RESUMO RACIONAL: O diagnóstico diferencial dos fatores causais da pancreatite aguda é fundamental para seu seguimento clínico, tornando-se relevante estabelecer critérios laboratoriais que elucidem a diferença entre as causas biliares e não biliares. OBJETIVOS: Estabelecer critérios baseados em testes laboratoriais para o diagnóstico diferencial entre pancreatite aguda de causa biliar e não biliar e identificar testes laboratoriais com sensibilidade suficiente para propor a criação de um algoritmo de diagnóstico diferencial entre as causas. MÉTODO: Análise observacional, com delineamento transversal, de exames laboratoriais de dois grupos de pacientes com pancreatite aguda: A — causa não biliar; e B — causa biliar. Foram investigados: hematócrito, número de leucócitos, lactato desidrogenase, glicose, lipase, amilase, bilirrubina total, transaminase oxalacética, transaminase pirúvica, gamaglutamiltransferase e fosfatase alcalina. Os dados foram submetidos a testes não paramétricos e ao receiver operating characteristic. RESULTADOS: Os valores de hematócrito, número de leucócitos, lactato desidrogenase e glicose não apresentaram diferença significante entre os grupos (p>0.1). Os valores de lipase, amilase, bilirrubina total, transaminase oxalacética, transaminase pirúvica, gamaglutamiltransferase e fosfatase alcalina apresentaram diferença significante entre os grupos (p<0.05), sendo que os testes de transaminase oxalacética, transaminase pirúvica e fosfatase alcalina mostraram-se os mais sensíveis na determinação da causa biliar, possibilitando o estabelecimento de um ponto de corte pelo teste receiver operating characteristic, a partir do qual a probabilidade de acerto aumenta: transaminase pirúvica: 123,0 U/L (sensibilidade: 69,2%; especificidade: 81,5%), transaminase oxalacética: 123,5 U/L (sensibilidade: 57,3%; especificidade: 78,8%) e fosfatase alcalina: 126,5 U/L (sensibilidade: 66,1%; especificidade: 69,4%). CONCLUSÃO: Foi possível estabelecer critérios baseados em testes laboratoriais para o diagnóstico diferencial entre pancreatite aguda de origem biliar e não biliar, porém, os testes não mostraram sensibilidade suficiente para propor a criação de um algoritmo de diagnóstico diferencial entre as mesmas causas.

ABSTRACT BACKGROUND: The differential diagnosis of the causal factors of acute pancreatitis is fundamental for its clinical follow-up, becoming relevant to establishing laboratory criteria that elucidate the difference between biliary and nonbiliary causes. AIM: The aim of this study was to establish criteria based on laboratory tests for the differential diagnosis between acute pancreatitis of biliary and nonbiliary causes and to identify laboratory tests with sufficient sensitivity to propose the creation of an algorithm for differential diagnosis between the causes. METHODS: The research consisted of observational analysis, with a cross-sectional design of laboratory tests of two groups of patients with acute pancreatitis: group A: nonbiliary cause and group B: biliary cause. Hematocrit, white blood cell count, lactate dehydrogenase, glucose, lipase, amylase, total bilirubin, oxalacetic transaminase, pyruvic transaminase, gamma-glutamyltransferase, and alkaline phosphatase were investigated. Data were submitted to nonparametric tests and receiver operating characteristics. RESULTS: Hematocrit values, number of leukocytes, lactate dehydrogenase, and glucose showed no significant difference between the groups (p>0.1). Lipase, amylase, total bilirubin, oxalacetic transaminase, pyruvic transaminase, gamma-glutamyltransferase, and alkaline phosphatase values showed a significant difference between groups (p<0.05). The oxalacetic transaminase, pyruvic transaminase, and alkaline phosphatase tests were most sensitive in determining the biliary cause, allowing the establishment of a cutoff point by the receiver operating characteristic test: pyruvic transaminase: 123.0 U/L (sensitivity: 69.2%; specificity: 81.5%), oxalacetic transaminase: 123.5 U/L (sensitivity: 57.3%; specificity: 78.8%), and alkaline phosphatase: 126.5 U/L (sensitivity: 66.1%; specificity: 69.4%), from which the probability of a correct answer increases. CONCLUSION: It was possible to establish criteria based on laboratory tests for the differential diagnosis between acute pancreatitis of biliary and nonbiliary origin; however, the tests did not show enough sensitivity to propose the creation of an algorithm for differential diagnosis between the same causes.

ABSTRACT Purpose: To evaluate the effect of hyperbaric oxygenation (HBO) on angiogenesis in random rat skin flaps, by immunoexpression of vascular endothelial growth factor A (VEGF-A). Methods: Forty adult rats were divided into four groups: GE) epilated; GE/HBO) epilated subjected to HBO; GER) epilated submitted to dorsal skin flap; GER/HBO) epilated subjected to dorsal skin flap + HBO. HBO was performed with rats inside a chamber under atmosphere close to 100% oxygen and pressure of 2.4 absolute atmospheres, 2h per day during seven consecutive days. GE and GER groups were placed in the hyperbaric chamber without HBO. Then, under anesthesia, skin flaps were removed and separated into three portions relative to pedicle fixation. The samples were fixed in formalin and processed for paraffin embedding. Histological sections were submitted to immunohistochemistry for VEGF-A detection. The number of immunostained-blood vessels were counted under light microscopy. Results: GE and GE/HBO groups showed normal and similar skin morphology in the three flap portions. A fibrin-leukocyte crust, along with denatured collagen and intense leukocyte infiltrate, was mainly observed in the dermis of the medial and distal flap portions of GER group. Meanwhile, the GER/HBO group presented more regions with intact collagen and small areas of leukocyte infiltrate in the three flap regions. VEGF-A-immunostained blood vessels were largely seen in all regions of GE and GE/HBO groups, whereas no significant differences were found between these groups. A decrease in vascularization was noticed in GER and GER/HBO groups, which was more evident in the most distal portion of the flaps. However, the number of VEGF-A-immunostained blood vessels in GER/HBO group was significantly higher when compared to GER group. Conclusions: Hyperbaric oxygenation was associated with increased angiogenesis and improved viability of rat skin flaps.

Abstract Purpose: To analyze the effects of ischemic preconditioning (IPC) in the expression of apoptosis-related genes in rat small intestine subjected to ischemia and reperfusion. Methods: Thirty anesthetized rats underwent laparotomy and were drive into five groups: control (CG); ischemia (IG); ischemia and reperfusion (IRG); IPC and ischemia (IG+IPC); IPC and ischemia and reperfusion (I/RG+IPC). Intestinal ischemia was performed by clamping the superior mesenteric artery for 60 minutes, whereas reperfusion lasted for 120 minutes. IPC was carried out by one cycle of 5 minutes of ischemia followed by 10 minutes of reperfusion prior to the prolonged 60-minutes-ischemia and 120-minutes-reperfusion. Thereafter, the rats were euthanized and samples of small intestine were processed for histology and gene expression. Results: Histology of myenteric plexus showed a higher presence of neurons presenting pyknotic nuclei and condensed chromatin in the IG and IRG. IG+IPC and I/RG+IPC groups exhibited neurons with preserved volume and nuclei, along with significant up-regulation of the anti-apoptotic protein Bcl2l1 and down-regulation of pro-apoptotic genes. Moreover, Bax/Bcl2 ratio was lower in the groups subjected to IPC, indicating a protective effect of IPC against apoptosis. Conclusion: Ischemic preconditioning protect rat small intestine against ischemia/reperfusion injury, reducing morphologic lesions and apoptosis.

Abstract Purpose: To investigate the gene expression related to inflammation on mice subjected to intestinal ischemia and reperfusion (I/R) and treated with ischemic preconditioning (IPC). Methods: Thirty rats (EPM-Wistar), distributed in five groups of six animals each, were underwent anesthesia and laparotomy. The ischemia time was standardized in 60 minutes and the reperfusion time 120 minutes. IPC was standardized in 5 minutes of ischemia followed by 10 minutes of reperfusion accomplished before I/R. The control group was submitted only to anesthesia and laparotomy. The other groups were submitted to ischemia, I/R, ischemia + IPC and I/R + IPC. It was collected a small intestine sample to analyses by Quantitative Polymerase Chain Reaction in real Time (RT-qPCR) and histological analyses. It was studied 27 genes. Results: The groups that received IPC presented downregulation of genes, observed in of genes in IPC+ischemia group and IPC+I/R group. Data analysis by clusters showed upregulation in I/R group, however in IPC groups occurred downregulation of genes related to inflammation. Conclusion: The ischemia/reperfusion promoted upregulation of genes related to inflammation, while ischemic preconditioning promoted downregulation of these genes.

Abstract Purpose: To investigate the role of atenolol in the gene expression of caspase 1 (Casp1) and Bcl2L1 on vascular endothelium of rat intestine after ischemia and reperfusion (IR). Methods: Eighteen adult male Wistar rats were randomly divided into 3 groups (n=6): SG (Sham group): no clamping of the superior mesenteric artery; IRG: IR plus saline group: IRG+At: IR plus Atenolol group. Rats from IRG and IRG+At were subjected to 60 min of intestinal ischemia and 120 min of reperfusion. Atenolol (2mg/kg) or saline were injected in the femoral vein 5 min before ischemia, 5 min and 55 min after reperfusion. Thereafter, intestinal segments were appropriately removed and processed for Endothelial Cell Biology Rat RT2 Profiler PCR Array. Results: the anti-apoptotic Bcl2L1 gene expression was significantly down-regulated (-1.10) in the IRG and significantly up-regulated in the IRG+At (+14.15). Meanwhile, despite Casp1 gene expression was upregulated in both groups, it was significantly higher in the IRG (+35.06) than the IRG+At (+6.68). Conclusions: Atenolol presents antiapoptotic effects on rat intestine subjected to IR partly by the up-regulation of the anti-apoptotic Bcl2L1 gene expression. Moreover, atenolol can mitigate the pro-apoptotic and pro-inflammatory effects of Casp1 gene on rat intestine after IR.

Abstract Purpose: To determine whether the absence of transglutaminase 2 enzyme (TG2) in TG2 knockout mice (TG2-/-) protect them against early age-related functional and histological arterial changes. Methods: Pulse wave velocity (PWV) was measured using non-invasive Doppler and mean arterial pressure (MAP) was measured in awake mice using tail-cuff system. Thoracic aortas were excised for evaluation of endothelial dependent vasodilation (EDV) by wire myography, as well as histological analyses. Results: PWV and MAP were similar in TG2-/-mice to age-matched wild type (WT) control mice. Old WT mice exhibited a markedly attenuated EDV as compared to young WT animals. The TG2-/-young and old mice had enhanced EDV responses (p<0.01) as compared to WT mice. There was a significant increase in TG2 crosslinks by IHC in WT old group compared to Young, with no stain in the TG2-/-animals. Optical microscopy examination of Old WT mice aorta showed thinning and fragmentation of elastic laminae. Young WT mice, old and young TG2-/-mice presented regularly arranged and parallel elastic laminae of the tunica media. Conclusion: The genetic suppression of TG2 delays the age-induced endothelial dysfunction and histological modifications.

Abstract Purpose: To investigate the role of the exogenous supply of adenosine triphosphate (ATP) in the expression of Bax and Bcl2L1 genes in intestinal ischemia and reperfusion (IR) in rats. Methods: The study was designed as a randomized controlled trial with a blinded assessment of the outcome. Eighteen adult male Wistar-EPM1 rats were housed under controlled temperature and light conditions (22-23°C, 12 h light/dark cycle). The animals were randomly divided into 3 groups: 1. Sham group (SG): no clamping of the superior mesenteric artery; 2. Ischemia and reperfusion group (IRG): 3. Ischemia and reperfusion plus ATP (IRG + ATP). ATP was injected in the femoral vein before and after ischemia. Afterwards, intestinal segments were appropriately removed and processed for Endothelial Cell Biology Rat RT2 Profiler PCR Array. Results: ATP promoted the upregulation of Bcl2L1 gene expression, whereas it did not have significant effects on Bax gene expression. In addition, the relation of Bax/Bcl2L1 gene expression in the IRG group was 1.39, whereas it was 0.43 in the IRG + ATP group. Bcl2L1 plays a crucial role in protecting against intestinal apoptosis after ischemia and reperfusion. Increased Bcl2L1 expression can inhibit apoptosis while decreased Bcl2L1 expression can trigger apoptosis. Conclusion: Adenosine triphosphate was associated with antiapoptotic effects on the rat intestine ischemia and reperfusion by upregulating of Bcl2L1 gene expression.

Abstract Purpose: To evaluate the effect of hyperbaric oxygenation (HBO) on the expression of the genes antioxidant glutathione peroxidase 4 (Gpx4) and lactoperoxidase (Lpo) in the lung of mice subjected to intestinal ischemia and reperfusion (IIR). Methods: Control group (CG) in which were subjected to anesthesia, laparotomy and observation for 120 minutes; an ischemia and reperfusion group (IRG) subjected to anesthesia, laparotomy, small bowel ischemia for 60 minutes and reperfusion for 60 minutes; and three groups treated with HBO during ischemia (HBOG + I), during reperfusion (HBOG + R) and during ischemia and reperfusion (HBOG + IR). Studied 84 genes of oxidative stress by the method (RT-qPCR). Genes with expression levels three times below or above the threshold cycle were considered significantly hypoexpressed or hyperexpressed, respectively (Student’s t-test p<0.05). Results: Gpx4 and Lpo were hiperexpressed on IRG, showing a correlation with these genes with lung oxidative stress. Treated with HBO, there was a significant reduction on genic expression on HBOG+I. Conclusion: Hyperbaric oxygenation showed to be associated with decreased expression of these antioxidant genes, suggesting a beneficial effect on the mechanism of pulmonary oxidative stress whenever applied during the ischemia.

Abstract Purpose: To investigate the expression of nitric oxide synthase (NOS) and apoptosis associated with ischemic preconditioning (IPC) and pentoxifylline (PTX) in intestinal ischemia (I) and reperfusion (R) injury. Methods: Thirty male rats were assigned to 5 groups: (CG), no clamping of the superior mesenteric artery (90 minutes); (IR-SS) saline + ischemia (30 minutes) + reperfusion (60 minutes); (IR-PTX) PTX + ischemia (30 minutes) + reperfusion (60 minutes); (IPC-IR-SS) 5 minutes of ischemia + 5 minutes of reperfusion (IPC) + saline + I(30 minutes)+R(60 minutes); and (IPC-IR-PTX) IPC + PTX + I(30 minutes)+ R(60 minutes). Results: The application of IPC and PTX showed a significantly lower immunohistochemistry reaction for active caspase-3 (P<0.05) compared to IR+SS. The number of cells immunoreactive to BCL-2 was higher in the IR-PTX group (P>0.05). The NOS-2 expression (qRTPCR) in the IR-PTX group (P<0.05) was higher than the values for the IPC+IR-SS and IPC-IR-PTX groups. The NOS-3 expression was significantly upper in the IPC-IR-PTX group than in the CG (P<0.05), the IR-SS (P<0.05) and the IR-PTX (P<0.05) groups. Conclusions: The BCL-2 and active caspase-3 showed beneficial effects on PTX and IPC. The expression of NOS-2 and NOS-3 in the IPC and IPC-PTX groups showed no synergistic effect.

Abstract Purpose: To investigate the effects of hyperbaric oxygenation (HBO) on intestinal ischemia and reperfusion (IR) injury, we evaluated the expression of 84 genes related to oxidative stress and the antioxidant response in mouse hearts. Methods: Four groups were subjected to 60 minutes of intestinal ischemia followed by 60 minutes of reperfusion: IRG, ischemia and reperfusion group without HBO; HBO-IG, which received HBO during ischemia; HBO-RG, which received HBO during reperfusion; and HBO-IRG, which received HBO during ischemia and reperfusion. The control group (CG) underwent anesthesia and laparotomy and was observed for 120 minutes. The (RT-qPCR) method was applied. Genes with expression levels three times below or above the threshold cycle were considered significantly hypoexpressed or hyperexpressed, respectively (Student’s t-test p<0.05). Results: Eight genes (9.52%) were hyperexpressed in the IRG. When the HBO groups were compared to the IRG, we found a decrease in the expression of eight genes in the HBO-IG, five genes in the HBO-RG, and seven genes in the HBO-IRG. Conclusion: The reduction in the expression of genes related to oxidative stress and antioxidant defense following HBO in mouse hearts resulting from intestinal IR injury was more favorable during the ischemic period than during the reperfusion period.

Abstract Purpose: To investigate the role of ischemic preconditioning (IPC) and pentoxifylline (PTX) in intestinal mucosa ischemia/reperfusion injury (IR). Methods: Thirty rats were assigned to 5 groups (N=6): (CG): no clamping of the superior mesenteric artery (90 min.); (IR-SS): saline + ischemia (30 min.) + reperfusion (60 min.); (IR-PTX): PTX + ischemia (30min.) + reperfusion (60 min.); (IPC-IR-SS): 5 min. of ischemia + 5 minutes of reperfusion (IPC) + saline + ischemia (30 min.) + reperfusion (60 min.); (IPC-IR-PTX ): 5 min. of ischemia + 5 min. of reperfusion (IPC) + PTX + 30 min. of I + 60 minutes of R. Results: The IR-PTX, IPC-IR-SS and IPC-IR-PTX groups had significantly lower scores of mucosa damage than the IR-SS group. IR-PTX group showed higher scores than the IPC-IR-PTX group, in accordance with the hypothesis of a favorable effect of IPC alone or in association with PTX. Additionally, IPC-IR-SS had a higher damage score than the IPC-IR-PTX. The villi height and crypt depth were similar in all groups. The villi height in the IR-SS was significantly lower. Conclusion: Ischemic preconditioning or pentoxifylline alone protect the intestinal mucosa from ischemia/reperfusion injury. However, they do not have a synergistic effect when applied together.

PURPOSE:To evaluate the morphology, necrotic area and collagen content in skin flaps of rats subjected to hyperbaric oxygenation (HBO).METHODS:Forty adult rats were divided into four groups: GEC - epilated; GE/HBO - epilated subjected to HBO; GER - epilated submitted to skin flap (2 cm in width /8 cm length in the dorsal area) and GER/HBO - epilated, subjected to skin flap and HBO. HBO (2.4 ATA) was performed for two hours during seven consecutive days. In the eighth day, the rats were anesthetized and the skin flaps were removed and separated into three portions, relative to pedicle fixation. The material fixed in 10% formalin was processed for paraffin embedding; sections were stained by H.E and subjected to picrosirius-red method. The slides examined under light microscopy for evaluation of the collagen content in polarized light microscope and ImageLab(r) software (Bio-Rad).RESULTS:The data showed larger area of necrosis and lower levels of collagen in the three regions of the GER group, whereas in the GER/HBO group the collagen content was similar to the GEC and GE/HBO groups.CONCLUSION: Hyperbaric oxygenation reduced the area of necrosis and preserved the morphology and collagen content in skin flaps of rats.

Objetivo: O objetivo desse estudo foi avaliar o Eye Retinopathy Trainer® como ferramenta didática complementar ao treinamento do exame ocular, em comparação ao método tradicional, baseado na aprendizagem com voluntários. Métodos: Noventa estudantes receberam treinamento em oftalmoscopia direta utilizando um modelo de simulação e voluntários humanos. Os alunos foram divididos em grupo Simulação e em grupo Controle mediante a inclusão ou ausência do simulador no treinamento em aula prática. Diferenças entre os grupos foram analisadas por teste t de Student não pareado. Resultados: O desempenho prático do Grupo Simulador mostrou-se superior ao Grupo Controle, evidenciando que 51,06% dos alunos do primeiro grupo foram bem sucedidos ao realizar a fundoscopia tanto no modelo anatômico de simulação quanto no modelo humano, comparado a 21,15% dos alunos grupo Controle. Conclusão: O simulador Eye Retinopathy Trainer® mostrou ser uma ferramenta didática efetiva para a prática e aprimoramento do exame oftalmológico entre estudantes do quarto ano de medicina.

Purpose: The aim of this study was to evaluate the Eye Retinopathy Trainer® as a teaching tool for direct ophthalmoscopy examination by comparing it with the traditional method using volunteers. Methods: Fourth year medical students received training in direct ophthalmoscopy using a simulation tool and human volunteers. Ninety students were randomized into a Simulation Group or a Control Group by the inclusion or absence of the simulation model in classroom practice. Differences between the groups were analyzed using unpaired Student’s t-test. Results: The Simulation Group was superior to the Control Group, with 51.06% successful in performing fundus examination in both the anatomical model simulation and the human model in comparison with 21.15% in the Control Group. Conclusion: The Eye Retinopathy Trainer® appears to be an effective teaching tool for practice and improvement of ophthalmologic examination among fourth year medical students.

RESUMO Há 50 anos, no Jefferson Davis Hospital, em Houston (EUA), realizou-se a primeira cirurgia de mamoplastia de aumento com implantes de silicone. Atualmente, o avanço da tecnologia médica disponibilizou no mercado implantes de diversas formas e texturas, assim como permitiu o desenvolvimento de inúmeras técnicas para a realização desta cirurgia. Este procedimento cirúrgico pode apresentar algumas complicações locais imediatas e tardias no pós-operatório. Por se tratar de um implante constituído de material biocompatível ao organismo, mesmo com 50 anos de evolução, deve-se sempre estudar e, se possível, relatar as possíveis complicações que possam ocorrer. O objetivo deste artigo é revisar as complicações mais frequentes que ocorrem no pós-operatório das mamoplastias de aumento com implante de silicone, bem como relatar o caso de uma complicação atípica, doença de Mondor, no pós-operatório desta cirurgia. 5 Hospital EUA, EUA , (EUA) realizouse realizou silicone Atualmente texturas pósoperatório. pósoperatório pós operatório. operatório organismo evolução devese deve possível ocorrer atípica Mondor (EUA

ABSTRACT The first breast augmentation surgery with silicone implants was performed at the Jefferson Davis Hospital in Houston (USA) about 50 years ago. Recent advances in medical technology have made implants of various shapes and textures commercially available and led to the development of numerous techniques for performing this surgery. However, this surgical procedure may have some immediate and long-term local complications . Since the implant is made of biocompatible material , it is important to investigate and report complications that occur despite the 50 years of research. The purpose of this study was to review the most frequent complications occurring after breast augmentation surgery with silicone implants and to report a case of an unusual complication, Mondor’s disease. USA (USA 5 ago However longterm long term research complication Mondors Mondor s disease

Objetivo: avaliar o uso perioperatório do atenolol na redução da incidência de hematoma pós-ritidoplastia.Métodos: entre janeiro de 2007 e fevereiro de 2013 foram randomizados 80 pacientes em dois grupos: Grupo A (n=26) recebeu atenolol perioperatório com objetivo de manter frequência de pulso (FP) ± 60 por minuto, Grupo B (n=54) não recebeu atenolol. Ambos os grupos foram submetidos à mesma técnica anestésico-cirúrgica. A pressão arterial (PA) e FP, formação de hematoma e a necessidade de drenagem foram monitorizados. Houve seguimento até o 90º dia de pós-operatório. As variáveis foram analisadas entre os dois grupos utilizando-se o teste de ANOVA. As variáveis contínuas foram apresentadas como média (± Desvio-padrão) e as diferenças foram comparadas utilizando-se o t de Student. Foram considerados significantes os valores p<0,05.Resultados: as médias no grupo A de PA (110-70mmHg ± 7,07) e FP (64 /min ± 5) foram menores (p<0,05) em relação ao grupo B (135-90mmHg ± 10,6) e (76/min ± 7,5), respectivamente. Houve quatro casos de hematoma expansivo no grupo B, todos com necessidade de reoperação para a sua drenagem e nenhum no grupo A (p<0,001).Conclusão: o uso do atenolol perioperatório promoveu a redução de pressão arterial e frequência de pulso e diminuiu a incidência de hematoma expansivo pós-ritidoplastia.

Objective: To evaluate the perioperative use of atenolol in reducing the incidence of hematoma after rhytidoplasty.Methods: Between January 2007 and February 2013, 80 patients were randomized into two groups: Group A (n = 26) received perioperative atenolol in order to maintain heart rate (PR) around 60 per minute; Group B (n = 54) did not receive atenolol. Both groups underwent the same anesthetic and surgical technique. We monitored blood pressure (BP), HR, hematoma formation and the need for drainage. Patients were followed-up until the 90th postoperative day. The variables were compared between the groups using the ANOVA test. Continuous variables were presented as mean ± standard deviation and the differences were compared with the Student's t test. Values of p d" 0.05 were considered significant.Results: In group A the mean BP (110-70mmHg ± 7.07) and HR (64 / min ± 5) were lower (p d" 0.05) than in group B (135-90mmHg ± 10.6) and (76 / min ± 7.5), respectively. There were four cases of expansive hematoma in group B, all requiring reoperation for drainage, and none in group A (p d" 0,001).Conclusion: The perioperative use of atenolol caused a decrease in blood pressure and heart rate and decreased the incidence of expanding hematoma after rhytidectomy.