INTRODUÇÃO: Na restrição de crescimento intrauterino, a resposta adaptativa a hipóxia, com priorização do fluxo sanguíneo para órgãos nobres, causa vasoconstricção periférica, com aumento da resistência nas artérias renais. Com isso, o desenvolvimento renal é prejudicado e fetos restritos apresentam volumes renais menores. No entanto, a literatura é escassa em estudos que utilizem a ultrassonografia tridimensional na avaliação renal e não descreve a relação desse possível dano renal com desfechos neonatais adversos. Tal técnica tem sido utilizada para mensurar volumes de órgãos e quantificar fluxos sanguíneos de baixa resistência, podendo ser também aplicada para melhorar a avaliação do volume e vascularização renal na restrição de crescimento. OBJETIVOS: Comparar a razão entre o volume renal total e o peso fetal estimado (VRT/PFE) entre fetos com e sem restrição. Além disso, correlacionar o VRT/PFE com a dopplervelocimetria fetal e os índices de vascularização renal e avaliar a associação dos parâmetros renais com eventos neonatais adversos nos fetos restritos. MÉTODOS: O volume total e a vascularização renal de fetos restritos e normais foram avaliados pela ultrassonografia tridimensional e a técnica VOCAL. Os índices de vascularização renal foram corrigidos pela profundidade renal (IVcp, IVFcp and IFcp). Os testes t para amostras independentes e Mann-Whitney foram utilizados para a comparação entre os grupos. Modelos lineares generalizados foram aplicados para avaliar a associação entre as características renais e os eventos neonatais adversos. RESULTADOS: Setenta e um fetos restritos foram comparados a 194 fetos com crescimento normal. O VRT/PFE foi menor no grupo restrito (p < 0,001). Porém essa razão não se correlacionaou com os parâmetros dopplervelocimétricos, os índices vasculares renais ou qualquer evento neonatal adverso. CONCLUSÃO: A razão entre o volume renal total e o peso fetal estimado tende a diminuir na restrição de crescimento intrauterino / INTRODUCTION: In fetal growth restriction, the adaptive response to hypoxia, with prioritization of blood flow to noble organs, causes peripheral vasoconstriction, such as increased resistance in the renal arteries. Then, renal development is impaired and restricted fetuses have lower renal volumes. However, the literature is scarse in studies using three-dimensional ultrasound in renal assessment and does not describe the relationship of this potential renal damage with adverse neonatal outcomes. That technique has been used to mesure volumes and quantify blood flows of low resistance and could also be applied to improve the evaluation of renal volume and vascularization in fetal growth restriction. OBJECTIVES: To compare the ratio of total renal volume to estimated fetal weight (TRV/EFW) among fetuses with and without grown restriction. Fhurthermore, we aim to correlate TRV/EFW with fetal dopplervelocimetry and renal vascularization indexes and to evaluate the association of renal parameters with adverse neonatal events in restricted fetuses. METHODS: Total renal volume and renal vascularization of restricted and normal fetuses were evaluated by three-dimensional ultrasonography and the VOCAL technique. Renal vascularization indexes were corrected for renal depth (VIcd, VFIcd and FIcd). The t-tests for independent samples and Mann-Whitney test were used for comparisons between groups. Generalized linear models were applied to evaluate the association between renal characteristics and adverse neonatal events. RESULTS: Seventy-one restricted fetuses were compared to 194 normally growing fetuses. The TRV/EFW was lower in the restricted group (p < 0.001). However, this ratio did not correlate with Doppler velocimetric parameters, renal vascular indexes or any adverse neonatal events. CONCLUSION: The ratio of total renal volume to estimated fetal weight tends to decrease in intrauterine growth restriction

INTRODUÇÃO: A dopplervelocimetria foi incorporada à propedêutica obstétrica por ser um método rotineiro e não-invasivo, que possibilita a avaliação da função placentária e da resposta fetal à hipoxia em gestações de alto risco. Várias curvas de valores de referência dos índices dopplervelocimétricos dos vasos de interesse na especialidade já foram publicados, porém os mais antigos utilizaram tecnologia ultra-sonográfica inferior à disponível atualmente; outros apresentaram falhas na execução do estudo (por ex. tamanho e seleção da amostra, número de exames; método estatística na análise dos dados). OBJETIVO: Este estudo tem como finalidade a confecção de curvas de normalidade dos índices dopplervelocimétricos das circulações uteroplacentária (artérias uterinas direita e esquerda maternas - AUT), fetoplacentária (artérias umbilicais - AU) e fetal (artéria cerebral média - ACM, aorta torácica descendente - ATD e ducto venoso - DV), da 14ª à 42ª semana de gestação, confeccionadas a partir de dados obtidos prospectivamente e longitudinalmente, de gestações normais cujos resultados de parto e neonatal não foram adversos. MÉTODOS: As gestantes foram recrutadas e avaliadas nas unidades de atendimento pré-natal de baixo risco da Clínica Obstétrica no Setor de Avaliação da Vitalidade Fetal do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brasil; no período de abril de 2000 a maio de 2004. Das 294 pacientes que foram recrutadas, somente 154 foram selecionadas para fazer parte da amostra analisada. As 908 avaliações dopplervelocimétricas foram realizadas somente por um operador, com taxa de sucesso de exame maior que 94% para cada vaso estudado. Foram utilizados aparelhos de ultra-sonografia com Doppler pulsátil e imagem em tempo real com dispositivo de mapeamento colorido de fluxo. Na análise estatística, adotou-se método de efeitos aleatórios ou modelo de múltiplos níveis descrito por Royston (1995). A distribuição dos valores dos índices para cada idade gestacional (IG em semanas) foi estudada. Quando verificada distribuição não-normal dos valores, aplicou-se modelos de transformação, sendo escolhido o modelo mais simples. Os valores originais dos índices foram mantidos quando a transformação não surtiu melhora da distribuição dos dados. A variável tempo (IG em semanas) foi testada por modelos de transformação polinomial (polinômios fracionários), sendo escolhido aquele que apresentou melhor desempenho. RESULTADOS: Foram determinados os intervalos de referência condicional e não-condicional dos valores dos índices dopplervelocimétricos de cada vaso, utilizando-se intervalo de confiança de 90% (alfa = 0,10). Após comparação, por sobreposição das curvas obtidas, considerando-se os intervalos de referência condicional e não-condicional, optou-se pelo uso dos valores calculados a partir de intervalos de referência não-condicionais por apresentarem curvas mais suaves e os valores serem muito semelhantes. CONCLUSÃO: foram obtidas as curvas de normalidade dos índices dopplervelocimétricos das AUT, das AU, das ACM e ATD fetais (relação S/D, IP e IR); e do DV (relação S/a, IPV e IDV), da 14ª à 42ª semana de gestação, a partir de dados coletados longitudinalmente de população brasileira, apresentando os percentis 5, 50 e 95. / INTRODUCTION: The Doppler velocimetry is a non-invasive method that allows the evaluation of the placental function and the fetal response to hypoxia in high-risk pregnancies. Many publications have presented the Doppler velocimetric indices reference ranges of the vessels. However, the oldest ones used inferior Doppler ultrasound technology when compared to what is currently available. Others have shown flaws in the methods size and selection of the samples, number of exams performed, the use of inappropriate statistical method to analyze the obtained data. OBJECTIVE: The purpose of this study is to construct the normal Doppler velocimetric indices reference ranges of the uteroplacental (maternal right and left uterine arteries - UAT), fetoplacental (umbilical arteries - UA) and fetal (middle cerebral artery - MCA, descendent thoracic aorta - DTA, ductus venosus - DV) circulations. Prospective and longitudinal data was obtained from normal pregnancies from 14 to 42 gestational weeks with normal delivery and neonatal outcomes. METHODS: Pregnant women were recruited from low-risk prenatal care units, and examined in the Fetal Surveillance Unit at the Obstetric Clinic (Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, SP, Brazil), between April 2000 and May 2004. Two-hundred ninety-four patients were recruited and 154 qualified to be part of the sample. A total of 908 Doppler velocimetric evaluations were performed by the same operator with a success rate of greater than 94% for each vessel studied, using ultrasound equipment with pulsatile Doppler and real-time color flow mapping technology. Random effects or multilevel models described by Royston (1995) were used in the analysis of the data obtained. The indices and the gestational age (in weeks) were tested for normal distribution by using fitted models and fractional polynomials transformation, respectively. When the transformed data did not show improvement in the normal distribution, the original values were used. RESULTS: The conditional and unconditional reference intervals for the 90% confidence interval were obtained for the indices of each vessel. Since the comparison between the unconditional and conditional reference intervals curves were very similar, the curves of the unconditional reference intervals were presented as they showed smoothed lines. CONCLUSION: The normal reference ranges of the Doppler velocimetric indices S/D ration, pulsatility index (PI) and resistance index (RI) of the UAT, UA, fetal MCA and DTA; and the S/a ratio, pulsatility index for veins (IPV) and DV index (IDV) of the DV were obtained from normal pregnancies between 14 and 42 weeks\' gestation, in a prospective and longitudinal study of the Brazilian population.

INTRODUÇÃO: O tratamento das neoplasias malignas anorretais exige ressecções que podem levar ao surgimento de defeitos perineais extensos. Esses defeitos necessitam de reconstrução que deve ser realizada, preferencialmente, com retalhos. Dentre eles, destacamos o retalho perfurante da artéria pudenda interna, localizado no sulco glúteo, vascularizado por vasos perfurantes cutâneos da artéria pudenda interna, e inervado por ramos do nervo pudendo e do nervo cutâneo femoral posterior. Esse retalho apresenta diversas vantagens em comparação com os outros utilizados para reconstrução perineal, e os dados relacionados à avaliação de sua sensibilidade cutânea são escassos, discrepantes e sujeitos a críticas metodológicas. OBJETIVO: Avaliar a sensibilidade cutânea do retalho perfurante da artéria pudenda interna após 12 meses da reconstrução perineal em cirurgias de amputação abdominoperineal de reto, e compará-la com a sensibilidade cutânea pré-operatória do sulco glúteo (área doadora do retalho). MÉTODOS: Estudo prospectivo com 25 pacientes submetidos à amputação abdominoperineal de reto por neoplasias malignas anorretais e reconstruídos com o retalho perfurante da artéria pudenda interna de avanço VY bilateral. As modalidades de sensibilidade tátil, dolorosa, térmica e vibratória foram analisadas em quatro áreas do sulco glúteo no pré-operatório e nas quatro áreas correspondentes do retalho 12 meses após a cirurgia. A avaliação da sensibilidade tátil foi realizada com o Pressure Specified Sensory Device(TM) (PSSD(TM)), aparelho que quantifica a pressão aplicada à pele, estática ou em movimento. As outras modalidades de sensibilidade foram analisadas com o método de escolha forçada, utilizando ponta de agulha para sensibilidade dolorosa, contato quente/frio para sensibilidade térmica e diapasão de 128 Hz para sensibilidade vibratória. RESULTADOS: Os limiares de sensibilidade tátil medidos com o PSSD(TM) no retalho perfurante da artéria pudenda interna após 12 meses da reconstrução perineal foram semelhantes aos limiares de sensibilidade tátil no sulco glúteo no pré-operatório, tanto no teste de pressão estática quanto em movimento. A comparação entre esses limiares não apresentou diferença estatisticamente significante, com valores de p superiores a 0,05 nas quatro áreas avaliadas, para ambos os testes. Todos os pacientes apresentaram sensibilidade dolorosa, térmica e vibratória nas quatro áreas testadas, tanto no sulco glúteo no pré-operatório quanto no retalho após 12 meses da cirurgia. CONCLUSÃO: Nas reconstruções perineais após amputação abdominoperineal de reto, espera-se que a sensibilidade cutânea do retalho perfurante da artéria pudenda interna seja mantida / INTRODUCTION: The treatment of anorectal malignancies requires resection that can lead to extensive perineal defects. These defects require reconstruction which should be performed, preferably, with flaps. Among them, we highlight the internal pudendal artery perforator flap, located on the gluteal fold, vascularized by cutaneous perforator vessels from the internal pudendal artery, and innervated by branches from the pudendal nerve and the posterior femoral cutaneous nerve. This flap has many advantages compared to others used for perineal reconstruction, and data related to the evaluation of its cutaneous sensibility are scarce, discrepant and subject to methodological criticisms. OBJECTIVE: To evaluate cutaneous sensibility of the internal pudendal artery perforator flap 12 months after perineal reconstruction in abdominoperineal resection of rectum, and compare it with the preoperative cutaneous sensibility of the gluteal fold (flap donor area). METHODS: A prospective study of 25 patients undergoing abdominoperineal resection of rectum for anorectal malignancies, and reconstruction with the internal pudendal artery perforator flap, in bilateral VY advancement. The modalities of tactile, pain, thermal and vibration sensibility were analyzed in four areas of the gluteal fold preoperatively and in the four corresponding areas of the flap 12 months after surgery. Tactile sensibility was assessed using the Pressure Specified Sensory Device(TM) (PSSD(TM)), a device that measures the pressure applied to the skin, static or moving. The other types of sensibility were analyzed with the forced-choice method, using a needle for pain sensibility, hot/cold contact for thermal sensibility and 128 Hz tuning-fork for vibration sensibility. RESULTS: The tactile sensibility thresholds measured with PSSD(TM) on the internal pudendal artery perforator flap 12 months after perineal reconstruction were similar to tactile sensibility thresholds of the gluteal fold preoperatively, both in static and moving pressure tests. The comparison between these thresholds showed no statistically significant difference, with p values greater than 0.05 in the four areas evaluated, for both tests. All patients presented pain, thermal and vibration sensibility in all four areas tested, on the both the gluteal fold preoperatively and the flap 12 months after surgery. CONCLUSION: In perineal reconstructions after abdominoperineal resection of rectum, it is expected that the cutaneous sensibility of the internal pudendal artery perforator flap is maintained

INTRODUÇÃO: A dopplervelocimetria foi incorporada à propedêutica obstétrica por ser um método rotineiro e não-invasivo, que possibilita a avaliação da função placentária e da resposta fetal à hipoxia em gestações de alto risco. Várias curvas de valores de referência dos índices dopplervelocimétricos dos vasos de interesse na especialidade já foram publicados, porém os mais antigos utilizaram tecnologia ultra-sonográfica inferior à disponível atualmente; outros apresentaram falhas na execução do estudo (por ex. tamanho e seleção da amostra, número de exames; método estatística na análise dos dados). OBJETIVO: Este estudo tem como finalidade a confecção de curvas de normalidade dos índices dopplervelocimétricos das circulações uteroplacentária (artérias uterinas direita e esquerda maternas - AUT), fetoplacentária (artérias umbilicais - AU) e fetal (artéria cerebral média - ACM, aorta torácica descendente - ATD e ducto venoso - DV), da 14ª à 42ª semana de gestação, confeccionadas a partir de dados obtidos prospectivamente e longitudinalmente, de gestações normais cujos resultados de parto e neonatal não foram adversos. MÉTODOS: As gestantes foram recrutadas e avaliadas nas unidades de atendimento pré-natal de baixo risco da Clínica Obstétrica no Setor de Avaliação da Vitalidade Fetal do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brasil; no período de abril de 2000 a maio de 2004. Das 294 pacientes que foram recrutadas, somente 154 foram selecionadas para fazer parte da amostra analisada. As 908 avaliações dopplervelocimétricas foram realizadas somente por um operador, com taxa de sucesso de exame maior que 94% para cada vaso estudado. Foram utilizados aparelhos de ultra-sonografia com Doppler pulsátil e imagem em tempo real com dispositivo de mapeamento colorido de fluxo. Na análise estatística, adotou-se método de efeitos aleatórios ou modelo de múltiplos níveis descrito por Royston (1995). A distribuição dos valores dos índices para cada idade gestacional (IG em semanas) foi estudada. Quando verificada distribuição não-normal dos valores, aplicou-se modelos de transformação, sendo escolhido o modelo mais simples. Os valores originais dos índices foram mantidos quando a transformação não surtiu melhora da distribuição dos dados. A variável tempo (IG em semanas) foi testada por modelos de transformação polinomial (polinômios fracionários), sendo escolhido aquele que apresentou melhor desempenho. RESULTADOS: Foram determinados os intervalos de referência condicional e não-condicional dos valores dos índices dopplervelocimétricos de cada vaso, utilizando-se intervalo de confiança de 90% (alfa = 0,10). Após comparação, por sobreposição das curvas obtidas, considerando-se os intervalos de referência condicional e não-condicional, optou-se pelo uso dos valores calculados a partir de intervalos de referência não-condicionais por apresentarem curvas mais suaves e os valores serem muito semelhantes. CONCLUSÃO: foram obtidas as curvas de normalidade dos índices dopplervelocimétricos das AUT, das AU, das ACM e ATD fetais (relação S/D, IP e IR); e do DV (relação S/a, IPV e IDV), da 14ª à 42ª semana de gestação, a partir de dados coletados longitudinalmente de população brasileira, apresentando os percentis 5, 50 e 95. / INTRODUCTION: The Doppler velocimetry is a non-invasive method that allows the evaluation of the placental function and the fetal response to hypoxia in high-risk pregnancies. Many publications have presented the Doppler velocimetric indices reference ranges of the vessels. However, the oldest ones used inferior Doppler ultrasound technology when compared to what is currently available. Others have shown flaws in the methods size and selection of the samples, number of exams performed, the use of inappropriate statistical method to analyze the obtained data. OBJECTIVE: The purpose of this study is to construct the normal Doppler velocimetric indices reference ranges of the uteroplacental (maternal right and left uterine arteries - UAT), fetoplacental (umbilical arteries - UA) and fetal (middle cerebral artery - MCA, descendent thoracic aorta - DTA, ductus venosus - DV) circulations. Prospective and longitudinal data was obtained from normal pregnancies from 14 to 42 gestational weeks with normal delivery and neonatal outcomes. METHODS: Pregnant women were recruited from low-risk prenatal care units, and examined in the Fetal Surveillance Unit at the Obstetric Clinic (Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, SP, Brazil), between April 2000 and May 2004. Two-hundred ninety-four patients were recruited and 154 qualified to be part of the sample. A total of 908 Doppler velocimetric evaluations were performed by the same operator with a success rate of greater than 94% for each vessel studied, using ultrasound equipment with pulsatile Doppler and real-time color flow mapping technology. Random effects or multilevel models described by Royston (1995) were used in the analysis of the data obtained. The indices and the gestational age (in weeks) were tested for normal distribution by using fitted models and fractional polynomials transformation, respectively. When the transformed data did not show improvement in the normal distribution, the original values were used. RESULTS: The conditional and unconditional reference intervals for the 90% confidence interval were obtained for the indices of each vessel. Since the comparison between the unconditional and conditional reference intervals curves were very similar, the curves of the unconditional reference intervals were presented as they showed smoothed lines. CONCLUSION: The normal reference ranges of the Doppler velocimetric indices S/D ration, pulsatility index (PI) and resistance index (RI) of the UAT, UA, fetal MCA and DTA; and the S/a ratio, pulsatility index for veins (IPV) and DV index (IDV) of the DV were obtained from normal pregnancies between 14 and 42 weeks\' gestation, in a prospective and longitudinal study of the Brazilian population.

INTRODUÇÃO: O tratamento das neoplasias malignas anorretais exige ressecções que podem levar ao surgimento de defeitos perineais extensos. Esses defeitos necessitam de reconstrução que deve ser realizada, preferencialmente, com retalhos. Dentre eles, destacamos o retalho perfurante da artéria pudenda interna, localizado no sulco glúteo, vascularizado por vasos perfurantes cutâneos da artéria pudenda interna, e inervado por ramos do nervo pudendo e do nervo cutâneo femoral posterior. Esse retalho apresenta diversas vantagens em comparação com os outros utilizados para reconstrução perineal, e os dados relacionados à avaliação de sua sensibilidade cutânea são escassos, discrepantes e sujeitos a críticas metodológicas. OBJETIVO: Avaliar a sensibilidade cutânea do retalho perfurante da artéria pudenda interna após 12 meses da reconstrução perineal em cirurgias de amputação abdominoperineal de reto, e compará-la com a sensibilidade cutânea pré-operatória do sulco glúteo (área doadora do retalho). MÉTODOS: Estudo prospectivo com 25 pacientes submetidos à amputação abdominoperineal de reto por neoplasias malignas anorretais e reconstruídos com o retalho perfurante da artéria pudenda interna de avanço VY bilateral. As modalidades de sensibilidade tátil, dolorosa, térmica e vibratória foram analisadas em quatro áreas do sulco glúteo no pré-operatório e nas quatro áreas correspondentes do retalho 12 meses após a cirurgia. A avaliação da sensibilidade tátil foi realizada com o Pressure Specified Sensory Device(TM) (PSSD(TM)), aparelho que quantifica a pressão aplicada à pele, estática ou em movimento. As outras modalidades de sensibilidade foram analisadas com o método de escolha forçada, utilizando ponta de agulha para sensibilidade dolorosa, contato quente/frio para sensibilidade térmica e diapasão de 128 Hz para sensibilidade vibratória. RESULTADOS: Os limiares de sensibilidade tátil medidos com o PSSD(TM) no retalho perfurante da artéria pudenda interna após 12 meses da reconstrução perineal foram semelhantes aos limiares de sensibilidade tátil no sulco glúteo no pré-operatório, tanto no teste de pressão estática quanto em movimento. A comparação entre esses limiares não apresentou diferença estatisticamente significante, com valores de p superiores a 0,05 nas quatro áreas avaliadas, para ambos os testes. Todos os pacientes apresentaram sensibilidade dolorosa, térmica e vibratória nas quatro áreas testadas, tanto no sulco glúteo no pré-operatório quanto no retalho após 12 meses da cirurgia. CONCLUSÃO: Nas reconstruções perineais após amputação abdominoperineal de reto, espera-se que a sensibilidade cutânea do retalho perfurante da artéria pudenda interna seja mantida / INTRODUCTION: The treatment of anorectal malignancies requires resection that can lead to extensive perineal defects. These defects require reconstruction which should be performed, preferably, with flaps. Among them, we highlight the internal pudendal artery perforator flap, located on the gluteal fold, vascularized by cutaneous perforator vessels from the internal pudendal artery, and innervated by branches from the pudendal nerve and the posterior femoral cutaneous nerve. This flap has many advantages compared to others used for perineal reconstruction, and data related to the evaluation of its cutaneous sensibility are scarce, discrepant and subject to methodological criticisms. OBJECTIVE: To evaluate cutaneous sensibility of the internal pudendal artery perforator flap 12 months after perineal reconstruction in abdominoperineal resection of rectum, and compare it with the preoperative cutaneous sensibility of the gluteal fold (flap donor area). METHODS: A prospective study of 25 patients undergoing abdominoperineal resection of rectum for anorectal malignancies, and reconstruction with the internal pudendal artery perforator flap, in bilateral VY advancement. The modalities of tactile, pain, thermal and vibration sensibility were analyzed in four areas of the gluteal fold preoperatively and in the four corresponding areas of the flap 12 months after surgery. Tactile sensibility was assessed using the Pressure Specified Sensory Device(TM) (PSSD(TM)), a device that measures the pressure applied to the skin, static or moving. The other types of sensibility were analyzed with the forced-choice method, using a needle for pain sensibility, hot/cold contact for thermal sensibility and 128 Hz tuning-fork for vibration sensibility. RESULTS: The tactile sensibility thresholds measured with PSSD(TM) on the internal pudendal artery perforator flap 12 months after perineal reconstruction were similar to tactile sensibility thresholds of the gluteal fold preoperatively, both in static and moving pressure tests. The comparison between these thresholds showed no statistically significant difference, with p values greater than 0.05 in the four areas evaluated, for both tests. All patients presented pain, thermal and vibration sensibility in all four areas tested, on the both the gluteal fold preoperatively and the flap 12 months after surgery. CONCLUSION: In perineal reconstructions after abdominoperineal resection of rectum, it is expected that the cutaneous sensibility of the internal pudendal artery perforator flap is maintained

O objetivo deste trabalho é apresentar o teste de esforço com o dinamômetro isocinético na avaliação objetiva da isquemia funcional da doença arterial oclusiva de membros superiores (DAOMS). Reuniu-se 23 pacientes com DAOMS unilateral, no grupo 1. Sete pacientes, sem DAOMS foram selecionados como o grupo controle (grupo 2). Os membros testados sem DAOMS do grupo 1 e do grupo 2 não apresentaram diferença estatística. A comparação de cada membro dos pacientes do grupo 1, com e sem DAOMS mostrou que os membros com DAOMS apresentaram desempenho significativamente menor que os membros sem lesão. Este teste permite a avaliação objetiva da limitação causada pela DAOMS de forma segura e objetiva / The objective of this work is to present the results of a stress test using an isokinetic dynamometer in patients with occlusive arterial disease in upper limbs (OADUL). Group 1 has 23 patients with unilateral subclavian occlusive disease. Seven patients, without OADUL, were included in a control group (group 2). No statistically difference was found in all parameters studied between limbs without OADUL in groups 1 and 2. So, each arm in group 1 (with and without OADUL) were tested. For all these parameters, the SOD limbs presented significantly lower values than the control limbs. This test gives an objective grade of limitation of the muscle function in patients with OADUL

No description available.

Although axillary artery injury occurs frequently with dislocations of the shoulder and fractures of the clavicle, it is rarely associated with fractures of the proximal humerus. If the axillary artery is damaged, prompt recognition and treatment are necessary to salvage the involved extremity.

No / BACKGROUND: The potential pathogenesis between the presence and severity of chronic cerebrospinal venous insufficiency (CCSVI) and its relation to clinical and imaging outcomes in brain parenchyma of multiple sclerosis (MS) patients has not yet been elucidated. The aim of the study was to investigate the relationship between CCSVI, and altered brain parenchyma venous vasculature visibility (VVV) on susceptibility-weighted imaging (SWI) in patients with MS and in sex- and age-matched healthy controls (HC). METHODS: 59 MS patients, 41 relapsing-remitting and 18 secondary-progressive, and 33 HC were imaged on a 3T GE scanner using pre- and post-contrast SWI venography. The presence and severity of CCSVI was determined using extra-cranial and trans-cranial Doppler criteria. Apparent total venous volume (ATVV), venous intracranial fraction (VIF) and average distance-from-vein (DFV) were calculated for various vein mean diameter categories: < .3 mm, .3-.6 mm, .6-.9 mm and > .9 mm. RESULTS: CCSVI criteria were fulfilled in 79.7% of MS patients and 18.2% of HC (p < .0001). Patients with MS showed decreased overall ATVV, ATVV of veins with a diameter < .3 mm, and increased DFV compared to HC (all p < .0001). Subjects diagnosed with CCSVI had significantly increased DFV (p < .0001), decreased overall ATVV and ATVV of veins with a diameter < .3 mm (p < .003) compared to subjects without CCSVI. The severity of CCSVI was significantly related to decreased VVV in MS (p < .0001) on pre- and post-contrast SWI, but not in HC. CONCLUSIONS: MS patients with higher number of venous stenoses, indicative of CCSVI severity, showed significantly decreased venous vasculature in the brain parenchyma. The pathogenesis of these findings has to be further investigated, but they suggest that reduced metabolism and morphological changes of venous vasculature may be taking place in patients with MS.

Das Vorkommen von über den Umgebungsdruck erhöhten Sauerstoffpartialdrucken in Geweben ist im Tierreich nur von der Schwimmblase und dem Auge von Knochenfischen bekannt. Die physiologischen Mechanismen dieser Sauerstoffkonzentrierung wurden an der Schwimmblase insbesondere des Aals intensiv untersucht, entsprechende Untersuchungen zu den Vorgängen im Auge der Knochenfische fehlen jedoch. In dieser Arbeit wurde daher eine Methode etabliert, mit der die Sauerstoffkonzentrierung im Auge der Knochenfische an isolierten Augen untersucht werden kann. 1. Das Gefäßsystem der Regenbogenforelle (Oncorhynchus mykiss, Walbaum 1792) wurde durch Gefäßausgüsse dargestellt. Das im Auge gelegene choroidale Rete mirabile wird über die Arteria ophthalmica, die gleichzeitig die efferente Pseudobranchienarterie darstellt, versorgt. Die Pseudobranchie selber empfängt das Blut aus der efferenten Arterie des ersten Kiemenbogens. Diese Gefäßtopologie, Versorgung der Pseudobranchie mit bereits im ersten Kiemenbogen oxygeniertem Blut und auschließliche Versorgung des choroidalen Rete mirabile mit Blut aus der Pseudobranchie, weist auf die Bedeutung der Pseudobranchie für die Prozesse im Auge hin. 2. Die Retina der Regenbogenforelle wurde mikroskopisch untersucht. Die einzelnen Schichten der Retina entsprechen denen anderer Wirbeltiere. Die Forellenretina ist mit 407 µm aber wesentlich dicker als z.B. die Retina von Mammaliern. Zusätzlich fehlt der Retina der Forelle die bei vielen Mammaliern vorhandene retinale Blutgefäßversorgung. Mit den der Retina am nächsten gelegenen Gefäßen in der Choroidea bestehen bei der Forelle wesentlich größere Diffusionsstrecken von den Blutgefäßen zum Ort des Sauerstoffverbrauchs in den Zellen der Retina als bei anderen Wirbeltieren. Dies wir durch den erhöhten Sauerstoffpartialdruck in den Choriokapillaren kompensiert. 3. Für die Messung des intraretinalen Sauerstoffpartialdrucks wurden im Rahmen dieser Arbeit Sauerstoffmikroelektroden inklusive der zur Betreibung der Elektroden notwendigen Elektronik entwickelt. Die Elektroden waren vom Recess-Typ: die reaktive Oberfläche schloss nicht mit dem Ende der Glaskapillare ab, sondern war unter Belassung eines Hohlraumes in der Elektrodenspitze (Recess) in das innere der Glaskapillare verlagert. Dadurch waren die Elektroden unempfindlich gegenüber Rühreffekten. Die Mikroelektroden hatten eine Spitzendurchmesser von < 10 µm und eine mittlere Empfindlichkeit von 172 fA Torr-1 O2. Die Linearität der Elektroden über eine Partialdruckbereich von 0 bis 760 Torr O2 war besser als r = 0,9998. 4. Zur Überprüfung des normale Sauerstoffpartialdrucks in der Retina wurden Regenbogenforellen betäubt und künstlich ventiliert. Die systemischen Parameter wie arterieller PO2-Wert, Blutdruck und Herzschlag entsprachen dabei im Mittel mit 99 Torr (arterieller PO2), 28 Torr (Blutdruck) und 1,23 Hz (Herzschlag) den Werten unbetäubter, freischwimmender Forellen. Lediglich der arterielle pH-Wert war mit 8,02 während der künstlichen Ventilation durch eine ungenügende Kompensation einer respiratorischen Alkalose leicht gegenüber dem normalen Wert von 7,9 erhöht. 5. Die Auswirkungen der Präparation des Auges zur Messung des intraretinalen Sauerstoffpartialdrucks auf den Augeninnendruck wurde überprüft. Der Augeninnendruck betrug 4,9 Torr. Die Einbringung der Sauerstoffmikroelektrode hatte keine Auswirkung auf den Augeninnendruck. Erst das Entfernen der Elektrode nach der Messung führte zu einer deutlichen Verringerung des Augeninnendrucks. 6. Zum ersten Mal wurde in der vorliegenden Arbeit die Durchblutungsrate des Auges eines Knochenfisches bestimmt. Aus präparatorischen Gründen wurde die Messung an der afferenten Pseudobranchienarterie durchgeführt. Der mittlere Blutfluss in dem Gefäß betrug 745 µl min-1 kg-1. Durch Verschluss des kontralateralen Gefäßes stieg der Fluss auf 135% des ursprünglichen Wertes, da jetzt durch das ipsilaterale Gefäß und über die zwischen den beiden Gefäßen bestehende Anastomose beide Augen durch das ipsilaterale Gefäß mit Blut versorgt wurden. 7. Die Funktion der Retina während der intraretinalen Sauerstoffmessung wurde durch Ableitung des Elektroretinogramms kontrolliert. Trotz der während der Versuche fortbestehenden Betäubung mit dem Betäubungsmittel MS222, welches sich negativ auf das Elektroretinogramm auswirken soll, konnten normale Elektroretinogramme aufgezeichnet werde. Die invasive Messung des intraretinalen PO2 wirkte sich nicht negativ auf die Funktionalität der Retina aus. 8. Der intraretinale Sauerstoffpartialdruck wurde an betäubten, künstlich ventilierten Forellen überprüft. Der mittlere maximale PO2 im Bereich der Bruch´schen Membran betrug 382 Torr. An der Innenseite der Retina wurde ein PO2 von 10 Torr gemessen. Der Bereich des O2-Partialdruckgradienten in der Retina, gemessen über den Vorschub der Sauerstoffmikroelektrode vom niedrigsten bis zum höchsten PO2, betrug 433 µm, ein Wert der gut mit der mikroskopisch bestimmten Dicke der Retina (407 µm) übereinstimmt. 9. Zur Untersuchung der Einflüsse von Blutparametern auf die Sauerstoffkonzentrierung im Auge der Forelle wurden isolierte Augen künstlich mit verschiedenen Erythrozytensuspensionen perfundiert. Dazu wurde zum einen eine Suspension von Forellenerythrozyten eingesetzt, bei der erst der Root-Effekt in Abhängigkeit vom pH-Wert der Suspension bestimmt wurde. Bei basischem pH-Werten war das Hämoglobin der Erythrozyten vollständig gesättigt. Bei einem pH-Wert von 7,68 war noch eine Sättigung von 90% vorhanden, die bis zu einem pH-Wert von 7,31 auf 50% abnahm. 10% Sättigung wurden bei einem pH-Wert von 6,94 erreicht. Für die Perfusion wurde die Suspension der Forellenerythrozyten mit einem pH-Wert von 7,48 eingesetzt. Bei diesem pH-Wert liegt die Sättigung bei ca. 82% und eine Änderung des pH hat in diesem Bereich eine deutliche Änderung der Sättigung zur Folge, was die Freisetzung von O2 von Hämoglobin erleichtert. Als alternative Perfusionslösung wurde eine Suspension von Humanerythrozyten eingesetzt. Humanhämoglobin weist keinen Root-Effekt auf, es kann also durch die im Auge der Knochenfische vorhandenen Mechanismen kein Sauerstoff freigesetzt werden. 10. Der mittlere intraretinale Sauerstoffpartialdruck isolierter Augen betrug bei Perfusion mit der Suspension von Forellenerythrozyten 99 Torr. Nach dem Wechsel auf die Suspension mit Humanerythrozyten fiel der intraretinale Sauerstoffpartialdruck sofort auf 30 Torr ab. Der Perfusionsdruck änderte sich bei dieser Umstellung nicht. Bei Perfusion mit Ringerlösung fiel der intraretinale PO2 auf 20 Torr, gleichzeitig fiel jetzt auch der Perfusionsdruck ab. 11. Eine Konzentrierung des Sauerstoffs konnte bei der künstlichen Perfusion isolierter Augen nicht nachgewiesen werden. Die Notwendigkeit des Root-Effekts für einen hohen Sauerstoffpartialdruck im Auge wird trotzdem deutlich, da bei Perfusion mit einer Suspension von Humanerythrozyten, die einen höheren Sauerstoffgehalt aufwies als die Suspension der Forellenerythrozyten, der intraretinale Sauerstoffpartialdruck deutlich geringer war. 12. Das Modell des isoliert perfundierten Auges ist zur physiologischen Untersuchung des choroidalen Rete mirabile und Sauerstoffkonzentrierung besser geeignet als in vivo - Experimente, da systemische Einflüsse vermieden und die Auswirkungen der Pseudobranchie auf die Blutchemie ausgeschaltet werden können. / Oxygen partial pressures (Po2) above ambient levels are found only in the swimbladder and the eye of teleost fish species. The mechanisms related to the involved oxygen concentration processes have been investigated to some detail in eel swimbladder, but little attention has been paid to analogous mechanisms of the teleost eye. This thesis has accordingly concentrated on developing a method promoting investigation of oxygen concentrating mechanisms in teleost eyes by application of an isolated perfused eye preparation. 1. The vascular supply of eye and pseudobranch in rainbow trout (Oncorhynchus mykiss, Walbaum, 1792) was depicted by corrosion casts of the vascular system. The choroid rete mirabile is supplied with blood by the ophthalmic artery as the efferent blood vessel of the pseudobranch, with a small anastomosis to the contralateral vessel. The pseudobranch in turn is fed by the efferent artery of the first gill arch. This pattern of serial vascular connection suggests a role for the pseudobranch in the process of providing high oxygen tensions required for the high metabolic demand of the visual perception in the retina. 2. Eyes of various fish species were sectioned after paraffin embedding and examined microscopically. The organisation of teleost fish retinae is characterised by the same features and organisation well known from other vertebrates. However, the total thickness of 407 µm found for the retina of the rainbow is much larger than that observed in other animals such as mammals. The conditions of diffusive oxygen supply of retinal nerve cells is further hampered by the complete lack of intraretinal blood vessels commonly found in mammals. In trout, blood is supplied to only the choroid layer, leaving large diffusion distances to the retinal nerve cells to be spanned by oxygen partial pressures, elevated as compared to the bulk arterial system in the choroid capillaries. 3. Intraretinal oxygen partial pressure was determined in long-term anaesthetised specimens of Oncorhynchus mykiss, using specially developed oxygen microelectrodes and required electronic circuitry. Characteristic features of the electrodes include insensitivity of the signal to stirring, achieved by a recess of the reactive metal surface in a glass capillary, an average tip diameter of less than 10 µm and a characteristic sensitivity to oxygen of 172 fA Torr-1. The response of the electrodes to oxygen was linear over a range of partial pressures from 0 to 760 Torr O2 (r= 0,9998). 4. Normal oxygen partial pressures in trout retina were measured in long-term anaesthetised and artificially ventilated specimens of Oncorhynchus mykiss. In order to conduct the experiments under conditions as close as possible to normal homoiostasis, several systemic valuables were monitored continuously. During experimentation arterial Po2 averaged 99 Torr, mean blood pressure was 28 Torr and heart frequency was on the average 74 bpm, respectively, data in the range of values determined in unanesthetized, freely swimming trout. As the one exception, arterial pH (8,02) was slightly elevated during artificial ventilation as compared to control values (7,89), a shift induced by an inadequately high rate of artificial ventilation. 5. The impact of insertion of electrodes required for intraretinal Po2 measurement into the eye was found to have little effect. The intraocular pressure remained unaffected by opening the eye by puncture with leading cannula and inserted micro-Po2-electrode. The intraocular pressure fell only after removing the electrode after completion of the experiment. 6. Normal function of the retina during experimentation in vivo was checked by repeatedly measuring electroretinograms provoked by light flashes under dark ambient conditions. Although extended anaesthesia with MS222 is expected to affect the electroretinogram in fish, there was no indication of abnormal or reduced electroretinograms during experimentation. Also puncture of the eye with insertion of electrodes did not affect the electroretinogram. 7. Intraretinal Po2 was measured in anaesthetised and artificially ventilated trout. Oxygen profiles were recorded during advancement of the electrode tip though the retina, from the lowest Po2 at the inner surface with about 10 Torr to the highest Po2 in the region of Bruch´s membrane with about 382 Torr, travelling a total distance of 433 µm. This distance closely corresponds to the thickness of the retina measured by microscopic sectioning. 8. Blood flow to the eye as an important parameter for the establishment of an isolated eye preparation was measured in the afferent artery of the pseudobranch. Due to the anatomical situation this represents the closest possible approximation to measurement of flow in the ophthalmic artery. The blood flow was estimated by ultrasonic Doppler techniques with in situ calibration to be 216 µl min-1. Occlusion of the contralateral vessel resulted in an increase of the blood flow in the ipsilateral vessel to 135% of the original as a result of flow through the small anastomosis between the two ophthalmic arteries. This estimate is the first performed for blood flow to the eye of a fish. 9. An isolated eye preparation was used to investigate the influence of specific blood parameters on oxygen concentrating processes in the eye of Oncorhynchus mykiss. Eyes were perfused with suspensions of trout erythrocytes, human erythrocytes and Ringer´s solution. The Root Effect of trout haemoglobin was confirmed in suspension of erythrocytes. The haemoglobin was fully saturated at pH 8.45, still 90% saturated at 7.68, 50% at 7.31 and 10% at pH 6.94. In order to provide optimal starting conditions for the release of oxygen by relatively small changes in pH, pH 7.48 (resulting in 82 % saturation) was chosen for the perfusion of isolated eyes. As a control perfusion, suspensions of human erythrocytes provided a perfusate lacking any Root effect, thus not supporting the oxygen concentrating processes in fish eyes. 10. Perfusion of isolated trout eyes with pH 7.48 trout erythrocyte suspension resulted in an average intraretinal Po2 of 99 Torr, whereas perfusion with human erythrocytes resulted in an immediate decrease of Po2 to (of) 30 Torr, with a further drop to 20 Torr during perfusion with Ringer´s solution. Changes in perfusion between erythrocyte suspensions were performed without any changes in perfusion pressure, but the switch to control perfusion with Ringer´s solution exhibited a drop in perfusion pressure due to the reduced viscosity of the medium. 11. Although perfusion of isolated eyes did not exhibit Po2 above ambient values, the effect of oxygen concentrating processes were clearly indicated by comparison with Root effect-lacking human erythrocyte perfusate (Po2´s of 99 vs. 30 Torr, respectively). 12. It is concluded that studies of oxygen concentrating mechanisms are to be performed preferably on isolated eye preparations. For closer analysis of the involved mechanisms this preparation allows for isolated control of individual parameter of the perfusate. In particular, uncontrolled effects of the pseudobranch on the perfusate can be eliminated.