Ο μαζικός αδένας σχηματίζεται την 6η εμβρυϊκή εβδομάδα ως πάχυνση του εξωδέρματος (μαζική ακρολοφία), ενώ κατά τον 5ο εμβρυϊκό μήνα αναπτύσσονται από τις αρχικές επιθηλιακές καταβολές, συμπαγείς χορδές κυττάρων στο υποκείμενο χόριο. Ο μαστός ως εξωκρινής αδένας φέρει υποδοχείς, μέσω των οποίων υπόκειται σε ορμονικό έλεγχο τόσο κατά τη διάρκεια του έμμηνου κύκλου, όσο και κατά τη διάρκεια της κύησης και της γαλακτοφορίας, η οποία αποτελεί και το σκοπό ύπαρξης του μαστού. Όμως ο μαστός αποτελεί ένα από τα όργανα του ανθρώπινου σώματος το οποίο υφίσταται καρκινική εξαλλαγή, αφού αποτελεί την 1η αιτία θανάτου από καρκίνο μεταξύ των γυναικών. Υπολογίζεται πως ο ετήσιος κίνδυνος για να προσβληθεί μία γυναίκα από καρκίνο του μαστού είναι 1: 37.000 μεταξύ των ηλικιών 30-40, ενώ ο αριθμός αυτός αυξάνει σε 1: 200-235 σε ηλικίες άνω των 70 ετών. Σημαντικοί τρόποι προληπτικού ελέγχου, και αυτοί οι οποίοι θα μελετηθούν, προκειμένου να διαγιγνώσκεται έγκαιρα μια κακοήθης αλλοίωση του μαστού είναι η μαστογραφία, που με τη βοήθεια πάντα του υπερηχογραφήματος και του έγχρωμου Doppler είναι σε θέση να εντοπίζει αλλοιώσεις μεγέθους ακόμα και 2 mm, οι οποίες δεν έχουν δώσει ακόμα κλινική σημειολογία. Όταν η μάζα γίνει ψηλαφητή αυτό σημαίνει ότι θα είναι ήδη μεγέθους 2 cm και θα έχει διηθήσει τους γύρω ιστούς. Το υπερηχογράφημα θα μειώσει τον αριθμό των γυναικών οι οποίες θα χρειαστεί να υποβληθούν σε βιοψία, καθώς δίνει τη δυνατότητα καθορισμού της κυστικής ή συμπαγούς σύστασης της απεικονιζόμενης στη μαστογραφία αλλοίωσης. Σκοπός του screening με τις απεικονιστικές αυτές μεθόδους είναι να μειωθεί ακόμα περισσότερο η θνητότητα και η θνησιμότητα από καρκίνο του μαστού καθώς ιάσιμη νόσος είναι αυτή η οποία δεν έχει δώσει ακόμα κλινική σημειολογία. / The mammary gland is formed during the 6th week of fetal life, as an exoderma thickening, while during the 5th month compact cords are being developed subcutaneously. The mammary gland as an exocrine gland, carries receptors through which is subject to hormonal control. Not only does this occur during menstrual circle, but also during gestation and lactation, which is the purpose of its existence. Statistics show that the mammary gland is among the human organs, which are most susceptible to cancerous transmutation, since breast cancer is the first cause of death from cancer among women. It is estimated that the annual risk a woman runs to be affected by breast cancer is 1: 37.000 between the ages 30-40, while this risk increases to 1: 200-235 to women above 70 years of age. Mammography along with ultrasonography and color Doppler are significant preventive measures, in order to obtain a prompt diagnosis of a malignant breast lesion. They are capable of pinpointing a lesion as small as 2mm, before this can be clinically detected. When it reaches the point of being palpable, it measures more than 2cm and will have already infiltrated the surrounding tissue. Ultrasonography will reduce the number of women who will need to undergo biopsy in order to distinguish the cystic or solid nature of a suspicious lesion detected in a mammogram. The aim of screening mammography along with ultrasonography is to decrease the morbidity of breast cancer, since breast cancer is curable only at the stage when clinical examination cannot detect it.

H παρούσα μελέτη είχε σαν στόχο την μελέτη και τον προσδιορισμό των αιμοδυναμικών αλλαγών που συμβαίνουν στο ηπατικό παρέγχυμα με τη βοήθεια της απλής (Gray Scale Ultrasonography, GSU) και της έγχρωμης Doppler υπερηχοτομογραφίας (Color Doppler, CDU), στην διάρκεια της χρόνιας ηπατικής νόσου. Ο απώτερος σκοπός ήταν ο διαχωρισμός της χρόνιας νόσου του ήπατος από την αρχόμενη καλά αντιρροπούμενη κίρρωση σε ομάδα ασθενών με ένα καλά τεκμηριωμένο ιστολογικό profil. Για τον λόγο αυτό, έγινε προσπάθεια να απομονωθούν εκείνες οι GSU και CDU παράμετροι που με μεγάλη ακρίβεια διαχώριζαν τους ασθενείς με τη χρόνια ηπατίτιδα από αυτούς που έπασχαν από καλά αντιρροπούμενη κίρρωση αρχικού σταδίου (CIR). / To assess the value of gray scale (GS) and colour Doppler ultrasonography (CDU) in differentiating the progression of chronic viral hepatitis (CVH) and compensated liver cirrhosis (CIR).

Background and Rationale: Reproductive dysfunction affects more than 15% of Canadian women; however, the underlying causes remain largely unknown. Ultrasonography is the most commonly used research and diagnostic tool for imaging the ovaries and uterus. However, current ultrasonographic techniques allow the detection of ovarian structures (eg. follicles, corpora lutea) at diameters of only ≥2 mm. The increased effectiveness of synchrotron technology for imaging ovaries in comparison to conventional imaging methods is currently unknown. Overall Objective: The overall objective of this research was to determine the effectiveness of synchrotron techniques for imaging ovaries. We hypothesized that synchrotron techniques would provide greater contrast for visualizing structural details of follicles, corpora lutea (CL), and cumulus oocyte complexes (COC), compared to conventional ultrasonography. Materials and Methods: Three studies were conducted to evaluate phase-contrast based synchrotron imaging methods. The first study involved Diffraction Enhanced Imaging (DEI) of bovine ovaries (n=6). The second study involved Propagation-Based Computed Tomography (PB-CT) imaging of bovine (n=4) and human ovaries (n=4). A third, preliminary study was conducted to explore the use of Talbot Grating Interferometry (TGI-CT) imaging of bovine (n=1) and human ovaries (n=1). Fresh and formalin-fixed bovine and human ovaries were imaged without or with contrast injection into the ovarian artery. Following synchrotron imaging, all ovarian samples were evaluated using diagnostic ultrasonography and histology. Images obtained using synchrotron techniques, ultrasonography and histology were qualitative and quantitatively compared. Results: DEI allowed the identification of 71% of follicles ≥2 mm and 67% of CL detected using ultrasonography. Mean follicle diameter was similar between DEI (9.6 ± 2.4 mm), ultrasonography (9.0 ± 2.6 mm), and histology (6.9 ± 1.9 mm) for fresh ovaries without contrast (P = 0.70). Likewise, no difference in CL diameter was detected between DEI (11.64 ± 1.67 mm), ultrasonography (9.34 ± 0.35 mm), and histology (9.6 ± 0.4 mm), (P = 0.34). Antral Follicle Count (AFC; ≥2mm) was similar between ultrasonography (6.5 ± 0.7 mm, fresh with no contrast; 6.5 ± 2.5 mm, preserved with no contrast) and DEI ( 4.5 ± 0.5 mm, fresh with no contrast; 6.5 ± 0.50 mm, preserved with no contrast) (P > 0.05). However, the contrast resolution for differentiating follicles and CL was inferior with DEI compared to ultrasonography. Small antral follicles <2mm, cell layers comprising the follicle wall and COC were not detected using either DEI or ultrasonography. PB-CT imaging enabled the visualization of 100% of follicles ≥2 mm and 100% of CL that were detected with ultrasonography. CL containing a central cystic cavity were identified using PB-CT; however, CL without a central cystic cavity were not well-visualized. Mean follicle and luteal diameters did not differ among PB-CT, ultrasonography and histology (P>0.05). PB-CT was superior to ultrasonography for detecting small antral follicles <2 mm in bovine ovaries (P = 0.04), and the granulosa and theca cell layers of the follicle wall in bovine and human ovaries (P < 0.0001). However, TGI-CT images exhibited greater contrast resolution for visualizing small and large antral follicles, CL, and the cell layers of the follicle wall compared to both PB-CT and ultrasonography. High contrast structures resembling COC were detected with both PB-CT and TGI-CT, but not with ultrasonography. Only TGI-CT permitted the visualization of the oocyte within the COC in fresh and preserved ovaries. Conclusions: DEI was inferior to ultrasonography for detecting ovarian follicles and CL. PB-CT was superior to ultrasonography for visualizing follicles <2 mm, COC, and the cell layers of the follicle wall. However, PB-CT was as effective as ultrasonography for detecting and measuring follicles ≥2 mm and cystic CL. Preliminary findings suggest that TGI-CT provides the greatest contrast for imaging both ovarian macro- and microanatomy compared to PB-CT, DEI, and ultrasonography.

The pattern of mucosal blood flow in normal human stomachs, and benign gastric ulcers was assesed with laser Doppler flowmetry and the relationship between a single determination of ulcer blood flow and the systemic level of growth factors was investigated. A significant ascending gradient in mucosal blood flow from the antrum to fundus was demonstrated. Different levels of cellular activity in the regions of the stomach may explain this gradient. In the gastric ulcers that healed on standard medical therapy mucosal blood flow was significantly increased in comparison to normal stomachs. In the ulcers that were refractory to standard medical therapy mucosal blood flow was significantly lower than in normal stomachs and healing ulcers. Higher systemic levels of the growth factor bFGF were demonstrated in healing ulcers compared to non-healing ulcers. Gastric mucosal blood flow can increase in response to the increased metabolic demands of healing, however impairment of this response may be an important factor preventing healing of benign gastric ulcers. It would appear that non-healing of gastric ulcers can be predicted at initial diagnosis by reduced peri-ulcer gastric mucosal blood flow and low blood levels of bFGF. / Thesis (M.Med.Sc.)-University of Natal, Durban, 1999.

Obstetric trauma is a major cause of faecal incontinence in women resulting in considerable social disability. Until recently the development of faecal incontinence has been attributed largely to damage to the pelvic nerves. However the advent of anal endosonography has added a new dimension to our understanding of the pathophysiology of faecal incontinence. In this thesis, gross dissection and histological studies of 19 anorectal specimens was performed to demonstrate the normal anatomy. Simultaneous dissection and sonography of the anorectum (14 in vivo and 12 in vitro studies) has clarified the normal sonographic anatomy of the anal sphincters. Anal endosonography was performed in 114 healthy volunteers to demonstrate gender differences in anal sphincter anatomy. A prospective study of 12 patients undergoing secondary sphincter repair and 15 patients undergoing lateral internal anal sphincterotomy has validated the appearance of sonographic sphincter defects. A new technique of demonstrating the anal sphincters at rest using vaginal endosonography has been demonstrated in 20 women. A prospective study of 202 pregnant women using anal endosonography and neurophysiological tests has demonstrated that 35% of primigravidae (13% symptomatic) and 44% of multigravidae (23% symptomatic) develop occult anal sphincter defects during vaginal delivery. Although pudendal nerve damage can be identified in 16% of women 6 weeks after delivery, in the majority this recovers with time. Forceps delivery was identified as the single independent variable associated with sphincter damage although damage was also sustained in the absence of instrumental delivery. In a separate study of 50 women who sustained a recognized third degree tear 47% were found to be symptomatic despite a primary sphincter repair. In 85% of these women persistent anal sphincter defects were identified sonographically. In a further study of 43 women who had an instrumental delivery (17 vacuum and 26 forceps) anal sphincter defects were identified in 81% (38% symptomatic) of women who were delivered by forceps compared to 12% (21% symptomatic) delivered by the vacuum extractor. One hundred and fifty doctors and midwives were interviewed to assess their knowledge and training in perineal anatomy and repair. There was a clear deficiency in knowledge and inconsistencies in classification of third degree tears were apparent highlighting the need for more focused training in perineal anatomy and repair. / Thesis (Ph.D.)-University of Natal, 1994.

BACKGROUND: There are many studies that have documented the increasing impact of stress and anxiety on an individual’s health and well-being. Everyone handles stress and anxiety differently with these conditions having varying physiological effects. To better recognize whether or not a person may need help in tackling these conditions, scholars have developed reliable validated instruments. Two prominent instruments that effectively assess stress and anxiety levels are the Perceived Stress (PSS) and Generalized Anxiety Disorder (GAD-7) scales. Furthermore, the literature has shed light onto the importance of the carotid intima-media thickness (c-IMT) measurement as a tool in evaluating the risk of cardiovascular disease. After all, heart disease has been reported as being the number one killer of Americans in recent years. The specific aims of this study were to determine if there was an association between perceived stress / generalized anxiety and c-IMT (static association), and also if higher levels of perceived stress / generalized anxiety result in a significant increase in c-IMT (changes over time). METHODS: Data was collected on about 700 participants comprised of employees from Emory University in Atlanta, Georgia. At baseline, six, twelve, and twenty-four months, the largest number of participants had completed and calculated their scores on the PSS and GAD-7 scales. At these same time points, participants had their IMT measured and recorded for the left and right common carotid arteries by a trained sonographer of the Emory Predictive Health Institute. Due to incomplete measurements and scores, only 228 participants were included for statistical analyses. This was still considered a suitable sample size given that this study only involved four measurement time points. Various statistical models were fitted for the data. All variables in the models were treated as categorical except for time which was continuous. Four separate models were built that included the variables perceived stress, age group, gender and time. In a similar manner, four models were built that included the variables generalized anxiety, age group, gender and time. AIC values, -2 log-likelihoods, partial correlations, p-values, and other relevant information were reported for these models. All statistical analyses were performed using the Statistical Analysis System (SAS), version 9.2. RESULTS: The mean c-IMT measurements for the Emory participants were higher than established normal ranges. A strong correlation existed between the PSS and GAD-7 two-year averages when treated as continuous variables (.7316, p <.0001). Likewise, a meaningful relationship existed when both scales were categorical (.4154, p < .0001). The analyses revealed that the left and right mean IMT measurements for the common carotid arteries modeled a linear trend with an unstructured covariance the best. The partial correlations for perceived stress and generalized anxiety revealed weak, but significant positive associations with the mean c-IMT measurement. Although the slope coefficients were not significant for perceived stress, an increase from below average to above average perceived stress level still resulted in an increase in mean c-IMT measurement. Conversely, mild generalized anxiety was found to be statistically significant in the regression model of the left mean c-IMT. This was after controlling for age group and gender. The p-value for mild generalized anxiety was 0.0258, and the slope coefficient was 0.04856. IMT measurements were consistently higher for males on both sides compared to females. They were also higher on the left side compared to the right. CONCLUSIONS: Failure to control anxiety could lead to c-IMT soaring to dangerous levels resulting in a myocardial infarction and/or cerebrovascular accident. Individuals should engage in healthy lifestyle practices that lower stress and anxiety levels to decrease the chances of cardiovascular disease. Based on this study’s findings, a person can certainly use their c-IMT readings, as well as their perceived stress and generalized anxiety scores, as indicators that lifestyle modifications may be needed.

Diss. (sammanfattning) Stockholm : Karolinska institutet, 2005. / Härtill 4 uppsatser.

Submitted by PRISCILA SILVA null (priscilasvet@gmail.com) on 2018-04-05T14:21:37Z No. of bitstreams: 1 Dissertação Priscila Silva.pdf: 1846233 bytes, checksum: 95363950f8300b574023fbfe2f7b3eb8 (MD5) / Approved for entry into archive by Alexandra Maria Donadon Lusser Segali null (alexmar@fcav.unesp.br) on 2018-04-06T10:29:16Z (GMT) No. of bitstreams: 1 silva_p_me_jabo.pdf: 1846233 bytes, checksum: 95363950f8300b574023fbfe2f7b3eb8 (MD5) / Made available in DSpace on 2018-04-06T10:29:16Z (GMT). No. of bitstreams: 1 silva_p_me_jabo.pdf: 1846233 bytes, checksum: 95363950f8300b574023fbfe2f7b3eb8 (MD5) Previous issue date: 2018-02-26 / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) / A incidência de neoplasmas mamários em cadelas tem aumentado o seu diagnóstico juntamente com a sobrevida desses animais e a avaliação completa das mamas e anexos é fundamental para o diagnóstico adequado. Uma característica dos neoplasmas mamários é a grande capacidade de desenvolver metástase e os linfonodos regionais por serem responsáveis pela drenagem das mamas, desenvolvem um papel importante na disseminação de células tumorais, sendo um fator prognóstico negativo para os pacientes. O desenvolvimento de novas técnicas para detecção do linfonodo sentinela e identificação prévia de alterações contribuem positivamente na sobrevida do paciente. Todavia, a maioria dos métodos utilizados para o diagnóstico conclusivo são métodos invasivos. Sendo assim, este estudo prospectivo visou avaliar a sensibilidade e especificidade das técnicas ultrassonográficas para avaliação de linfonodos locoreginais em cadelas com tumores mamários (Modo-B, Doppler em cores e Elastografia Acoustic Radiation Force Impulse - ARFI), pela diferenciação da malignidade (livres, reativos e metastáticos) Linfonodos axilares (n = 96) e inguinais (n = 100) ipsilaterais de cadeias mamárias de 100 cadelas acometidas foram avaliados por meio da ultrassonografia modo-B (comprimento, altura, relação eixo curto/longo, forma, ecotextura e ecogenicidade), Doppler em cores (presença ou ausência de vascularização) e Elastografia ARFI (rigidez, padrão, deformabilidade, velocidade de cisalhamento e profundidade). As variáveis que obtiveram diferença significativa foram valor de corte, sensibilidade, especificidade, área sobre a curva e acurácia. A velocidade de cisalhamento obtida pela elastografia ARFI apresentou sensibilidade de 95%, especificidade de 87% e acurácia de 90% em linfonodos inguinais com metástase, com valor de corte > 2.5 m/s, e sensibilidade 100%, especificidade 94% e acurácia 90%, com valor de corte > 2,4m/s em axilares metastáticos, demonstrando ser um método adequado e não invasivo para detecção de linfonodos com metástase. Ao elastograma, a presença de estruturas neoplásicas mais rígidas (áreas avermelhadas) foram indicativas de malignidade, com as reativas com menor rigidez (áreas esverdeadas) e as normais (áreas azuladas) menos rígidas que as anteriores. Concluiu-se que a avaliação dos linfonodos por meio da elastografia ARFI é um preditor eficaz na detecção de linfonodos com metástase, reativos ou livres. Assim, a inclusão deste exame na clínica veterinária e oncologia é recomendada principalmente por ser uma técnica não invasiva, inócua e que pode melhorar o prognóstico do paciente. / The incidence of mammary neoplasms in bitches has increased their diagnosis along with a survival of the animals and a complete evaluation of the mammarys and appendages is fundamental for the proper diagnosis. A characteristic of mammary neoplasms is a great capacity to develop regional metaphors and lymph nodes because they are responsible for the production of breasts, they play an important role in the dissemination of tumor cells, being a negative prognostic factor for the patients. The development of new techniques for lymph node detection and the preventive identification of positive contributions to patient survival. However, most of the methods used for conclusive diagnosis are invasive methods. (B-mode, Doppler in nuclei and Acoustic Radiation Force Impulse Elastography - ARFI), by the difference in the literature, reactive and metastatic measurements of malignancy (lp, Doppler color and Elastography). Axillary lymph nodes (n = 96) and inguinal lymph nodes (n = 100) ipsilateral mammary chains of 100 bitches were reassessed by means of B-mode ultrasonography (length, height, short / long axis, shape, ecotexture and echogenicity), core Doppler (presence or absence of vascularization) and ARFI Elastography (stiffness, pattern, deformability, shear velocity and depth). The variables that obtained the significant difference have cut-off value, sensitivity, specificity, area over the curve and accuracy. The shear velocity obtained by ARFI elastography showed 95% sensitivity, 87% specificity and 90% accuracy in metastasis inguinal lymph nodes, with cutoff value> 2.5 m / s, and sensitivity 100%, specificity 94% and 90% accuracy, with cutoff value> 2.4 m / s in metastatic axillaries, proving to be an adequate and noninvasive method for the detection of lymph nodes with metastasis. Electrolytes, the presence of more rigid neoplastic structures, such as reactive ones with less stiffness (green areas) and as normal (bluish areas) less rigid than before. It was concluded that the evaluation of lymph nodes through elasticity. ARFI is an effective predictor for the detection of metastatic lymph nodes, either reactive or free. Thus, an inclusion of this examination in the veterinary clinic and oncology is recommended mainly because it is a noninvasive technique, innocuous and that can improve the prognosis of the patient.

Orientador: José Carlos Peraçoli / Banca: Roberto Antonio de Araújo Costa / Banca: Claudia Garcia Magalhães / Banca: Alberto Moreno Zaconeta / Banca: Roseli Mieko Yamamoto Nomura / Resumo: Introdução: A pré-eclâmpsia contribui consideravelmente para o aumento da morbimortalidade materna e perinatal. Pode ser classificada em precoce e tardia, de acordo com a época de seu aparecimento. O Doppler da artéria oftálmica é um método objetivo que pode facilitar o diagnóstico da hipertensão durante a gestação, identificando suas diferentes formas de manifestação. Objetivo: Diferenciar, por meio do Doppler da artéria oftálmica, o padrão hemodinâmico da artéria oftálmica das gestantes portadoras de pré-eclâmpsia precoce daquelas portadoras de pré-eclâmpsia tardia. Metodologia: Estudo transversal de 67 gestantes com pré-eclâmpsia precoce e 93 gestantes com pré-eclâmpsia tardia realizado no terceiro trimestre de gestação. Todas as gestantes realizaram Doppler da artéria oftálmica direita, que avaliou os seguintes parâmetros, para quantificação da onda de velocidade de fluxo: índice de resistência (IR), índice de pulsatilidade (IP), pico de velocidade sistólica (PVS), pico de velocidade diastólica (PVD), velocidade diastólica final (VDF) e razão entre picos de velocidade (RPV). Os resultados foram submetidos à análise estatística, considerando-se significativos quando p<0,05. Resultados: As médias dos índices dopplervelocimétricos das gestantes com pré-eclâmpsia precoce e pré-eclâmpsia tardia foram respectivamente: IR= 0,7 ± 0,1; 0,7 ± 0,1, IP= 1,3 ± 0,4; 1,4 ± 1,1, PVS: 33,2 ± 8,2; 34,3 ± 10,0, PVD: 26,5 ± 8,1; 25,5 ± 9,4, VDF: 11,2 ± 3,8; 11,7 ± 4,6 e RPV: 0,8 ± 0,2; 0,7 ± 0,2. A razão de pico de velocidade foi significativamente maior nas gestantes com pré-eclâmpsia precoce. Não houve diferença significativa em relação aos valores de índice de resistência, índice de pulsatilidade, pico de velocidade sistólica, pico de velocidade diastólica e velocidade diastólica final. Conclusão: O Doppler da artéria oftálmica é um exame que pode ser usado na avaliação de... / Abstract: Introduction: Preeclampsia contributes considerably to increased maternal and perinatal morbidity and mortality. This disease can be classified into early and late onset preeclampsia, according to the timing of their clinical manifestations appearance. The ophthalmic artery Doppler is an objective method that can facilitate the diagnosis of hypertension during pregnancy, identifying its different manifestations. Objective: Differentiate through the Doppler of the ophthalmic artery the hemodynamic pattern of the ophthalmic artery of early and late onset preeclampsia. Methods: Cross-sectional study of 67 pregnant women with early preeclampsia and 93 pregnant women with late preeclampsia performed in the third trimester of pregnancy. All women had performed the right ophthalmic artery Doppler that evaluated the following parameters for the quantification wave flow rate: resistance index (RI), pulsatility index (PI), peak systolic velocity (PSV), peak diastolic velocity (PVD), end-diastolic velocity (EDV) and peak velocity ratio (RPV). The results were subjected to statistical analysis, considering significant when p <0.05. Results: The mean Doppler indices of early and late onset preeclampsia were: RI = 0.7 ± 0.1 vs 0.7 ± 0.1, IP= 1.3 ± 0.4 vs 1.4 ± 1.1, PVS: 33.2 ± 8.2 vs 34.3 ± 10.0, PVD: 26.5 ± 8.1 vs 25.5 ± 9.4, VDF: 11.2 ± 3.8 vs 11.7 ± 4.6 and RPV: 0.8 ± 0.2 vs 0.7 ± 0.2. The speed of peak ratio was significantly higher in patients with early preeclampsia. There was no significant difference in terms of resistance index values, pulsatility index, peak systolic velocity, peak diastolic velocity and end diastolic velocity. Conclusion: The Doppler of the ophthalmic artery is a test that can be used in the evaluation of pregnant women with preeclampsia, showing difference in quantitative indices such as peak velocity ratio when comparing women with early and late onset preeclampsia / Doutor

Introdução: Descontinuação prematura ou tardia da ventilação mecânica invasiva (VM) associa-se a maior morbimortalidade. Redução da pressão intratorácica durante o teste de respiração espontânea (TRE) pode precipitar disfunção cardíaca através da elevação abrupta do retorno venoso e da pós-carga do ventrículo esquerdo. Da mesma maneira, alterações na demanda respiratória e cardíaca que ocorrem ao longo do TRE também podem manifestar-se à ultrassonografia pulmonar. O padrão B é um artefato sonográfico que se correlacionada com edema intersticial. Um ensaio clínico randomizando concluiu que a ultrassonografia pulmonar foi capaz de prever insuficiência ventilatória pós extubação através de variações na aeração pulmonar observadas durante o procedimento de desmame; contudo, a ferramenta não pôde rastrear pacientes antes da submissão ao TRE. O impacto do balanço hídrico (BH) e de sinais radiológicos de congestão pulmonar antes do TRE sobre os desfechos no desmame também precisam ser determinados. Métodos: Cinquenta e sete indivíduos elegíveis para o desmame ventilatório foram recrutados. Traqueostomizados foram excluídos. Realizou-se avaliação ultrassonográfica de seis zonas pulmonares imediatamente antes e ao final do TRE. Predominância B foi definida como qualquer perfil com padrão B presente bilateralmente em região torácica anterior. Os pacientes foram seguidos por até 48 horas depois da extubação. Após esse estudo piloto, foi conduzido um estudo observacional, prospectivo, multicêntrico em duas unidades de terapia intensiva (UTIs) clínico-cirúrgicas ao longo de dois anos. Os mesmos critérios de inclusão e de exclusão foram aplicados; contudo, a ultrassonografia foi realizada apenas antes do TRE. O desfecho primário foi falha no TRE, definido como incapacidade de tolerar o teste T durante 30 a 120 minutos e, nesse caso, o paciente não era extubado. Dados demográficos e fisiológicos, BH das 48 horas antecedendo o TRE (entrada de fluidos menos débitos durante 48 horas) e desfechos foram coletados. Em uma análise post hoc de 170 procedimentos de desmame, um radiologista aplicou um escore radiológico na interpretação de radiografias digitais de tórax realizadas previamente ao TRE – o exame mais recente disponível foi avaliado em termos de congestão pulmonar. Resultados: No estudo piloto, 38 indivíduos foram extubados com sucesso, 11 falharam no TRE e 8 necessitaram de reintubação em até 48 horas após a extubação. No início do teste T, padrão B ou consolidação já estava presente em porções inferiores e posteriores dos pulmões em mais da metade dos casos, e tais regiões mantiveram-se não aeradas até o final do teste. Perda de aeração pulmonar durante o TRE foi observada apenas no grupo que falhou no mesmo (p= 0,07). Esses pacientes também demonstraram maior predominância B ao final do teste (p= 0,019). Antes do procedimento de desmame, todavia, não foi possível discernir indivíduos que falhariam no TRE, tampouco aqueles que necessitariam de reintubação dentro de 48 horas. Posteriormente, de 2011 a 2013, 250 procedimentos de desmame foram avaliados. Falha no TRE ocorreu em 51 (20,4%). Cento e oitenta e nove pacientes (75,6%) foram extubados na primeira tentativa. Indivíduos que falharam no TRE eram mais jovens (mediana de 66 versus 75 anos, p= 0,03) e apresentaram maior duração de VM e maior prevalência de doença pulmonar obstrutiva crônica (DPOC) (19,6 versus 9,5%, p= 0,04). Predominância B mostrou-se um preditor muito fraco para falha no TRE, exibindo sensibilidade de 47%, especificidade de 64%, valor preditivo positivo de 25% e valor preditivo negativo de 82%. Não houve diferença estatisticamente significativa no BH das 48 horas antecedendo o TRE entre os grupos (falha no TRE: 1201,65 ± 2801,68 ml versus sucesso no TRE: 1324,39 ± 2915,95 ml). Entretanto, em pacientes portadores de DPOC, ocorreu associação estatisticamente significativa entre BH positivo nas 48 horas antes do TRE e falha no TRE (odds ratio= 1,77 [1,24 – 2.53], p= 0,04). O escore radiológico, obtido em 170 testes T, foi similar entre os pacientes com falha e sucesso no TRE (mediana de 3 [2 – 4] versus 3 [2 – 4]), p= 0, 15). Conclusão: Maior perda de aeração pulmonar observada à ultrassonografia durante o TRE pode sugerir disfunção cardiovascular e aumento na água extravascular, ambos induzidos pelo processo de desmame. BH, sinais radiológicos de congestão pulmonar ou padrão B documentado através de um protocolo ultrassonográfico simplificado não devem contraindicar o TRE em pacientes estáveis hemodinamicamente e adequadamente oxigenados, haja vista o fato de tais variáveis não terem predito maior probabilidade de falha de desmame em pacientes críticos clínico-cirúrgicos. Ainda assim, evitar BH positivo em pacientes com DPOC parece otimizar os desfechos do desmame. / Introduction: Both delayed and premature liberation from mechanical ventilation (MV) are associated with increased morbi-mortality. Inspiratory fall in intra-thoracic pressure during spontaneous breathing trial (SBT) may precipitate cardiac dysfunction through abrupt increase in venous return and in left ventricular afterload. Changes in respiratory and cardiac load occurring throughout SBT might manifest with dynamic changes in lung ultrasound (LUS). B-pattern is an artifact that correlates with interstitial edema. A randomized controlled trial concluded that bedside LUS could predict post extubation distress due to changes in lung aeration throughout weaning procedure; however, it could not screen patients before submission to SBT. The impact of fluid balance (FB) as well as of radiological signs of pulmonary congestion prior to SBT on weaning outcomes must also be determined. Methods: Fifty-seven subjects eligible for ventilation liberation were enrolled. Patients with tracheostomy were excluded. LUS assessment of six thoracic zones was performed immediately before and at the end of SBT. B-predominance was defined as any profile with anterior bilateral B-pattern. Patients were followed up to 48 hours after extubation. After this pilot report, we conducted a 2-year prospective, multicenter, observational study in two adult medical surgical intensive care units (ICUs). Same inclusion and exclusion criteria were applied; however, LUS was performed only immediately before SBT. The primary outcome was SBT failure, defined as inability to tolerate a T-piece trial during 30 to 120 minutes, in which case patients were not extubated. Demographic, physiologic, FB in the preceding 48 hours of SBT (fluid input minus output over the 48-hour period), and outcomes data were collected. As a post hoc analysis in 170 weaning procedures performed in one of the ICUs, an attending radiologist applied a radiological score on interpretation of digital chest x-rays performed before SBT - the most recent available exam was analyzed regarding degree of lung fluid content. Results: In the pilot study, 38 subjects were successfully extubated, 11 failed the SBT and 8 needed reintubation within 48 hours of extubation. At the beginning of T-piece trial, B-pattern or consolidation were already found at lower and posterior lung regions in more than half of the individuals and remained nonaerated at the end of the trial. Loss of lung aeration during SBT was observed only in SBT-failure group (p= 0.07). These subjects also exhibited higher B-predominance at the end of trial (p= 0.019). Prior to weaning procedure, however, we were not capable to discriminate individuals who would fail SBT, nor who would need reintubation within 48 hours. Afterwards, from 2011 to 2013, 250 weaning procedures were evaluated. SBT failure occurred in 51 (20.4%). One hundred eighty-nine patients (75.6%) were extubated at first attempt. Individuals who failed SBT were younger (median 66 versus 75 years, p= 0.03), had higher duration of MV (median 7 versus 4 days, p< 0.0001) and higher prevalence of chronic obstructive pulmonary disease (COPD) (19.6 versus 9.5%, p= 0.04). B-predominance was a very weak predictor for SBT failure, showing 47% sensitivity, 64% specificity, 25% positive predictive value, and 82% negative predictive value. There were no statistically significant differences in 48 hour-FB prior to SBT between groups (SBT failure: 1201.65 ± 2801.68 mL versus SBT success: 1324.39 ± 2915.95 mL). However, in COPD subgroup, we found significant association between positive FB in the 48 hours prior to SBT and SBT failure (odds ratio = 1.77 [1.24 – 2.53], p= 0.04). Radiological score, obtained in 170 T-piece trials, was similar between SBT failure and success subjects (median 3 [2 - 4] vs 3 [2 - 4], p= 0.15). Conclusion: Higher loss of lung aeration observed by LUS during SBT might suggest cardiovascular dysfunction and increases in extravascular lung water, both induced by weaning. Neither FB, nor radiological findings of pulmonary congestion, nor B-pattern detected by a simplified LUS protocol should preclude hemodynamically stable, sufficiently oxygenated patients from performing an SBT, since such variables did not predict greater probability of weaning failure in medical-surgical critically ill population. Notwithstanding, avoiding positive FB in COPD patients might improve weaning outcomes.