No description available.

Water movement in the body is determined by the osmotic forces acting on the cell membrane. Ingestion of a highly-hypertonic glycerol solution resulting in high extracellular osmolality could drive water out of the intracellular space into the vascular space resulting in reduced muscle hydration and increased blood volume. The aim of this thesis was to study the effects of altered body water distribution during exercise. In chapter 3, ingestion of a 400 ml glycerol solution (1 g·kg-1 body mass) increased serum osmolality (309 mosmol·kg-1) which was associated with a 4.0% increase in blood volume due to a 7.2% increase in plasma volume, attributed to a shift of water from the intracellular space, resulting presumably in tissue dehydration. Glycerol ingestion was then used as a means of altering body water distribution in the other studies described in this thesis. Altered body water distribution had no acute effect on force production during quadriceps muscle isometric exercise (chapter 4), or handgrip strength (chapter 5). Regarding chronic effects (chapter 5), two groups of participants exercised handgrip and initiated recovery after ingestion of either a glycerol solution or placebo over a period of 8 weeks. Maximum handgrip strength increased in both groups and there was no statistically significant difference between the two groups. In chapters 6 and 7, the subjects performed a cycling exercise protocol to fatigue. In the glycerol trial, time to fatigue decreased compared with the iso-osmotic trial during an incremental VO2max test (chapter 6) and during cycling against a constant load at 100% VO2max intensity (chapter 7). In the glycerol trial, there was an accelerated increase in blood lactate and an accelerated increase in serum potassium (chapter 7), indicating altered muscle metabolism which may have contributed to the early development of fatigue.

This study examines a possible relationship between Total Body Water (TBW) levels, osteoarthritic pain and functional performance in a sample of untrained adults. Participants complete a Western Ontario and McMaster Universities Arthritis Index (WOMAC) questionnaire, TBW is measured using single-frequency bioelectrical impedance (SF-BIA) and strength, balance and physical function are measured by the completion of 7 standardized functional tests. Participants in this study will include adult men and women, age 35 years and older, who have been previously diagnosed with Osteoarthritis (OA) in the hip or knee, or who score 35 or higher on the WOMAC. This study aims to determine if TBW values, specifically its intracellular compartment (ICW), will have a relationship to WOMAC scores and if intracellular water (ICW) will have a positive correlation to participants’ overall performance on balance, strength, and physical function tests. It is hypothesized that the data will show a negative correlation between ICW and WOMAC scores and a positive correlation between ICW and performance on balance, strength and physical function tests. Little research exists on the relationship between TBW and functional performance in older adults; particularly those whose TBW may be affected by inflammatory conditions such as OA. A goal of this study is to contribute to existing research on the relationship between performance and TBW, while providing insight and data on this relationship in an untrained population.

Introdução: O índice de pressão tornozelo-braquial (ITB) é definido como a relação da maior pressão arterial sistólica nos membros inferiores sobre a maior pressão arterial sistólica nos membros superiores. O ITB, quando alterado, seja baixo ou alto, é capaz de marcar pacientes em hemodiálise (HD) com maior risco de mortalidade. Porém, alterações agudas deste índice na HD são pouco estudadas. Acreditamos que uma maior variabilidade do ITB possa refletir alterações funcionais dos vasos ou do sistema nervoso autônomo. Uma maior concentração de cálcio no dialisato, poderia levar a um maior estímulo simpático e influenciar o comportamento das variações agudas do ITB. O objetivo central do presente estudo foi analisar o comportamento do ITB pré vs. pós-diálise, tanto de forma absoluta quanto categórica (aumentar vs. baixar), em uma população de pacientes incidentes em HD, comparando uso de dialisato com concentrações de cálcio (Ca) 3,5 e 2,5 mEq/l. Métodos: Este foi um estudo prospectivo em que os pacientes foram estudados na HD do meio da semana, em duas semanas consecutivas, com banho na concentração de Ca de 3,5 e 2,5 mEq/l. Dados clínicos, demográficos, bioquímicos, além do ITB pré e pós HD, análise de fluidos corporais (por bioimpedância) e análise do sistema nervoso autônomo através de variabilidade de frequência cardíaca (obtida com Finometer®) foram obtidos. Resultados: Foram estudados 30 pacientes, com idade média de 47 ± 16 anos hipertensos na totalidade, 10% diabéticos. Anemia, hipocalcemia e altos níveis de fração N-terminal de peptídeo natriurético cerebral foram observados. A maior parte dos pacientes apresentaram pré diálise um ITB normal (entre 0,9 e 1,3), enquanto ITB alto ( > 1,3) foi encontrado em 16,7 a 23,3% e ITB baixo ( < 0,9) em 3,3 a 13,4% dos casos, dependendo da fase do estudo (Ca 3,5 ou 2,5 mEq/l). Não houve diferença na média do ITB pré vs. pós HD tanto com Ca 3,5 quanto com Ca 2,5 mEq/l (p=0,888 e p=0,712, respectivamente). Não encontramos diferença entre o número de pacientes que aumentou e diminuiu o ITB com as duas concentrações de Ca (p=0,889). Um aumento da relação baixa frequência/alta frequência, que indica maior estímulo simpático, foi mais frequente com o uso de Ca 3,5 mEq/l (p=0,026). Pacientes que aumentaram esta relação tiveram 4,5 vezes maior risco de apresentarem queda do ITB (p=0,031) com o Ca 3,5 mEq/l. A avaliação vascular através da velocidade de onda de pulso não se correlacionou com variações intra-dialíticas do ITB. Conclusão: Apesar de concentrações maiores de Ca no dialisato estarem associadas a uma melhor estabilidade hemodinâmica durante a HD, isto possivelmente ocorre em decorrência da hiperatividade simpática, que pode levar a consequências deletérias a longo prazo. A atividade simpática com o uso de Ca 3,5 mEq/l se associou com queda do ITB de pré para pós HD. Se este comportamento agudo do ITB pode trazer consequências a longo prazo ainda não sabemos e novos estudos serão necessários / Introduction: The ankle-brachial index (ABI) is defined as the ratio of the higher systolic blood pressure in the lower limbs and the higher systolic blood pressure in the upper limbs. Both low and high ABI can predict mortality among patients on hemodialysis (HD). However, little is known about acute changes in this index during HD. We believe that greater variability of ABI may reflect functional changes of vessels or changes in the autonomic nervous system. A higher dialysate calcium concentration could lead to an increase of sympathetic activity and influence the behaviour of acute variations of the ABI. The aim of this study was to analyze the ABI pre- vs. post-dialysis, both as continuous and categorized (increased vs. decreased) variable, in a population of incident hemodialysis patients, comparing the use of dialysate calcium (Ca) concentration of 3.5 and 2.5 mEq/L. Methods: this was a prospective study, in which patients were studied in the midweek HD session, in two consecutive weeks, with Ca 3.5 and 2.5 mEq/l. Clinical, demographic, biochemical, and also pre and post HD ITB, fluid volume analysis (by bioimpedance) and analysis of the autonomic nervous system (by heart rate variability obtained with Finometer®) were evaluated. Results: 30 patients were studied, mean age 47 ± 16 years, all hypertensive, and 10% diabetics. Anemia, hypocalcemia and high levels of N-terminal brain natriuretic peptide were observed. Most patients had a normal pre dialysis ABI (0.9 to 1.3), while ABI high ( > 1.3) was found in 16.7 to 23.3% and low (<0.9) in 3.3 to 13.4% of cases, depending on the study phase (Ca 3.5 or 2.5 mEq/l). There was no difference in ABI average pre vs. post HD with Ca 3.5 and Ca 2.5 mEq/L (p = 0.888 and p = 0.712, respectively). We found no difference between the percentage of patients in which ABI has increased or decreased (p = 0.889). An increase in the ratio low frequency/high frequency, indicating a higher sympathetic stimulation, was more frequent with the use of Ca 3.5 mEq/l (p = 0.026). Patients that have increased this ratio had 4.5 times higher risk of presenting fall in ABI during HD with the Ca 3.5 mEq/l (p = 0.031). The vascular assessment by pulse wave velocity had no correlation with intra-dialysis variations of ABI. Conclusion: Although higher concentrations of Ca in the dialysate are associated with better hemodynamic stability during HD, this happens possibly due to the sympathetic hyperactivity, which can have deleterious long-term consequences. Sympathetic activity with the use of Ca 3.5 mEq/l seems to be associated with fall of the ITB during HD. If this acute behaviour of ABI can lead to long-term consequences is still unknown and deserve further studies

Doctor of Philosophy / Introduction Cachexia is characterised by a marked weight loss and the presence of anorexia, anaemia, and asthenia. Although cachexia is often associated with the presence and growth of tumour and observed in solid tumours of the upper gastrointestinal tract, its presence is not unique to cancer and is often also present in most chronic, end-stage diseases processes. The loss of body fat, altered lipid metabolism, increase in the resting energy expenditure, and the increased loss of body protein the degree of which is associated with poor survival, are all hallmarks of this detrimental disease. The clinical aspects and consequences of cachexia can simply be summarised as morbidity, debilitating conditions, and mortality. The conditions such as loss of muscle mass, impaired muscle function, fatigue, reduced activity and functional capacity by themselves are enough to severely and significantly affect the patients’ QL. Although different interventional procedures and therapies are available for the treatment of cachexia and its symptoms, effective methods to evaluate their benefits and outcomes have not been tested or investigated. It was, therefore, the aim of this project to use body composition analysis as a clinical tool and evaluate the effectiveness and outcome of interventional and therapeutic procedures in three groups of patients with cancer. Methods Three patient groups were investigated: 1) patients with pancreatic cancer undergoing Whipple’s Procedure, 2) patients with pancreatic cancer undergoing cancer chemotherapy and receiving either EPA or placebo, and 3) patients with malignant mesothelioma undergoing cancer chemotherapy plus thalidomide or thalidomide alone. Body composition analysis techniques were used to assess the changes in TBN, TBF, TBK, and TBW. In addition, the body composition parameters together with clinical measures were also used to determine parameters influencing survival. The malignant mesothelioma patients were randomised into patients who received gemcitabine / cisplatin plus thalidomide and those who received thalidomide alone. The pancreatic cancer patients undergoing chemotherapy were randomised into the group who were receiving EPA and those who were receiving placebo. In addition, these patients were also investigated on the basis of their disease extent where they were separated into two groups of metastatic and locally advanced. Unpaired T-Test and ANOVA were used to determine differences between groups. Kaplan-Meier analysis and Cox’s Regression were used to assess survival in all three patient cohorts. The Whipple’s Procedure patients were separated into those who received a Clear Margin and those who received an Unclear Margin during their resection. Results 1) In the pancreatic cancer patients undergoing Whipple’s Procedure, compared to the base-line, there were highly significant changes in Weight (p=0.006), BMI (p=0.005), and FM (p=0.007) followed by significant changes in %BFat (p=0.016), TBK/Ht (p=0.021), LBM (By TBK) (p=0.023), LBM (Van Loan) (p=0.034), and LBM (Segal) (p=0.038) at the 14 week time-point. At the 26 weeks post-operative time point, the only significant changes were in the FM (p=0.012), %BFat (p=0.003), and BMI (p=0.027) parameters. There was also a deviation between the two groups in their TBN, LBM and TBW content observable in a long-term setting and fat content in the relatively shorter-term. Although the Unclear Margin group had lower body composition values, both groups seem to begin to gradually “equalise” around the 14 weeks post-operative time-point. The survival analysis results for the Whipple’s Procedure patients demonstrated that Margin Status (p=0.001), Fat Mass (p=0.003) and Age (p=0.081) were significant and could influence survival. 2) When the second cohort pancreatic cancer patients undergoing chemotherapy were analysed, they were initially separated according to the extent of their disease The results of the analyses of body composition changes between measurement time-points for the each group separately, suggested that the patients with locally advanced disease maintain their Weight, FM, and TBN but are more likely to have a lower TBW by the end of the four month of chemotherapy. However, the patients with metastatic pancreatic cancer maintain their TBW but are more likely to have a decreased fat compartment and a higher FFM. The QL analysis showed that the metastatic group are performing “worse” than the locally advanced group especially in term of their Dyspnoea, Nausea & Vomiting, and Sexuality. In addition, the Karnofsky score showed that the metastatic group are not performing as well as the locally advanced group. Furthermore, for the metastatic group there was an increase in the patients’ pain with a decline in mood and general performance as well as increase in gastrointestinal symptoms. Pain Card scores also showed a general increase for the metastatic group and a general decrease for the locally advanced group. When the pancreatic cancer patients undergoing chemotherapy were separated according to whether they received EPA or placebo, the results demonstrated that firstly, due to the fact that the patients were well randomised, the two groups commenced the trial with similar and statistically non-significantly different body composition parameters. Secondly, the two groups were also found to be statistically not different at their corresponding measurement time-points. And thirdly, the patients receiving placebo compared to those receiving EPA lost more Weight, and FM but less TBW throughout the trial. The TBK/Ht (p=0.044), TBK (p=0.042), and LBM (By TBK) (p=0.042), however, showed statistically significant differences where in all three parameters the EPA showed an increase compared to the base-line (pre-chemotherapy). Results of the survival analysis demonstrated that the use of EPA in this group of pancreatic cancer patients did not provide any benefit. In fact, as it was shown in the Kaplan-Meier plot, the group of patients receiving the EPA had a “worse” survival than the group receiving the placebo. The QL results showed that placebo group improved in their functional scales, but increased their Altered Bowel Habit scores with an increase in the perception of pain and decrease in relief from pain. The EPA group, however, showed a decrease in the Loss of Appetite, Dyspnoea, Pain, Pancreatic Pain, and Fatigue, and improvements in Role Functioning and Sexuality. 3) Results of the malignant mesothelioma patients demonstrated that both study arms show similar weight changes. In addition, body composition measurements indicated that the gemcitabine / cisplatin chemotherapy plus thalidomide group had a greater TBN loss and a greater TBW gain than the thalidomide-alone group. This loss of TBN and gain in TBW looked to be “concealed” in the weight. The results of the survival analysis carried out on the mesothelioma patient group suggested that haemoglobin levels (p=0.001), Age (p=0.007), and NI (p=0.008) are the parameters that can influence the survival of patients with malignant mesothelioma undergoing chemotherapy. Conclusions 1) The trend in body composition changes in the Whipple’s Procedure group showed that, although both groups may start with non-significantly different body composition, they tended to grow closer around the 14 week point indicating that the Clear Margin group may lose more than Unclear Margin group. The implications of these findings, therefore, were that once the most appropriate surgical procedure is performed, an adjuvant therapy regimen (such as chemotherapy) at around 14 weeks may have the most impact on the patient’s overall treatment outcome. 2) When the pancreatic cancer patients were separated by the extent of their disease, the results lead to the conclusion that the patients with locally advanced disease maintain their Weight, FM, and TBN but are more likely to have a lower TBW by the end of the four month of chemotherapy. However, the patients with metastatic pancreatic cancer maintain their TBW but are more likely to have a decreased fat compartment and a higher FFM. The QL analysis concluded that the results may point to a worsening and/or progressing disease which is consistent with classic metastatic disease aetiology. From the results of the pancreatic cancer patients undergoing cancer chemotherapy it was concluded that the use of EPA in this group of pancreatic cancer patients undergoing cancer chemotherapy with gemcitabine results in a non-significant reduction in weight loss, FM loss, and TBW gain with a statistically significant increase in FFM. The results of the survival analysis was, however, contradictory suggesting that patients receiving EPA may have a worse survival than the placebo group. The QL analysis here concluded that that EPA does improve the QL of this group of pancreatic cancer patients. 3) From the malignant mesothelioma group it was concluded that provided that the overall anti-cancer potential of gemcitabine / cisplatin plus thalidomide is comparable with that of thalidomide-alone, then by looking purely from the body composition angle one may be able to suggest the use of thalidomide alone in the treatment of malignant mesothelioma in this group of patients. From the results of the survival analysis, the fact that the Study Arm parameter did not reach statistical significance could indicate that survival in these patients is not affected by the presence or absence of chemotherapy with gemcitabine and cisplatin. The body composition techniques were used here as a tool to monitor changes in various body composition parameters to assess the outcomes, including survival, of the administration of different therapies and interventional procedures in these three groups of cancer patients. For these purposes, these techniques were demonstrated to be an effective and invaluable tool.

Doctor of Philosophy / Introduction Cachexia is characterised by a marked weight loss and the presence of anorexia, anaemia, and asthenia. Although cachexia is often associated with the presence and growth of tumour and observed in solid tumours of the upper gastrointestinal tract, its presence is not unique to cancer and is often also present in most chronic, end-stage diseases processes. The loss of body fat, altered lipid metabolism, increase in the resting energy expenditure, and the increased loss of body protein the degree of which is associated with poor survival, are all hallmarks of this detrimental disease. The clinical aspects and consequences of cachexia can simply be summarised as morbidity, debilitating conditions, and mortality. The conditions such as loss of muscle mass, impaired muscle function, fatigue, reduced activity and functional capacity by themselves are enough to severely and significantly affect the patients’ QL. Although different interventional procedures and therapies are available for the treatment of cachexia and its symptoms, effective methods to evaluate their benefits and outcomes have not been tested or investigated. It was, therefore, the aim of this project to use body composition analysis as a clinical tool and evaluate the effectiveness and outcome of interventional and therapeutic procedures in three groups of patients with cancer. Methods Three patient groups were investigated: 1) patients with pancreatic cancer undergoing Whipple’s Procedure, 2) patients with pancreatic cancer undergoing cancer chemotherapy and receiving either EPA or placebo, and 3) patients with malignant mesothelioma undergoing cancer chemotherapy plus thalidomide or thalidomide alone. Body composition analysis techniques were used to assess the changes in TBN, TBF, TBK, and TBW. In addition, the body composition parameters together with clinical measures were also used to determine parameters influencing survival. The malignant mesothelioma patients were randomised into patients who received gemcitabine / cisplatin plus thalidomide and those who received thalidomide alone. The pancreatic cancer patients undergoing chemotherapy were randomised into the group who were receiving EPA and those who were receiving placebo. In addition, these patients were also investigated on the basis of their disease extent where they were separated into two groups of metastatic and locally advanced. Unpaired T-Test and ANOVA were used to determine differences between groups. Kaplan-Meier analysis and Cox’s Regression were used to assess survival in all three patient cohorts. The Whipple’s Procedure patients were separated into those who received a Clear Margin and those who received an Unclear Margin during their resection. Results 1) In the pancreatic cancer patients undergoing Whipple’s Procedure, compared to the base-line, there were highly significant changes in Weight (p=0.006), BMI (p=0.005), and FM (p=0.007) followed by significant changes in %BFat (p=0.016), TBK/Ht (p=0.021), LBM (By TBK) (p=0.023), LBM (Van Loan) (p=0.034), and LBM (Segal) (p=0.038) at the 14 week time-point. At the 26 weeks post-operative time point, the only significant changes were in the FM (p=0.012), %BFat (p=0.003), and BMI (p=0.027) parameters. There was also a deviation between the two groups in their TBN, LBM and TBW content observable in a long-term setting and fat content in the relatively shorter-term. Although the Unclear Margin group had lower body composition values, both groups seem to begin to gradually “equalise” around the 14 weeks post-operative time-point. The survival analysis results for the Whipple’s Procedure patients demonstrated that Margin Status (p=0.001), Fat Mass (p=0.003) and Age (p=0.081) were significant and could influence survival. 2) When the second cohort pancreatic cancer patients undergoing chemotherapy were analysed, they were initially separated according to the extent of their disease The results of the analyses of body composition changes between measurement time-points for the each group separately, suggested that the patients with locally advanced disease maintain their Weight, FM, and TBN but are more likely to have a lower TBW by the end of the four month of chemotherapy. However, the patients with metastatic pancreatic cancer maintain their TBW but are more likely to have a decreased fat compartment and a higher FFM. The QL analysis showed that the metastatic group are performing “worse” than the locally advanced group especially in term of their Dyspnoea, Nausea & Vomiting, and Sexuality. In addition, the Karnofsky score showed that the metastatic group are not performing as well as the locally advanced group. Furthermore, for the metastatic group there was an increase in the patients’ pain with a decline in mood and general performance as well as increase in gastrointestinal symptoms. Pain Card scores also showed a general increase for the metastatic group and a general decrease for the locally advanced group. When the pancreatic cancer patients undergoing chemotherapy were separated according to whether they received EPA or placebo, the results demonstrated that firstly, due to the fact that the patients were well randomised, the two groups commenced the trial with similar and statistically non-significantly different body composition parameters. Secondly, the two groups were also found to be statistically not different at their corresponding measurement time-points. And thirdly, the patients receiving placebo compared to those receiving EPA lost more Weight, and FM but less TBW throughout the trial. The TBK/Ht (p=0.044), TBK (p=0.042), and LBM (By TBK) (p=0.042), however, showed statistically significant differences where in all three parameters the EPA showed an increase compared to the base-line (pre-chemotherapy). Results of the survival analysis demonstrated that the use of EPA in this group of pancreatic cancer patients did not provide any benefit. In fact, as it was shown in the Kaplan-Meier plot, the group of patients receiving the EPA had a “worse” survival than the group receiving the placebo. The QL results showed that placebo group improved in their functional scales, but increased their Altered Bowel Habit scores with an increase in the perception of pain and decrease in relief from pain. The EPA group, however, showed a decrease in the Loss of Appetite, Dyspnoea, Pain, Pancreatic Pain, and Fatigue, and improvements in Role Functioning and Sexuality. 3) Results of the malignant mesothelioma patients demonstrated that both study arms show similar weight changes. In addition, body composition measurements indicated that the gemcitabine / cisplatin chemotherapy plus thalidomide group had a greater TBN loss and a greater TBW gain than the thalidomide-alone group. This loss of TBN and gain in TBW looked to be “concealed” in the weight. The results of the survival analysis carried out on the mesothelioma patient group suggested that haemoglobin levels (p=0.001), Age (p=0.007), and NI (p=0.008) are the parameters that can influence the survival of patients with malignant mesothelioma undergoing chemotherapy. Conclusions 1) The trend in body composition changes in the Whipple’s Procedure group showed that, although both groups may start with non-significantly different body composition, they tended to grow closer around the 14 week point indicating that the Clear Margin group may lose more than Unclear Margin group. The implications of these findings, therefore, were that once the most appropriate surgical procedure is performed, an adjuvant therapy regimen (such as chemotherapy) at around 14 weeks may have the most impact on the patient’s overall treatment outcome. 2) When the pancreatic cancer patients were separated by the extent of their disease, the results lead to the conclusion that the patients with locally advanced disease maintain their Weight, FM, and TBN but are more likely to have a lower TBW by the end of the four month of chemotherapy. However, the patients with metastatic pancreatic cancer maintain their TBW but are more likely to have a decreased fat compartment and a higher FFM. The QL analysis concluded that the results may point to a worsening and/or progressing disease which is consistent with classic metastatic disease aetiology. From the results of the pancreatic cancer patients undergoing cancer chemotherapy it was concluded that the use of EPA in this group of pancreatic cancer patients undergoing cancer chemotherapy with gemcitabine results in a non-significant reduction in weight loss, FM loss, and TBW gain with a statistically significant increase in FFM. The results of the survival analysis was, however, contradictory suggesting that patients receiving EPA may have a worse survival than the placebo group. The QL analysis here concluded that that EPA does improve the QL of this group of pancreatic cancer patients. 3) From the malignant mesothelioma group it was concluded that provided that the overall anti-cancer potential of gemcitabine / cisplatin plus thalidomide is comparable with that of thalidomide-alone, then by looking purely from the body composition angle one may be able to suggest the use of thalidomide alone in the treatment of malignant mesothelioma in this group of patients. From the results of the survival analysis, the fact that the Study Arm parameter did not reach statistical significance could indicate that survival in these patients is not affected by the presence or absence of chemotherapy with gemcitabine and cisplatin. The body composition techniques were used here as a tool to monitor changes in various body composition parameters to assess the outcomes, including survival, of the administration of different therapies and interventional procedures in these three groups of cancer patients. For these purposes, these techniques were demonstrated to be an effective and invaluable tool.

Thesis (doctoral)--University of Jyväskylä, 1994. / Thesis is based on six separately published papers which are reprinted at end. Includes bibliographical references.

Thesis (doctoral)--University of Jyväskylä, 1994. / Thesis is based on six separately published papers which are reprinted at end. Includes bibliographical references.

Introdução: O índice de pressão tornozelo-braquial (ITB) é definido como a relação da maior pressão arterial sistólica nos membros inferiores sobre a maior pressão arterial sistólica nos membros superiores. O ITB, quando alterado, seja baixo ou alto, é capaz de marcar pacientes em hemodiálise (HD) com maior risco de mortalidade. Porém, alterações agudas deste índice na HD são pouco estudadas. Acreditamos que uma maior variabilidade do ITB possa refletir alterações funcionais dos vasos ou do sistema nervoso autônomo. Uma maior concentração de cálcio no dialisato, poderia levar a um maior estímulo simpático e influenciar o comportamento das variações agudas do ITB. O objetivo central do presente estudo foi analisar o comportamento do ITB pré vs. pós-diálise, tanto de forma absoluta quanto categórica (aumentar vs. baixar), em uma população de pacientes incidentes em HD, comparando uso de dialisato com concentrações de cálcio (Ca) 3,5 e 2,5 mEq/l. Métodos: Este foi um estudo prospectivo em que os pacientes foram estudados na HD do meio da semana, em duas semanas consecutivas, com banho na concentração de Ca de 3,5 e 2,5 mEq/l. Dados clínicos, demográficos, bioquímicos, além do ITB pré e pós HD, análise de fluidos corporais (por bioimpedância) e análise do sistema nervoso autônomo através de variabilidade de frequência cardíaca (obtida com Finometer®) foram obtidos. Resultados: Foram estudados 30 pacientes, com idade média de 47 ± 16 anos hipertensos na totalidade, 10% diabéticos. Anemia, hipocalcemia e altos níveis de fração N-terminal de peptídeo natriurético cerebral foram observados. A maior parte dos pacientes apresentaram pré diálise um ITB normal (entre 0,9 e 1,3), enquanto ITB alto ( > 1,3) foi encontrado em 16,7 a 23,3% e ITB baixo ( < 0,9) em 3,3 a 13,4% dos casos, dependendo da fase do estudo (Ca 3,5 ou 2,5 mEq/l). Não houve diferença na média do ITB pré vs. pós HD tanto com Ca 3,5 quanto com Ca 2,5 mEq/l (p=0,888 e p=0,712, respectivamente). Não encontramos diferença entre o número de pacientes que aumentou e diminuiu o ITB com as duas concentrações de Ca (p=0,889). Um aumento da relação baixa frequência/alta frequência, que indica maior estímulo simpático, foi mais frequente com o uso de Ca 3,5 mEq/l (p=0,026). Pacientes que aumentaram esta relação tiveram 4,5 vezes maior risco de apresentarem queda do ITB (p=0,031) com o Ca 3,5 mEq/l. A avaliação vascular através da velocidade de onda de pulso não se correlacionou com variações intra-dialíticas do ITB. Conclusão: Apesar de concentrações maiores de Ca no dialisato estarem associadas a uma melhor estabilidade hemodinâmica durante a HD, isto possivelmente ocorre em decorrência da hiperatividade simpática, que pode levar a consequências deletérias a longo prazo. A atividade simpática com o uso de Ca 3,5 mEq/l se associou com queda do ITB de pré para pós HD. Se este comportamento agudo do ITB pode trazer consequências a longo prazo ainda não sabemos e novos estudos serão necessários / Introduction: The ankle-brachial index (ABI) is defined as the ratio of the higher systolic blood pressure in the lower limbs and the higher systolic blood pressure in the upper limbs. Both low and high ABI can predict mortality among patients on hemodialysis (HD). However, little is known about acute changes in this index during HD. We believe that greater variability of ABI may reflect functional changes of vessels or changes in the autonomic nervous system. A higher dialysate calcium concentration could lead to an increase of sympathetic activity and influence the behaviour of acute variations of the ABI. The aim of this study was to analyze the ABI pre- vs. post-dialysis, both as continuous and categorized (increased vs. decreased) variable, in a population of incident hemodialysis patients, comparing the use of dialysate calcium (Ca) concentration of 3.5 and 2.5 mEq/L. Methods: this was a prospective study, in which patients were studied in the midweek HD session, in two consecutive weeks, with Ca 3.5 and 2.5 mEq/l. Clinical, demographic, biochemical, and also pre and post HD ITB, fluid volume analysis (by bioimpedance) and analysis of the autonomic nervous system (by heart rate variability obtained with Finometer®) were evaluated. Results: 30 patients were studied, mean age 47 ± 16 years, all hypertensive, and 10% diabetics. Anemia, hypocalcemia and high levels of N-terminal brain natriuretic peptide were observed. Most patients had a normal pre dialysis ABI (0.9 to 1.3), while ABI high ( > 1.3) was found in 16.7 to 23.3% and low (<0.9) in 3.3 to 13.4% of cases, depending on the study phase (Ca 3.5 or 2.5 mEq/l). There was no difference in ABI average pre vs. post HD with Ca 3.5 and Ca 2.5 mEq/L (p = 0.888 and p = 0.712, respectively). We found no difference between the percentage of patients in which ABI has increased or decreased (p = 0.889). An increase in the ratio low frequency/high frequency, indicating a higher sympathetic stimulation, was more frequent with the use of Ca 3.5 mEq/l (p = 0.026). Patients that have increased this ratio had 4.5 times higher risk of presenting fall in ABI during HD with the Ca 3.5 mEq/l (p = 0.031). The vascular assessment by pulse wave velocity had no correlation with intra-dialysis variations of ABI. Conclusion: Although higher concentrations of Ca in the dialysate are associated with better hemodynamic stability during HD, this happens possibly due to the sympathetic hyperactivity, which can have deleterious long-term consequences. Sympathetic activity with the use of Ca 3.5 mEq/l seems to be associated with fall of the ITB during HD. If this acute behaviour of ABI can lead to long-term consequences is still unknown and deserve further studies

Title: Lifestyle changes to lifestyle modification for people with multiple sclerosis Aim: Designing a program that affects lifestyle, fitness and physiological parameters in subjects of different age and different sex of people who have a diagnosis of multiple sclerosis (MS). Method: A literary review to make a summary of knowledge on MS and use of physical activities as opportunities to influence the overall lifestyle of people with MS. Results: The result is an overview of the programs and its evaluation - changes in physiological parameters, condition and subjective feelings. We found that when respecting the state of health programs may be implemented in the long term. Conclusion: The success of interventions depends on collaboration, time availability, but also the respecting of the designed programs of people involved. At the same time, however, assumes that an active lifestyle affects the mental aspect of individuals and their subjective feelings. Keywords: Multiple sclerosis, physical condition, subjective feelings, body fat percentage, body water percentage, body weight, muscle dysbalance