Human gait is a complex process that involves the coordination of the central nervous and muscular systems. A disruption to the either system results in the impairment of a person’s ability to walk. Impairments can be caused by neurological disorders such as stroke and physical conditions like amputation. There is not a standardized method to quantitatively assess the gait asymmetry of affected subjects. The purpose of this research is to understand the fundamental aspects of asymmetrical effects on the human body and improve rehabilitation techniques and devices. This research takes an interdisciplinary approach to address the limitations with current rehabilitation methodologies. The goal of my Doctoral research is to understand the fundamental effects of asymmetry caused by physical and neurological impairments. The methods discussed in this document help in developing better solutions to rehabilitate impaired individuals’ gait. I studied four major hypothesis in regards to gait asymmetry. The first hypothesis is the potential of asymmetric systems to have symmetric output. The second hypothesis is that a method that incorporates a wider range of gait parameter asymmetries can be used as a measure for gait rehabilitation. The third hypothesis is that individuals can visually identify subtle gait asymmetries. Final hypothesis is to establish the relationship between gait quality and function. Current approaches to rehabilitate impaired gait typically focus on achieving the same symmetric gait as an able-body person. This cannot work because an impaired person is inherently asymmetric and forcing them to walk symmetrically causes them to adopt patterns that are not beneficial long term. Instead, it is more prudent to embrace the asymmetry of the condition and work to minimize in specific gait parameters that may cause more harm over the long run. Combined gait asymmetry metric (CGAM) provides the necessary means to study the effect of the gait parameters and it is weighted to balance each parameter’s effect equally by normalizing the data. CGAM provides the necessary means to study the effect of the gait parameters and is weighted towards parameters that are more asymmetric. The metric is also designed to combine spatial, temporal, kinematic, and kinetic gait parameter asymmetries. It can also combine subsets of the different gait parameters to provide a more thorough analysis. CGAM will help define quantitative thresholds for achievable balanced overall gait asymmetry. The studies in this dissertation conducted on able-body and impaired subjects provides better understanding of some fundamental aspects of asymmetry in human gait. Able body subjects test devices that aim to make an individual’s gait more asymmetric. These perturbations include a prosthetic and stroke simulator, addition of distal mass, and leg length alterations. Six able-body subjects and one amputee participated in the experiment that studied the effect of asymmetric knee height. The results which consisted of analyses of individual gait parameters and CGAM scores revealed that there is evidence of overall reduction of asymmetry in gait for both able-body subject on prosthetic simulators and transfemoral amputee. The transfemoral amputee also walked with a combination of distal mass with lowered knee height. Although this configuration showed better symmetry, the configuration is detrimental in terms of energy costs. Analyzing the data of gait with the stroke simulator showed that the subject’s gait does undergo alterations in terms of overall gait asymmetry. The distal mass and leg length alteration study has revealed some significant findings that are also reflected in the prosthetic study with distal mass. A leg length discrepancy (LLD) or the change of limb mass can result in asymmetric gait patterns. Although adding mass and LLD have been studied separately, this research studies how gait patterns change as a result of asymmetrically altering both leg length and mass at a leg’s distal end. Spatio-temporal and kinetic gait measures are used to study the combined asymmetric effects of placing LLD and mass on the opposite and same side. There were statistically significant differences for the amount of mass and leg length added for all five parameters. When LLD is added to longer leg, the temporal and kinetic gait parameters of the shorter limb and the altered limb’s spatial parameter become more asymmetric. Contrary to the hypothesis, there was no significant interaction between the amount of mass and leg length added. There were cases in all perturbations where a combination of mass and LLD make a gait parameter more symmetric than a single effect. These cases exhibit the potential for configurations with lower overall asymmetries even though each parameter has a slight asymmetry as opposed to driving one parameter to symmetry and other parameters to a larger asymmetry. CGAM analysis of the results revealed that the addition of distal mass contributes more towards overall asymmetry than LLD. Analyzing 11 gait parameters for LLD and mass on the same side showed that the overall asymmetry decreased for the combination of small LLD and mass. This is consistent with the findings from analyzing five individual gait parameters. Impaired subjects include individuals with stroke and amputees. The clinical trials for individuals with stroke involve training with the Gait Enhancing Mobile Shoe (GEMS) that pro- vides an asymmetric effect on the subject’s step length and time. Training with the GEMS showed improvement in clinical measures such as timed up and go (TUG), six minute walk test (6MWT), and gait velocity. The subjects also showed lower step length symmetry as intended by the GEMS. The ground reaction force asymmetries became more asymmetric as the spatial and temporal parameters became more symmetric. This phenomenon shows evidence that when an individual with stroke is corrected, for spatial and temporal symmetry is at the expense of kinetic symmetry. The CGAM scores also reflected similar trends to that of spatial and temporal symmetry and the r2 correlation with the gait parameters proved that double limb support asymmetry has no correlation with CGAM while ground reaction force asymmetry has a weak correlation. Step length, step, and swing time showed high correlation to CGAM. I also found the r2 correlation between the clinical measures and the CGAM scores. The CGAM scores were moderately correlated to 6MWT and gait velocity but had a weak correlation with TUG. CGAM has positive correlation with TUG and has negative correlation with 6MWT and gait velocity. This gives some validation to CGAM as a potential metric that can be used to evaluate gait patterns based on their asymmetries. Transfemoral amputees were tested for their gait with varied prosthetic knee heights to study the asymmetrical effects and trained split-belt treadmill. Asymmetric knee heights showed improvement in multiple gait parameters such as step length, vertical, propulsive, and braking force asymmetry. It also decreased hip and ankle angle asymmetries. However, these improvements did lead other parameters to become more asymmetric. The CGAM scores reflect this and they show overall improvement. Although the lowest knee height showed improvement, the input from the amputee suggested that the quality of gait decreased with the lowest knee height. These exploratory results did show that a slightly lower knee height may not affect the quality of gait but may provide better overall symmetry. Another exploratory study with split-belt treadmill training, similar to the protocol followed for individuals with stroke, showed definitive improvement in double limb support, swing time, step length and time symmetry. This was also reflected in the improvements seem post training in the CGAM scores as well. I found the r2 correlation of the CGAM and the gait parameters including gait velocity. Step length and swing time show consistent correlation for individual subjects and all the data combined to CGAM. Gait velocity shows a moderate correlation to CGAM for one subject and a high correlation to the other one. However, the combined data of gait velocities does not have any correlation with CGAM. These results show that CGAM can successfully represent the overall gait parameter asymmetry. The trends seen in the gait parameters is closely reflected in the CGAM scores. This research combines the study of asymmetry with people’s perception of human gait asymmetry, which will help in estimating the thresholds for perceivable asymmetrical changes to gait. Sixteen videos were generated using motion capture data and Unity game engine. The videos were chosen to represent the largest variation of gait asymmetries. Some videos were also chosen based on CGAM values that were similar but had large variation in underlying gait parameters. The dataset consisted of results of perturbation experiments on able-body subjects and asymmetric knee height prosthesis on transfemoral amputee. These videos were rated on a seven point Likert scale by subjects from 7 being normal to 1 being abnormal. Thirty one subjects took part in the experiment, out of which only 22 subject’s data was used because they rated at least 3 videos. The results show that the subjects were able to differentiate asymmetric gait with perturbations to able-body gait without perturbation at a self-selected speed. r2 correlation analysis showed that hip angle had mild correlation to the Likert scale rating of the 16 different gait patterns. Multivariate linear regression analysis with a linear model showed significant contribution of ankle and hip angles, vertical, propulsive, and braking forces. It is interesting that the majority of parameters that showed significance are not perceivable visually. Ankle and hip angles are visually perceivable and this significance revealed that subjects seemed to perceive asymmetric ankle and hip angles as abnormal. However, the subjects do not perceive asymmetric knee angles as completely abnormal with evidence of no significance, no correlation, and neutral Likert rating for gait patterns that perturbed knee angles.

A cardiomiopatia dilatada (CMD) é uma doença freqüente na clínica veterinária que acomete, principalmente, a espécie canina, habitualmente os machos, jovens ou adultos-jovem, das raças grandes e gigantes, em especial Doberman e Boxer. A doença caracteriza-se por uma redução na contratilidade e, freqüentemente, por arritmias que resultam na diminuição do volume sistólico e do débito cardíaco. O tratamento convencionalmente preconizado para cães acometidos pela CMD consiste na prescrição de vasodilatadores, agentes inotrópicos positivos (digitálico), diuréticos, dieta hipossódica e, quando necessário, antiarrítmicos. A ativação do sistema nervoso simpático (SNAS) ocorre em resposta à redução do débito cardíaco e da pressão arterial observados em casos de insuficiência cardíaca. Porém a partir de um certo grau os efeitos hipertensivos, cronotrópicos e inotrópicos positivos do SNAS geram graves alterações cardíacas como a sobrecarga de pressão e volume nos ventrículos, conseqüente isquemia miocárdica, morte de miócitos com deposição de tecido conjuntivo, diminuição da contratilidade cardíaca e nova sobrecarga de pressão e volume. O carvedilol é um β-bloqueador de 3a geração, não seletivo, que bloqueia igualmente e competitivamente os receptores β1, β2 e β1. O carvedilol produz uma evidente vasodilatação periférica, exerce efeitos anti-oxidantes, removendo radicais livres de oxigênio e prevenindo a peroxidação lipídica nas membranas cardíacas, prevenindo a perda de miócitos e a ocorrência de arritmias e reduzindo a taxa de mortalidade em pacientes humanos. O objetivo do presente estudo foi avaliar clínica, eletrocardiográfica, radiográfica e ecocardiograficamente a evolução de cães com cardiomiopatia dilatada (CMD) tratatos com terapia convencional associada ao carvedilol. Para tal foram avaliados 49 cães com CMD divididos em: grupo NT, tratado com terapia convencional, e grupo T, tratado com terapia convencional associada ao carvedilol. Os animais foram submetidos à avaliação clínica e a exames complementares durante o período de um ano. Os resultados demonstraram que a terapia com carvedilol apresentou boa tolerabilidade na dose de 0,3 mg/kg/12-12horas, aumentou a sobrevida dos cães em 30,9%, não alterou as pressões sistólica e diastólica, reduziu a freqüência cardíaca após três semanas de terapia, melhorou significantemente as frações de encurtamento e ejeção após seis meses de tratamento, não promoveu alterações radiográficas e da distância E-septo, diminuiu o índice de letalidade da doença, fato demonstrado pela melhora no escore clínico e na classe funcional dos animais, obtidas após três semanas de terapia com carvedilol. / Dilated cardiomyopathy (DCM) is a frequent disease in veterinary clinics which occurs specially in dogs, mostly males, young or young-adults, of big and giant breeds, mainly Dobermans and Boxers. The disease is characterized by a reduction in contractility and, frequently, by arrhythmias resulting in decrease of systolic volume and cardiac output. Commonly prescribed therapy for dogs presenting DCM consists of vasodilators, positive inotropic drugs (digitalics), diuretics, low-sodium diet and, when necessary, anti-arrhythmics. Activation of sympathetic nervous system (SNS) occurs in response to decrease in cardiac output and arterial pressure observed in cases of heart failure. However, after a certain degree, hypotensive, chronotropic and positive inotropic effects of SNS lead to severe heart alterations like pressure and volume overload on ventricles with consequent myocardial ischemia, death of myocytes with connective tissue deposition, decrease in heart contractility, and again pressure and volume overload. Carvedilol is a third generation non-selective ?- blocker which blocks equally and competitively β1, β2 and β1 receptors. Carvedilol produces an evident peripheral vasodilation, exerts anti-oxidative effects, removing free radicals of oxygen and preventing lipidic peroxydation of cardiac membranes, and the loss of myocytes and arrhythmias, as well as reducing mortality rate in human patients. The aim of the present study was to evaluate by physical examination, electrocardiography, radiography, and echocardiography the evolution of dogs with dilated cardiomyopathy (DCM) treated by conventional therapy associated to carvedilol. Forty-nine dogs with DCM were divided in two groups: group NT: treated with conventional therapy, and group T: treated with conventional therapy associated to carvedilol. The animals were submitted to clinical and complementary examinations during one year. The results demonstrated that carvedilol therapy presented good tolerability on the dose of 0,3 mg/Kg each 12 hours, prolonged lifetime of the dogs in 30,9%, did not alter systolic or diastolic pressure, reduced heart frequency after three weeks of treatment, significantly enhanced shortening and ejection fractions after six months of treatment, did not promote radiographic or E-septum distance alterations, decreased patients letality, as demonstrated by improvement of clinical score and functional class (heart failure according to NYHA) of the animals, obtained three weeks after the beginning of cavedilol therapy.

A técnica de \"Inflow Occlusion\" pode ser utilizada em cirurgias cardíacas quando se pretende manter o coração aberto apenas por alguns minutos, para realização de pequenos reparos. No entanto, a parada circulatória total, evento decorrente da técnica em questão, pode acarretar severas alterações metabólicas e neurológicas, sendo necessária monitorização trans e pósoperatória do paciente. Neste estudo foram utilizados 12 cães sem raça definida, os quais foram divididos em dois grupos, A e B, submetidos a 7 e 8 minutos de parada circulatória total, respectivamente, utilizando-se da técnica de \"Inflow Occlusion\". Tentou-se estabelecer normotermia dos animais durante os procedimentos cirúrgicos. Foram realizados exames hemogasométricos, e avaliações clínica e neurológica nos momentos preconizados. Alterações neurológicas transitórias foram observadas em ambos os grupos. Ocorreram dois óbitos transoperatórios no grupo B, e um animal do mesmo grupo apresentou cegueira permanente no período pós-operatório. Apesar da acidose metabólica observada durante os procedimentos, o pH, pressão parcial de dióxido de carbono no sangue arterial, e bicarbonato plasmático arterial de ambos os grupos, retornaram aos valores normais após trinta minutos da parada circulatória. Apesar das alterações observadas, é lícito afirmar que o \"Inflow Occlusion\" é seguro por até 7 minutos. Após este período, no entanto, é contra-indicado, segundo resultados obtidos e óbitos transoperatórios relatados. / \"Inflow Occlusion\" technique can be used in heart surgeries when heart is required to be opened just for few minutes, to allow quick repairs. However, circulatory arrest, event occasioned by this technique, can produce serious metabolic and neurologic consequences to the patient, and monitorization on trans, and postoperatory moments is well recommended. In this study, 12 mongrel dogs were used, and were divided into two groups, A and B, submmited to 7 and 8 minutes of total circulatory arrest, respectively, using \"Inflow Occlusion\" technique. Normothermia was tried during surgical procedures. Hemogasometric analysis, and clinical and neurological exams were made, each of them, on the moments established for the experiment. There were some transitory neurological problems related to both groups. There were two transoperatory deaths in group B and one case of permanent blindness in the same group, on postoperatory period. Despite metabolic acidosis occurred during procedures, pH values, arterial dioxide carbon parcial pressure, and arterial plasmatic bicarbonate related to both groups, returned to basal levels thirty minutes after surgery. Even occuring some hemogasometric and neurologic alterations, we can say that \"Inflow Occlusion\" is safe for periods up to 7 minutes. After this period of time, however, it is contraindicated, as seen after these results and because transoperatory deaths.

A disfagia orofaríngea é uma manifestação comum apresentada na fase aguda do acidente vascular cerebral (AVC). A aspiração decorrente das dificuldades de deglutição é um sintoma que deve ser considerado devido à freqüente presença de pneumonias aspirativas que podem influenciar na recuperação do paciente trazendo complicações ao seu quadro clínico em geral e até mesmo risco de morte. A caracterização clínica precoce das alterações de deglutição pode auxiliar na definição de condutas e evitar a administração de dieta por via oral oferecendo riscos ao paciente. O presente estudo teve por objetivo, propor a via mais segura de alimentação na fase aguda do acidente vascular cerebral isquêmico (AVCI) com o intuito de minimizar complicações, utilizando a escala de AVC proposta pelo \"National Institutes of Health\", o NIHSS e considerando alguns fatores de risco para disfagia na clínica apresentada por estes pacientes, com a formulação de um algoritmo. Para tanto, foram avaliados 50 pacientes internados na Unidade de Emergência do Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo com diagnóstico de AVCI confirmado, clinicamente, por um médico neurologista, dentro de, no máximo, 48 horas entre o início dos sintomas e a avaliação. Os pacientes foram avaliados desde que se enquadrassem nos critérios propostos, sendo 25 do gênero feminino e 25 do masculino, com idade média de 64,90 anos (variação de 26 a 91 anos). Uma anamnese foi realizada antes da participação do paciente no estudo, para que fosse assegurada a ausência de história de dificuldades de deglutição anteriores ao quadro atual. A avaliação clínica fonoaudiológica foi realizada à beira do leito através de um protocolo constituído por dados de identificação do paciente, data do início dos sintomas, data de entrada no hospital, escore da escala de coma de Glasgow (ECG) e do NIHSS obtidos na avaliação neurológica inicial e no dia da avaliação, fatores de risco para AVC, achados clínicos obtidos na avaliação neurológica do paciente, resultado do exame de imagem (tomografia computadorizada ou ressonância magnética). A segunda parte foi destinada à escala do NIHSS e, por fim, a terceira parte constou da avaliação da deglutição, sendo subdividida em estrutural e funcional. Para a avaliação funcional da deglutição foram utilizadas as consistências alimentares pastosa, líquida e sólida (quando possível, dependendo das condições apresentadas pelo paciente). O volume da oferta também dependeu das possibilidades apresentadas: aqueles pacientes que não ofereciam condições clínicas para a realização da avaliação, como os que se encontravam com intubação orotraqueal, estado de sonolência profunda ou em estado de coma, esta foi contra-indicada. Após a avaliação clínica, com a obtenção dos dados estruturais e funcionais, concluiu-se se a avaliação clínica da deglutição apresentava-se normal ou alterada. A partir de então, era concluído sobre a possibilidade de introdução de dieta por via oral. Para a análise estatística foi utilizado o teste exato de Fisher, verificando a associação entre as variáveis. Para avaliar se o escore do NIHSS caracterizaria um indicador de fator de risco para a disfagia, foi construída a curva ROC visando obter características quanto à sensibilidade e especificidade da escala para este propósito. Os resultados demonstraram que a disfagia é uma manifestação freqüente na fase aguda do AVCI, presente em 32% dos pacientes analisados. A avaliação clínica da deglutição é um método confiável de detecção das dificuldades de deglutição. Entretanto, os fatores preditivos de risco para a função devem ser ponderados, devendo ser considerada a gravidade do quadro, o nível de consciência e a presença de comorbidades pré-existentes. A hipertensão arterial sistêmica (HAS) demonstrou ser o principal fator de risco para o AVC apresentada por 72% dos pacientes, seguida do tabagismo (36%), etilismo (20%) e diabete melito (20%). Gênero e hemisfério cerebral acometido não tiveram associação estatisticamente significante com a presença de disfagia. Idade, NIHSS, ECG, alterações de fala e linguagem e topografia da lesão são fatores preditivos de disfagia apresentando diferenças estatisticamente significantes. Pacientes com lesões em território carotídeo apresentaram maior prevalência quanto à presença de disfagia (58,88%). O NIHSS apresenta alta sensibilidade (88%) e especificidade (85%) para detecção de disfagia considerando 12 como valor de corte para sua existência. A formulação de um algoritmo para detecção de disfagia na fase aguda do AVCI poderá auxiliar na definição de condutas quanto à melhor via de administração da dieta enquanto se aguarda uma avaliação fonoaudiológica especializada. / Oropharyngeal Dysphagia is a common manifestation presented in the acute phase of cerebrovascular accident (CVA). The aspiration resulting from the difficulties of deglutition is a symptom that should be considered due to the frequent occurrence of aspirative pneumonia that could influence the patient\'s recovery, causing complications to the general clinical and even the risk of death. The early clinical characterization of deglutition alterations can help to specify the proper behavior and to avoid the prescription of a diet that could offer the patients risks. The present study had as objective to propose the most secure feeding for the patient in the acute phase of the ischemic cerebrovascular accident (ICVA) with the aim to minimize complications, using the CVA scale proposed by the National Institutes of Health (NIHSS) and considering some risk factors of dysphagia in the practice presented by these patients, with the creation of an algorithm. Thus, 50 inpatients were evaluated at the Unidade de Emergência do Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo with clinically confirmed ICVA diagnosis by a neurologist, within, at most, 48 hours from the onset of the symptoms and the evaluation. The patients were assessed randomly as long as, in which 25 were women and 25 were men, and 64,90 years old were the average ages (variation from 26 to 91 years old). An anamnesis was carried out before the patient\'s participation in the study, so that the previously absence of the history of deglutition difficulties was ensured. The clinical phonoaudiological assessment was carried out on bed side through a protocol constituted by patients identification data, symptoms onset date, admission date in the hospital, Glasgow Coma Scale (GCS) and NIHSS score obtained in the initial neurological evaluation and in the evaluation\'s day, risk factors for CVA, clinical findings obtained from the patient\'s neurological evaluation, result of the screenings (computed tomography or magnetic resonance imaging). The second part was designed to the NIHSS scale and, the third part was constituted by the clinical deglutition evaluation, subdivided in structural and functional. For the functional deglutition evaluation the pasty, liquid and solid feeding consistencies were used (when possible, depending on the conditions presented by the patient). The volume of the offer also depended on the presented possibilities: those patients who did not present clinical conditions for the evaluation, such as the ones who were with orotraqueal intubation, deep sleep state or coma; it was counter-indicated. After the clinical evaluation, with the structural and functional data obtained, it was concluded whether the clinical deglutition evaluation was normal or altered. Since then, it was concluded the possibility of a diet prescription. For the statistical analysis the Fisher exact test was used to verify the association between variables. To evaluate if the NIHSS score would characterize a risk factor indicator for dysphagia, the curve ROC was built aiming to obtain characteristics related to the sensitivity and specificity of the scale for this purpose. The study allowed us to conclude that dysphagia is a frequent manifestation in the acute phase of ICVA, present in 32% of the analyzed patients. The clinical deglutition evaluation is a reliable method of difficulties deglutition detection. However, the predicting risk factors for the function should be balanced and the severity of the clinical picture, the consciousness level and the presence of preexistent comorbidities should be considered. The systemic arterial hypertension (SAH) demonstrated to be the main risk factor for the CVA presented by 72% of the patients, followed by tabagism (36%), alcoholism (20%) e diabetes mellitus (20%). Gender and damaged cerebral hemisphere did not have a statistically significant association to the presence of dysphagia. Age, NIHSS, GCS, speaking and language alterations and lesion topography are predicting factors of dysphagia presenting statistically significant differences. Patients with lesions in the carotid territory presented more prevalence regards the presence of dysphagia (58,88%). NIHSS presents high sensitivity (88%) and specificity (85%) to the detection of dysphagia considering 12 as the cutoff value for its existence. The creation of an algorithm to detect dysphagia in the acute phase of ICVA will be able to help the definition of the proper behavior regards the prescription of a diet while a specialized speech pathological evaluation is awaited.

This is a retrospective study utilizing data complied over the past two years during the formative assessment process by the University of South Florida (USF) Department of Communication Sciences and Disorders (CSD) in the development of the new audiology clinical doctoral (Au.D.) program. Final adoption of the new certification standards in audiology was received in 1997 and several Au.D. programs have been implemented since that time. This study responds to the requirements of appropriate assessment and documentation of clinical skill acquisition across the academic and clinical training program. The purpose of this review was to complete a qualitative analysis of the data gathered previously to determine indicators of clinical competency specific to the USF Au.D. program. This study focused on determining minimal knowledge and clinical skills that should be acquired at the end of the second and third years relative to competencies outlined in Standard IV-D: Evaluation and Standard IV-E: Treatment. Expectations relative to skills that audiology students should possess at designated points in the educational process are pertinent to developing effective tools for assessing clinical performance. Two focus group discussion sessions were held. One group included USF audiology academic and clinical faculty and the other group was composed of external practicing audiologists who provide supervision for audiology students in extern assignments. Participation was on a voluntary basis and anonymity was maintained. A guided discussion format was followed to obtain information about their expectations for student clinical competency levels at the end of the second and third years of study. The analysis of the data set included a review and summary of comments and ratings completed by the participants. The summary provided a highlight of key points, trends, and similarities/differences in the ratings provided by the two groups.

Indiana University-Purdue University Indianapolis (IUPUI) / Background. Despite widespread criticism of physician-performed evaluations of medical students’ clinical skills, clinical clerkship evaluations (CCEs) remain the foremost means by which to assess trainees’ clinical prowess. Efforts undertaken to improve the quality of feedback students receive have ostensibly led to higher assessment demands on physician faculty; the consequences of which remain unknown. Accordingly, this study investigated the extent to which physicians’ evaluative responsibilities influenced the quality of CCEs and qualitatively explored physicians’ perceptions of these evaluations. Methods. A questionnaire was delivered to physicians (n = 93) at Indiana University School of Medicine to gauge their perceived evaluative responsibilities. Evaluation records of each participant were obtained and were used to calculate one’s measurable quantity of CCEs, the timeliness of CCE submissions, and the quality of the Likert-scale and written feedback data included in each evaluation. A path analysis estimated the extent to which one’s evaluative responsibilities affected the timeliness of CCE submissions and CCE quality. Semi-structured interviews with a subset of participants (n = 8) gathered perceptions of the evaluations and the evaluative process. Results. One’s measurable quantity of evaluations did not influence one’s perceptions of the evaluative task, but did directly influence the quality of the Likert-scale items. Moreover, one’s perceptions of the evaluative task directly influenced the timeliness of CCE submissions and indirectly influenced the quality of the closed-ended CCE items. Tardiness in the submission of CCEs had a positive effect on the amount of score differentiation among the Likert-scale data. Neither evaluative responsibilities nor the timeliness of CCE submissions influenced the quality of written feedback. Qualitative analysis revealed mixed opinions on the utility of CCEs and highlighted the temporal burden and practical limitations of completing CCEs. Conclusions. These findings suggest physicians’ perceptions of CCEs are independent of their assigned evaluative quantity, yet influence both the timeliness of evaluation submissions and evaluative quality. Further elucidation of the mechanisms underlying the positive influence of evaluation quantity and timely CCE submissions on CCE quality are needed to fully rationalize these findings and improve the evaluative process. Continued research is needed to pinpoint which factors influence the quality of written feedback.

Background. Multiple sclerosis (MS) is a chronic autoimmune inflammatory disease of the central nervous system. It is the most common neurological disease in young adults, affecting mostly women at the peak of their productive age. The most frequent disease phenotype is the relapsing remitting MS, where patients present relapses with a total or partial recovery of their symptoms. A group of these patients develops a secondary progressive course (SPMS), with an accumulation of MS-related disability independent of the relapse activity. As the identification of SPMS represents a significant diagnostic challenge, the identification of disease disability plays an important role in the monitoring of these patients. Gait and balance problems stand out among the most important symptoms of disability in MS patients. Due to the heterogeneity of the demyelinating lesions and their burden, several anatomic structures with a consequence in postural control may be affected by the MS. Recent advances in technology make possible a reliable evaluation of balance through objective measures. The implementation of static posturography could complement the classical neurological evaluation through the Expanded Disability Status Scale (EDSS) in the detection and characterization of balance impairment. Additionally, in the recent years, several new disease modifying treatment (DMTs) options have been developed for the treatment of MS. Fingolimod is a modulator of the S1P receptor that alters the trafficking of lymphocytes, decreasing the absolute count in blood. Several adverse effects have been described for this drug through its mechanism of action, such as cardiac or vascular alterations. Animal models have demonstrated a reduction of the fecal secretory immunoglobulin A (sIgA) levels through an impairment of the local immune response in the colon and a reduction of plasma cell precursors controlled by the S1P receptor. Human studies for this effect have not been so far. A similar effect in MS patients could lead to an impairment in the gut function and alter the commensal bacteria in the gut microbiome. Considering the limitations of the classic neurological evaluation and the still incomplete but growing understanding of MS, the investigation of clinical and paraclinical characteristics of MS patients and the effects of DMTs gains a remarkable importance. The main objective of this dissertation was to characterize people with MS through clinical outcome measures, as well as through the evaluation of fecal immunity after long-term treatment with fingolimod. Additionally, an assessment of balance parameters generated through static posturography was performed as well as physiological characteristics and alterations of postural control in this group. Methods. A cross-sectional evaluation of MS patients and healthy controls was performed. Patients with confirmed diagnosis of MS according to the 2010’s McDonald’s criteria and healthy controls were evaluated. An EDSS score was calculated for each patient according to the neurostatus scoring guidelines. Static posturography measures were performed with patients standing on a force platform in a standardized position equivalent to the Romberg test. The following balance outcomes were generated through an automatized software fur further evaluation: delineated area, average sway and average speed of sway. Both were obtained in the open and closed eyes conditions. The difference between the conditions was calculated. Fecal and salivary samples of a group of 25 patients with MS diagnosis and treatment with fingolimod or glatirameracetat for over twelve months were analyzed after a proper standardization. Through ELISA immunoasays free sIgA levels were calculated in the supernant. Required statistical analysis were performed. Results. 99 people with MS and 30 healthy controls participated in the static posturography evaluation. The MS had a worse performance than healthy controls in the three static posturography outcomes. Both groups had a worse performance in the closed eyes condition. However, the magnitude of the effect of vision was more significant in the MS patients as a significant interaction between vision and MS diagnosis was seen in the delineated area (p < 0.001) and average speed of sway (p = 0.001). There were moderate and significant correlations between most of the evaluated parameters and the EDSS and MSFC (r’s ranging from 0.207 to 0.537, p < 0.05). The highest correlations were seen for the delineated area and average speed in the closed eyes condition and their difference between the open and closed eyes evaluations. Especially these two parameters could differentiate between disability groups and healthy controls. Additionally, patients without postural instability documented through the Romberg test score of the EDSS assessment showed significantly worse outcomes in the delineated area [+1.97 cm2, 95%-CI (0.61–3.34); p = 0.002] than healthy controls. A similar trend was observed for the comparison between MS patients with normal cerebellar function EDSS-systems and healthy subjects. On the other hand, 15 patients with fingolimod and 10 with glatirameracetat participated in the measure of fecal sIgA. There was no significant difference between both groups at the evaluated time point. A similar pattern was seen in the salivary sIgA and serum immunoglobulins. In our studie, we evaluated the static posturography as a complement of the neurological assessment through the EDSS, which could characterize disease disability already at early stages of the diseases. The MS patients were more dependent of the visual feedback than HC to maintain postural control. In contrast, we could not confirm a decrease of fecal sIgA after a long-term treatment with fingolimod, although further longitudinal studies are needed for further analysis. / Hintergrund. Die Multiple Sklerose (MS) ist eine chronisch entzündliche Autoimmunerkrankung des Zentralnervensystems. Sie ist die häufigste neurologische Erkrankung bei jungen Erwachsenen und betrifft vor allem Frauen auf dem Höhepunkt ihres produktiven Alters. Der häufigste Krankheitsverlauf ist die schubförmig remittierende MS (RRMS), bei der die Patienten Schübe mit einer vollständigen oder teilweisen Erholung ihrer Symptome aufweisen. Eine Gruppe dieser Patienten entwickelt einen sekundär progredienten Verlauf (SPMS), wobei eine schleichende MS-bedingte Behinderungsprogression unabhängig von der Schubsaktivität beschrieben wird. Da die Diagnose von SPMS eine bedeutende diagnostische Herausforderung darstellt, spielt die frühzeitige Erkennung der krankheitsbedingten Einschränkungen eine wichtige Rolle beim Monitoring von MS-Patienten. Gang- und Gleichgewichtsstörungen gehören zu den wichtigsten Beschwerden bei MS-Patienten. Aufgrund einer breiten Heterogenität der demyelinisierenden Läsionen können mehrere anatomische Strukturen mit Auswirkungen in der Haltungskontrolle betroffen sein. Jüngste technologische Fortschritte ermöglichen eine zuverlässige Bewertung des Gleichgewichts durch objektive Messungen. Die Anwendung der statischen Posturographie könnte die klassische neurologische Untersuchung durch die Expanded Disability Status Scale (EDSS) hinsichtlich einer Erkennung und Charakterisierung von Gleichgewichtsstörungen ergänzen. Darüber hinaus wurden in den letzten Jahren mehrere neue krankheitsmodifizierende therapeutische Optionen (DMTs) für die Behandlung von MS-Patienten entwickelt. Fingolimod ist ein Modulator des S1P-Rezeptors, der die Lymphozytendistribution modifiziert mit einer absoluten Verminderung der Anzahl im Blut. Für dieses Medikament wurden mehrere unerwünschte Wirkungen durch seinen Wirkmechanismus beschrieben, wie z.B. kardiale oder vaskuläre Veränderungen. In Tiermodellen wurde eine Verringerung der fäkalen sekretorischen Immunglobulin-A-Spiegel (sIgA) durch eine Beeinträchtigung der lokalen Immunantwort im Dickdarm und eine Verringerung der durch den S1P-Rezeptor kontrollierten Plasmazellvorläufer nachgewiesen. Humanuntersuchungen bezüglich dieses Effekts sind zu diesem Zeitpunkt noch nicht durchgeführt worden. Ein ähnlicher Effekt bei MS-Patienten könnte zu einer Beeinträchtigung der Darmfunktion führen und die kommensalen Bakterien der Darmflora verändern. In Anbetracht der Einschränkungen der klassischen neurologischen Unteruschung und des noch unvollständigen, jedoch wachsenden Verständnisses der MS gewinnt die klinische und paraklinische Phenotypisierung von MS-Patienten und der Wirkungen von DMTs eine bemerkenswerte Bedeutung. Das Hauptziel dieser Dissertation war die Phenotypisierung von Menschen mit MS durch klinische Ergebnismessungen sowie durch die Bewertung der fäkalen Immunität nach Langzeitbehandlung mit Fingolimod. Zusätzlich wurde eine Bemessung von Gleichgewichtsparametern, die durch statische Posturographie erzeugt wurden, sowie physiologische Merkmale und Veränderungen der posturalen Kontrolle in dieser Gruppe durchgeführt. Methoden. Es wurde eine Querschnittanalyse von MS-Patienten und gesunden Kontrollen durchgeführt. Patienten mit einer bestätigten MS-Diagnose nach den Revisionen der McDonald's-Kriterien von 2010 und gesunde Kontrollpersonen wurden untersucht. Für jeden Patienten wurde ein EDSS-Score nach den Neurostatus-Scoring-Leitlinien erhoben. Statische posturographische Messungen wurden durchgeführt, wobei die Patienten auf einer Kraftplattform in einer standardisierten Position standen, die dem Romberg-Test entsprach. Die folgenden Gleichgewichtsparameter wurden durch eine automatisierte Software zur weiteren Auswertung generiert: „delineated area“ (abgegrenzter Bereich), „average sway“ (durchschnittliches Schwanken) und „average speed of sway“ (durchschnittliche Schwenkgeschwindigkeit). Diese wurden mit dem Patienten mit offenen und geschlossenen Augen erhoben. Die Differenz zwischen beiden Bedingungen wurde dazu berechnet. Stuhl- und Speichelproben einer Gruppe von 25 Patienten mit MS-Diagnose nach Behandlung mit Fingolimod oder Glatirameracetat für über zwölf Monate wurden nach einer angemessenen Standardisierung analysiert. Mittels ELISA-Immunassays wurden die freien sIgA-Konzentrationen im Supernant berechnet. Die erforderliche statistische Analyse wurde durchgeführt. Ergebnisse. 99 Personen mit MS und 30 gesunde Kontrollen nahmen an der statischen posturographischen Auswertung teil. Die MS-Gruppe hatte in den drei statischen Posturographie-Ergebnissen eine schlechtere Leistung als gesunde Kontrollen. Beide Gruppen hatten eine schlechtere Leistung im Zustand mit geschlossenen Augen. Das Ausmaß der Auswirkung des Sehens war jedoch bei den MS-Patienten bedeutsamer, da eine signifikante Interaktion zwischen Sehen und MS-Diagnose im abgegrenzten Bereich (p < 0,001) und der durchschnittlichen Schwankungsgeschwindigkeit (p = 0,001) in einer ANCOVA-Analyse zu beobachten war. Es gab mäßige und signifikante Korrelationen zwischen den meisten der evaluierten Parameter und der EDSS und dem MSFC (die r-Werte lagen zwischen 0,207 und 0,537, p < 0,05). Die höchsten Korrelationen wurden für die „delineated area“ und die „average speed of sway“ im Zustand mit geschlossenen Augen und deren Differenz zwischen dem Zustand mit offenen und geschlossenen Augen festgestellt. Insbesondere diese beiden Parameter konnten zwischen (leicht) Behindertengruppen und gesunden Kontrollen unterscheiden. Zusätzlich zeigten Patienten ohne klinisch sichtbare Gleichgewichtsstörungen, die durch den Romberg-Testscore der EDSS-Bewertung dokumentiert wurden, signifikant schlechtere Ergebnisse der „delineated area“ [+1,97 cm2, 95%-CI (0,61-3,34); p = 0,002] als gesunde Kontrollen. Ein ähnliches Muster wurde für den Vergleich zwischen MS Patienten mit normaler Kleinhirnfunktion und gesunden Probanden beobachtet. Auf der anderen Seite nahmen 15 Patienten mit Fingolimod und 10 mit Glatirameracetat an der Messung der fäkalen sIgA teil. Zum ausgewerteten Zeitpunkt gab es keinen signifikanten Unterschied zwischen beiden Gruppen. Ein ähnliches Muster zeigte sich bei der Speichel-sIgA und den Serum-Immunglobulinen. In unseren Studien evaluierten wir die statische Posturographie als Ergänzung der neurologischen Beurteilung durch die EDSS, die die Krankheitsinvalidität bereits in frühen Krankheitsstadien charakterisieren könnte. Die MS-Patienten waren zur Aufrechterhaltung der posturalen Kontrolle stärker vom visuellen Feedback abhängig als von der HC. Im Gegensatz dazu konnten wir eine Abnahme der fäkalen sIgA Konzentration nach einer Langzeitbehandlung mit Fingolimod nicht bestätigen, wobei zur weiteren Analyse Längsschnittstudien erforderlich sind.

Lumbal spinal stenos är ett av de vanligaste patologiska tillstånden i ryggen. Primärt mål för de flesta av interventionerna vid lumbal spinal stenos är en förbättring av gångförmågan. I det Svenska ryggregistret för uppföljning av kirurgi saknas utvärdering av objektivt uppmätt gångförmåga. Syfte: Att undersöka hur objektivt uppmätt gångförmåga påverkas efter en operation av lumbal spinal stenos samt hur den korrelerar mot subjektivt skattad gångförmåga och mot skattad rygghälsa samt livskvalitet. Metod: Etthundrasjuttiotre patienter i ålder 50-81 år utförde pre och 24 månader postoperativt ett standardiserat six minutes walk test (6 MWT) samt besvarade enkäter om självskattad gångförmåga, livskvalitet (EQ5D) och rygghälsa (ODI). Signifikans på förändring av medelvärdet av gångförmågan beräknades med ett parat t-test och 95 % konfidensintervall. Korrelation mellan uppmätt gångförmåga och självskattad gångförmåga samt mot EQ5D och ODI beräknades med Spearmans rangkorrelation. Resultat: Gångförmågan mätt med 6MWT förbättrades från 314 meter preoperativt till 396 meter 24 månader postoperativt. Korrelationen mellan uppmätt gångförmåga och självskattad gångförmåga var 0,68 postoperativt. Korrelationen mellan 6 MWT och EQ5D var 0,60 och mot ODI 0,65, 2 år postoperativt. Konklusion: Resultatet i denna studie visade på en signifikant förbättring av objektivt uppmätt gångförmåga två år efter en operation av lumbal spinal stenos. Korrelationen mellan självskattad gångförmåga och 6 MWT var moderat. Korrelationen mellan 6 MWT och EQ5D var moderat och moderat till stark mot ODI. / Lumbar spinal stenosis is one of the most common pathological conditions in the lower back. A primary goal for most of the interventions for lumbar spinal stenosis is an improvement of walking ability. In the Swedish back registry for follow-up surgery objectively measured gait is missing. Objective: To examine how objectively measured walking capacity is affected by an operation of lumbar spinal stenosis and how it correlates with subjective estimated walking capacity, back health (ODI) and quality of life (EQ5D). Method: Onehundredseventythree patients in age 50-81 years performed pre and 24 months postoperatively a standardized six minutes walk test (6 MWT) and responded to questionnaires about self-rated gait, EQ5D and ODI. Significance of the change in mean walking ability was calculated by using a paired t-test and 95% confidence intervals. Correlation between the measured gait and self-rated gait as well as against EQ5D and ODI were calculated with Spearman rank correlation. Result: Walking capacity measured by the 6MWT improved from 314 to 396 meters, 24 months postoperatively. The correlation between the measured and self-rated gait were 0,68 postoperatively. Correlation between 6MWT and EQ5D were 0,60 and against ODI 0.65, 2 years postoperatively. Conclusion: The results of this study showed a significant improvement in objectively measured walking capacity, two years after an operation of lumbar spinal stenosis. Correlation between self-rated gait and 6 MWT were moderate. Correlation between 6MWT and EQ5D were moderate and against ODI moderately strong.

Devido à crescente utilização de componentes cerâmicos como estruturas de suporte para restaurações sobre implantes e a ausência de resultados conclusivos, em longo prazo, sobre a influência deste tipo de material no processo de formação e manutenção do biofilme oral e saúde dos tecidos peri-implantares, este estudo teve por objetivo investigar o perfil microbiano do biofilme formado sobre próteses unitárias de implantes com conectores de zircônia (Zr) ou titânio (Ti) e sua implicação clínica nos tecidos de suporte ao longo de 3 anos de função. Vinte indivíduos saudáveis participaram do estudo e foram reabilitados com implantes dentários e coroas protéticas unitárias cimentadas sobre conectores de zircônia (n=10; região anterior de maxila) ou conectores de titânio (n=10; região posterior da mandíbula). Amostras de biofilmes supra e subgengival, e dados de indicadores clínicos (profundidade e sangramento à sondagem, recessão gengival e nível ósseo marginal) foram coletados dos sítios peri-implantares e dentes contralaterais em 4 períodos distintos, na instalação da prótese (T0) e após 12 (T1), 24 (T2) e 36 (T3) meses de função mastigatória. Trinta e sete espécies microbianas foram identificadas e quantificadas pelo método de hibridização DNA-DNA Checkerboard. Os dados foram submetidos à análise estatística não-paramétrica de regressão linear mista (Brunner and Langer nonparametric analysis of longitudinal data in factorial experiments) e múltiplas comparações foram realizadas por meio do teste de Friedman-Conover, corrigido por Benjamini-Hockberg False Discovery Rate (FDR). Para análise da reabsorção óssea marginal foi utilizado o teste Two-Way ANOVA. Todas as análises foram realizadas com um nível de significância de 5%. O perfil microbiano detectado nos implantes restaurados com conectores de zircônia, titânio e seus respectivos dentes contralaterais foi semelhante a partir do período de 12 meses de investigação. Espécies patogênicas e não-patogênicas foram detectadas nos biofilmes supra e subgengival dos dois substratos, com um aumento significante da quantificação das espécies ao longo do tempo. Apesar do perfil semelhante, os substratos investigados influenciaram na quantidade total de micro-organismos identificados (p<0,05). Os conectores de Zr apresentaram maior quantificação de genomas totais nas amostras subgengivais quando comparadas aos conectores de Ti (p<0,05). A profundidade de sondagem reduziu nos implantes com Zr após 12 meses, enquanto nos implantes com Ti aumentou no mesmo período (p<0,05). O sangramento à sondagem e a recessão gengival aumentaram ao longo do tempo para Zr e Ti. Não houve diferença significante nos valores da reabsorção óssea marginal, entre os dois materiais, após 36 meses (p>0,05). De modo geral, pode-se concluir que o perfil microbiano dos biofilmes supra e subgengival dos implantes com Zr ou Ti foi semelhante, com um aumento da quantificação das espécies ao longo do tempo. A microbiota investigada neste estudo parece não ter influenciado os indicadores clínicos ao longo dos 36 meses de acompanhamento. Os resultados clínicos sugerem a manutenção da saúde dos tecidos peri-implantares nos diferentes substratos investigados / Due to the increasing use of ceramic abutments as support structures for implant restorations and the lack of long-term conclusive results on the influence of this type of material on the oral biofilm formation and maintenance of peri-implant tissue health, the purpose of this study was to investigate the microbial biofilm profiles of single-implant restorations using zirconia (Zr) or titanium (Ti) abutments and their clinical implications in the supporting tissues over a 3-year period. Twenty healthy subjects participated in the study and were rehabilitated with single-unit implant restorations cemented on zirconia (n = 10; anterior maxilla) or titanium abutments (n = 10; posterior mandible). Supra and subgingival biofilm samples, and clinical parameters data (probing depth and bleeding on probing, gingival recession and marginal bone level) were collected from the peri-implant sites and contralateral teeth at 4 different time-periods, at the prosthesis installation (T0) and after 12 (T1), 24 (T2) and 36 (T3) months of loading. Thirty-seven microbial species were identified and quantified by DNA-DNA Checkerboard hybridization method. The data were submitted to Brunner and Langer nonparametric analysis of longitudinal data in factorial experiments followed by Friedman-Conover multiple comparisons test, corrected by Benjamin-Hockberg False Discovery Rate (FDR). Two-Way repeated ANOVA was used to analyze marginal bone resorption. Statistical significance was set at 0.05 probability level. The microbial profiles detected in the implants restored with zirconia or titanium abutments and their respective contralateral teeth were similar from the 12-month follow-up. Pathogenic and non-pathogenic species were detected in the supra and subgingival biofilms of the two substrates, with a significant increase in the microbial counts over time. Despite the similar profile, the investigated substrates influenced the total amount of microorganisms identified (p <0.05). The Zr abutments presented higher total genome counts in the subgingival samples when compared to Ti abutments (p <0.05). The probing depth reduced in the implants with Zr after 12 months, whereas in the implants with Ti increased in the same period (p <0.05). Bleeding on probing and gingival recession increased over time for both Zr and Ti. There was no significant difference in marginal bone resorption values between the two materials after 36 months (p>0.05). Overall, it can be concluded that the microbial profile of supra and subgingival biofilms of the implants with Zr or Ti was quite similar, and the microbial counts increased over time. The microbiota investigated in this study does not seem to have influenced the clinical parameters during the 36 months of follow-up. The clinical results suggest the maintenance of peri-implant tissue health in the different substrates investigated

Submitted by Eunice Novais (enovais@uepg.br) on 2018-07-31T17:58:28Z No. of bitstreams: 2 license_rdf: 811 bytes, checksum: e39d27027a6cc9cb039ad269a5db8e34 (MD5) Jullian Josnei de Souza.pdf: 4272870 bytes, checksum: 6f1511f275e8e910ee0c183db991dd9c (MD5) / Made available in DSpace on 2018-07-31T17:58:28Z (GMT). No. of bitstreams: 2 license_rdf: 811 bytes, checksum: e39d27027a6cc9cb039ad269a5db8e34 (MD5) Jullian Josnei de Souza.pdf: 4272870 bytes, checksum: 6f1511f275e8e910ee0c183db991dd9c (MD5) Previous issue date: 2018-02-16 / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / O objetivo desse trabalho foi avaliar a influência da habilidade do operador, em seu nível de experiência, no desempenho clínico de restaurações diretas de resinas composta em lesões cervicais não cariosas (LCNC), realizadas por acadêmicos do último ano do curso de Odontologia da Universidade Estadual de Ponta Grossa e por profissionais com mais de 5 anos de formação. Foram realizadas 4 diferentes estratégias adesivas: convencional de 3 e 2 passos e autocondicionante de 2 e 1 passo, aplicadas em um modelo de ensaio clínico aleatorizado. 70 voluntários foram selecionados e alocados de forma aleatória em 2 grupos segundo o operador: profissionais (n=35) e acadêmicos (n=35). As 4 estratégias adesivas também foram distribuídas aleatoriamente dentre as LCNC de cada voluntário, e realizadas seguindo as intruções do fabricante. As avaliações foram feitas imediatamente e após 3 anos, por avaliadores previamente calibrados e cegos em relação à estratégia utilizada, utilizando 2 instrumentos de avaliação FDI (Federação Dentária Internacional) e USPHS (Serviço de Saúde Pública dos Estados Unidos), os quais são divididos em propriedades tais como: fratura/retenção; adaptação marginal; desadaptação marginal; sensibilidade pós operatória; e recorrência de cárie adjacente à restauração. Foram realizados os testes estatísticos de Friedman para comparar todos os grupos em tempos diferentes e Wilcoxon ente os pares dos grupos (α = 0.05). Após 3 anos o índice de comparecimento foi de 74% dos voluntários e observamos que foram perdidas apenas 5 restaurações no grupo dos profissionais: 1 pelo adesivo FL (Optibond FL covencional de 3 passos); 2 pelo adesivo XTR (Optibond XTR autocondicionante de 2 passos) ; 2 pelo adesivo AIO (Optibond All-In-One autocondicionante de 1 passo), totalizando uma taxa de retenção de 96% para FL; 92% para XTR; e 92% para AIO. Já no grupo dos acadêmicos foram perdidas 13 restaurações: 5 pelo adesivo FL (Optibond FL convencional de 3 passos); 2 pelo adesivo SP (Optibond Solo Plus convencional de 2 passos); 4 pelo adesivo XTR (Opitbond XTR autocondicionante de 2 passos); e 2 pelo AIO (Optibond All-In-One autocondicionante de 1 passo), totalizando uma taxa de retenção de 80% para FL; 92% para SP; 85%para XTR; e 92% para AIO pelo período de 3 anos. As técnicas adesivas mais complexas (convencional de 3 passos e autocondicionante de 2 passos) parecem apresentar dificuldades na aplicação para ambos os grupos de operadores (profissionais e acadêmicos), impactando negativamente na taxa de retenção. Assim, outros estudos e períodos mais longos de avaliação precisam ser realizados para esclarecer estas diferenças. Palavras-chave: adesivo dentinário, lesões cervicais não cariosas, avaliação clínica. / The aim of this study was to evaluate the influence of the operator skills in your level of experience (student and professional), on clinical performance of the composite restorations in non-carious cervical lesions (NCCL), made by senior year academics of Dentistry of the State University of Ponta Grossa and by professionals with 5 or more years of graduation, those restorations made using 4 different strategies adhesive (etch and rinse of 3 and 2 steps and self etch of 2 or 1 step), applied in random clinical test model. In order to make this study 70 volunteers were selected and put in random form of 2 groups according to the operator: professionals (n=35) and academics(n=35). The 4 adhesive strategies were too divided randomly between NCCL of each volunteer and made following the manufacture´s instructions. The evaluations were done immediately and after 3 years, by evaluaters previously callibrated and blind regarding the used strategy, were made 2 criterios of the evaluation FDI (International Dentistry Federation) and USPHS (Unied States Public Health Services), which or divided in properties such as: fracture and retation; marginal adaptation, marginal staining, pós operative sensibility and recourrence of caries near restoration. Statiscal analyses were performed with Friedman to compare all groups at different times and Wilcoxon between the pairs of the groups (α = 0.05). After 3 years the attendance rate was 74% of the volunteers and we observed that only 5 restorations were lost in the professionals group: 1 by the FL adhesive; 2 by the XTR adhesive; 2 by the AIO adhesive, totaling a 96% retention rate for FL; 92% for XTR; and 92% for AIO. Already in the group of the academics 13 restorations were lost: 5 by the adhesive FL; 2 by the adhesive SP; 4 by the adhesive XTR; and 2 by the AIO, totaling a retention rate of 80% for FL; 92% for SP; 85% for XTR; and 92% for AIO for a period of 3 years. The more complex adhesive techniques (etch and rinse 3-step and self-etch 2-step) seem to present difficulties in applying to both groups of operators (professionals and academics), negatively impacting the retention rate. Thus, other studies and longer periods of evaluation need to be performed to clarify these differences.