), phobic disorders (15/131 [11.5%] patients), and psychogenic disorders (11/131 [8.4%] patients). Common triggers were stress (52/131 [39.7%] patients), bright lights (35/131 [26.7%] patients), weather changes (34/131 [26.0%] patients), and sleep deprivation (34/131 [26.0%] patients). Interictal neuro-otologic examination was abnormal in 56/131 (42.7%), usually hyperventilation-induced, head-shaking-induced, vibration-induced, and positional nystagmus. The most common balance-test finding was impaired sharpened Romberg's test (22/130 [16.9%] patients). CONCLUSIONS: In this single center study, we found that VM typically affects women in their 40s, with a personal and family history of migraine. Typical ictal symptoms were triggered and spontaneous vertigo, associated with photophobia and phonophobia, nausea, aural symptoms, and headache. Interictal vestibular symptoms, comorbid psychiatric disorders, and non-specific interictal neuro-otologic findings were common.

8.
Mult Scler ; 25(3): 361-371, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-29125422

RESUMO

BACKGROUND: Morphologic macular abnormalities (MMAs) are frequently seen on macular optical coherence tomography (OCT) imaging in neuroimmunology practice, yet studies pragmatically assessing prevalence and risk factors of MMAs to date are limited. OBJECTIVE: To describe the characteristics of MMAs in a neuroimmunology-based academic practice. METHODS: Cross-sectional study of 1450 patients (2900 eyes) who underwent spectral-domain macular OCT between June 2010 and June 2012. The association between MMAs and demographic variables was analyzed using mixed-effects logistic regression. Odds ratios (ORs) were calculated per 5-year age increments. RESULTS: MMAs were observed in 338/2872 eyes (11.7%) of 232/1445 participants (16.1%). The most common abnormalities identified, included drusen (6.0%), epiretinal membrane (ERM; 5.5%), and microcystoid macular pathology (MMP; 1.9%). Overall, patients with MMAs were older (OR: 1.79, p = 5 × 10-5) and more likely to be males (OR: 2.45, p = 0.014). In particular, advancing age was associated with higher risk of drusen and ERM (OR: 1.80 and 4.26, p = 2 × 10-5 and 7 × 10-3, respectively). MMP prevalence declined with age (OR: 0.73, p = 0.015) and was associated with African-American ethnicity (OR: 15.0, p = 5 × 10-5). CONCLUSION: Unexpected or incidental MMAs are common in patients assessed with OCT in neuroimmunology practice, emphasizing the importance of comprehensive OCT image review for risk stratification and appropriate ophthalmology referral.


Assuntos
Esclerose Múltipla/diagnóstico por imagem , Doenças Retinianas/diagnóstico por imagem , Centros Médicos Acadêmicos , Adulto , Idoso , Estudos Transversais , Membrana Epirretiniana/diagnóstico por imagem , Membrana Epirretiniana/epidemiologia , Membrana Epirretiniana/patologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Esclerose Múltipla/epidemiologia , Doenças Retinianas/epidemiologia , Tomografia de Coerência Óptica
9.
Neurol Clin Pract ; 8(5): 389-396, 2018 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-30564492

RESUMO

Background: Alice in Wonderland syndrome (AIWS) is a rare sensory perception disorder, most often caused by migraine in adults. We aimed to characterize the clinical characteristics of AIWS in a cohort of vestibular migraine (VM) patients. Methods: Retrospective chart review of patients diagnosed with VM seen between August 2014 and January 2018. Results: Seventeen patients were identified (10 women) with a median age at onset of 45 years (range 15-61 years), and median age at presentation of 49 years (range 17-63 years). Eighty-two percent reported 1 AIWS symptom, 12% reported 3 symptoms, and 6% described 2 symptoms. The most common symptom was visual distortions (47%), followed by extrapersonal misperceptions (41%) and somesthetic distortions (29%). Most AIWS occurred during VM episodes (77%). Eleven patients were seen in follow-up; 10 described complete or partial resolution of both AIWS and VM with migraine preventive therapy, while 1 experienced complete resolution of VM but continued to have AIWS. Neuro-otologic abnormalities improved in 2 patients. Conclusions: This study characterizes the clinical features of AIWS in patients with VM. We observed several rare and highly unusual AIWS misperceptions (frosted-glass vision, underwater vision, dolly zoom effect, sensation of the brain coming out of the head, closed-eye visual hallucinations, and headlight glare-induced marco/microsomatognosia), and resolution or improvement in AIWS and VM with migraine preventive treatment.

10.
Headache ; 58(7): 1113-1117, 2018 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30152162

RESUMO

Episodic positional vertigo is typically due to benign paroxysmal positional vertigo (BPPV) but may also be a manifestation of vestibular migraine. Distinguishing vestibular migraine from BPPV is essential since the treatment of each disorder is markedly different. The 31-month clinical course of a 41-year-old woman with vestibular migraine causing recurrent positional vertigo is described. During vestibular migraine attacks, she developed left-beating nystagmus in the upright position with removal of fixation, and geotropic horizontal nystagmus during the supine roll test. Interictally, her exam demonstrated positional apogeotropic horizontal nystagmus with the supine roll test, more intense in the supine head left position. Her vestibular migraine was successfully controlled with topiramate and eletriptan.


Assuntos
Vertigem Posicional Paroxística Benigna/diagnóstico , Transtornos de Enxaqueca/diagnóstico , Nistagmo Patológico/diagnóstico , Nistagmo Fisiológico , Adulto , Feminino , Humanos
12.
J Neurol Sci ; 373: 268-273, 2017 Feb 15.
Artigo em Inglês | MEDLINE | ID: mdl-28131203

RESUMO

Central pontine myelinolysis (CPM) is a potentially-devastating complication of rapid osmolar shifts, classically attributed to overlyaggressive correction of chronic hyponatremia. Magnetic resonance imaging (MRI) allowed earlier diagnosis of CPM, but most importantly, it has revealed that the odds of good functional recovery are surprisingly high. A trident shaped pontine lesion is a typical finding in CPM (the trident sign). The "piglet sign" is a much less well-known radiologic finding in CPM. Due to the rarity of CPM, very little has been published on the evolution of these MRI findings. We present a case of CPM in an alcoholic young man, and describe the temporal evolution of both the trident and piglet signs on MRI in CPM.


Assuntos
Encéfalo/diagnóstico por imagem , Imagem por Ressonância Magnética , Mielinólise Central da Ponte/diagnóstico por imagem , Adulto , Alcoolismo/complicações , Alcoolismo/diagnóstico por imagem , Alcoolismo/metabolismo , Alcoolismo/terapia , Diagnóstico Diferencial , Progressão da Doença , Humanos , Masculino , Mielinólise Central da Ponte/complicações , Mielinólise Central da Ponte/metabolismo , Mielinólise Central da Ponte/terapia , Concentração Osmolar , Síndrome
13.
J Neuroophthalmol ; 37(1): 87-98, 2017 03.
Artigo em Inglês | MEDLINE | ID: mdl-27643747

RESUMO

BACKGROUND: The cerebellum plays a central role in the online, real-time control, and long-term modulation of eye movements. EVIDENCE ACQUISITION: We reviewed the latest (fifth) edition of Leigh and Zee's textbook, The Neurology of Eye Movements, and literature in PUBMED using the following terms: cerebellum, flocculus, paraflocculus, vermis, oculomotor vermis, dorsal vermis, caudal fastigial nucleus, fastigial oculomotor region, uvula, nodulus, ansiform lobule, eye movements, saccades, ipsipulsion, contrapulsion, smooth pursuit, vergence, convergence, divergence, gaze-holding, down beat nystagmus, vestibulo-ocular reflex (VOR), angular VOR, translational VOR, skew deviation, velocity storage. RESULTS: The cerebellum is vital in optimizing the performance of all classes of gaze-shifting and gaze-stabilizing reflexes. The flocculus-paraflocculus are crucial to VOR gain and direction, pulse-step matching for saccades, pursuit gain, and gaze-holding. The ocular motor vermis and caudal fastigial nuclei are essential in saccadic adaptation and accuracy, and pursuit gain. The nodulus and ventral uvula are involved in processing otolothic signals and VOR responses, including velocity storage. CONCLUSIONS: The cerebellum guarantees the precision of ocular movements to optimize visual performance and occupies a central role in all classes of eye movements both in real-time control and in long-term calibration and learning (i.e., adaptation).


Assuntos
Cerebelo/fisiologia , Movimentos Oculares/fisiologia , Reflexo Vestíbulo-Ocular/fisiologia , Animais , Humanos
14.
J Neurol Sci ; 372: 187-195, 2017 Jan 15.
Artigo em Inglês | MEDLINE | ID: mdl-28017209

RESUMO

BACKGROUND: At sufficiently high doses, methotrexate (HDMTX) achieves substantial CNS penetration, whereas other tissues can be rescued from the effects of HDMTX by leucovorin rescue (LR), which does not penetrate the blood-brain barrier. OBJECTIVES: To report on the efficacy and safety of HDMTX with LR (HDMTX-LR), in the treatment of acute demyelinating inflammatory CNS syndromes refractory to conventional immunotherapy. METHODS: We performed a retrospective chart review of 12 patients treated (6 multiple sclerosis [MS], 4 neuromyelitis optica [NMO], and 2 Sjogren's syndrome myelopathy [SSM]) with HDMTX-LR after failing to improve, or exhibiting worsening following conventional immunotherapy. 11 patients were followed for a total of 6months following HDMTX-LR (one was lost to follow up after 1month); and clinical findings were documented at 1month, 3months, and 6months following HDMTX-LR therapy. RESULTS: Ten patients demonstrated both clinical and radiologic evidence of near, if not complete, abolishment of disease activity, in conjunction with impressive reconstitution of neurologic function in the 6-month period following HDMTX-LR. Mean Kurtzke Expanded Disability Status Scale (EDSS) prior to HDMTX-LR was 8.1 (±1.4). Following HDMTX-LR, mean EDSS was 6.6 (±2.4) at 1month, 5.8 (±2.3) at 3months, and 5.7 (±2.3) at 6months. CONCLUSIONS: In this retrospective assessment of treatment-recalcitrant fulminant inflammatory CNS syndromes, HDMTX-LR was observed to be a safe and highly effective treatment, producing the rapid and near complete cessation of disease activity, in conjunction with an important corresponding and 'durable remission' in the majority of our small treatment cohort.


Assuntos
Imunossupressores/administração & dosagem , Leucovorina/administração & dosagem , Metotrexato/administração & dosagem , Esclerose Múltipla/tratamento farmacológico , Neuromielite Óptica/tratamento farmacológico , Síndrome de Sjogren/tratamento farmacológico , Adulto , Encéfalo/diagnóstico por imagem , Encéfalo/efeitos dos fármacos , Encéfalo/patologia , Avaliação da Deficiência , Reposicionamento de Medicamentos , Resistência a Medicamentos , Feminino , Humanos , Imunossupressores/efeitos adversos , Leucovorina/efeitos adversos , Masculino , Metotrexato/efeitos adversos , Pessoa de Meia-Idade , Esclerose Múltipla/diagnóstico por imagem , Esclerose Múltipla/patologia , Neuromielite Óptica/diagnóstico por imagem , Neuromielite Óptica/patologia , Estudos Retrospectivos , Síndrome de Sjogren/diagnóstico por imagem , Síndrome de Sjogren/patologia , Fatores de Tempo , Resultado do Tratamento
15.
Neurol Clin ; 34(3): 483-523, 2016 08.
Artigo em Inglês | MEDLINE | ID: mdl-27445239

RESUMO

Multiple sclerosis (MS) is the most common disabling neurologic disease of young adults. There are now 16 US Food and Drug Administration (FDA)-approved disease-modifying therapies for MS as well as a cohort of other agents commonly used in practice when conventional therapies prove inadequate. This article discusses approved FDA therapies as well as commonly used practice-based therapies for MS, as well as those therapies that can be used in patients attempting to become pregnant, or in patients with an established pregnancy, who require concomitant treatment secondary to recalcitrant disease activity.


Assuntos
Esclerose Múltipla/tratamento farmacológico , Feminino , Humanos , Esclerose Múltipla/terapia , Gravidez
16.
J Clin Neurosci ; 26: 116-21, 2016 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-26765759

RESUMO

We report four patients with monocular visual loss for whom optical coherence tomography (OCT) was helpful in distinguishing the sequelae of retinal artery occlusion from those of primary optic neuropathy. Determinations of the peripapillary retinal nerve fiber layer (RNFL) thickness as well as macular retinal layer thicknesses and architecture were used. The major findings in our patients show that changes in the inner retinal layers (including ganglion cell and inner plexiform layer) with disruption of normal macular architecture supports a diagnosis of retinal artery occlusion. Our results support the use of OCT imaging for patients with monocular visual loss of uncertain etiology; macular imaging as well as peripapillary RNFL thickness measurement can be helpful in differentiating primary retinal disease or ischemia from primary disorders of the optic nerve.


Assuntos
Cegueira/complicações , Cegueira/diagnóstico , Oclusão da Artéria Retiniana/complicações , Oclusão da Artéria Retiniana/diagnóstico , Tomografia de Coerência Óptica/estatística & dados numéricos , Adulto , Idoso , Diagnóstico Diferencial , Feminino , Humanos , Macula Lutea/patologia , Masculino , Pessoa de Meia-Idade , Nervo Óptico/patologia , Doenças do Nervo Óptico/complicações , Doenças do Nervo Óptico/diagnóstico , Células Ganglionares da Retina/patologia , Tomografia de Coerência Óptica/métodos
17.
Pract Neurol ; 15(1): 5-13, 2015 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-25216669

RESUMO

Posterior cortical atrophy (PCA) is a neurodegenerative syndrome dominated by deterioration of higher visual function (particularly visuospatial and visuoperceptual abilities). It is most commonly due to Alzheimer's disease pathology, but may also be caused by dementia with Lewy bodies, corticobasal degeneration or Creutzfeldt-Jakob disease. Patients often present to optometrists, ophthalmologists and/or neurologists with non-specific visual complaints, and unless clinicians seek the specific symptoms and signs of PCA (beyond that of the 'standard' neurological examination), this infrequent disorder is easily missed, delaying its diagnosis and treatment. We review the clinical features of PCA, focusing on its visual manifestations, to help neurologists recognise this important syndrome.


Assuntos
Doença de Alzheimer/diagnóstico , Encefalopatias/diagnóstico , Córtex Cerebral/patologia , Doença de Alzheimer/psicologia , Atrofia , Encefalopatias/patologia , Diagnóstico Tardio , Feminino , Humanos , Pessoa de Meia-Idade
19.
Neurol Clin ; 32(4): 1009-80, 2014 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-25439294

RESUMO

The cerebellum is responsible for refining ocular movements, thereby guaranteeing the best possible visual acuity and clarity despite changes in body or head positions or movement of the object of interest. The cerebellum is involved in the control of all eye movements, in their real-time, immediate modulation, and in their long-term adaptive calibration. The flocculus-paraflocculus complex and the caudal vermis (nodulus and uvula) together constitute the vestibulocerebellum. Lesions affecting these different regions give rise to 3 principal clinical cerebellar syndromes. This article discusses the various neuro-ophthalmic manifestations of various cerebellar disorders, as well as some therapeutic options for oscillopsia.


Assuntos
Doenças Cerebelares/complicações , Oftalmopatias/etiologia , Movimentos Oculares/fisiologia , Humanos , Nistagmo Fisiológico/fisiologia , Reflexo Vestíbulo-Ocular/fisiologia
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