La debilidad de los músculos de la cadera, en especial la del músculo Glúteo Medio, ha sido relacionada con diversas lesiones deportivas de la extremidad inferior. El tratamiento de varias de estas lesiones es conservador, considerándose en él además de la activación de los abductores de cadera, la disminución de la tensión de la Banda Iliotibial, sin embargo, aún la evidencia es limitada respecto a qué ejercicios serían más apropiados. El propósito de nuestro estudio fue determinar el nivel de activación de los músculos abductores de cadera en dos ejercicios utilizados en la práctica clínica. La muestra fue de 22 mujeres, sanas y físicamente activas (edad 23 ± 2 años). Se analizó la amplitud de la señal electromiográfica de los músculos Glúteo Medio y Tensor de la Fascia Lata en los ejercicios Pelvic Drop y Wallbanger, siendo expresada como porcentaje de la máxima contracción isométrica voluntaria. Los resultados fueron analizados con el programa IBM SPSS Statistics 20, mediante la prueba de Wilcoxon. La activación del músculo Glúteo Medio fue de un 23,946% ± 11,321 (promedio ± DE) en el ejercicio Pelvic Drop y de un 18,197% ± 9,61en el ejercicio Wallbanger. La activación del músculo Tensor de la Fascia Lata fue de un 26,581% ± 19,264 en el ejercicio Pelvic Drop y de un 12,953% ± 11,129 en el ejercicio Wallbanger. En ambos casos, al analizar por músculo, las diferencias fueron estadísticamente significativas, al igual que la obtenida entre la activación del Glúteo Medio y Tensor de la Fascia Lata en el ejercicio Wallbanger. Se concluye que el ejercicio Pelvic Drop logra una mayor activación de los músculos abductores de cadera, sin embargo, es el ejercicio Wallbanger el que consigue una activación diferenciada, activando menos al Tensor de la Fascia Lata que al Glúteo Medio. Se espera que la información encontrada aporte al conocimiento más acabado sobre el tratamiento y prevención de distintas patologías de miembro inferior, sirviendo de base para estudios posteriores que optimicen el tiempo de recuperación de los pacientes. / Hip muscle weakness, especially in the Gluteus Medius, has been associated with several lower extremity sport injuries. The treatment of several of these injuries is conservative, where it is considered in addition to activation of the hip abductors, decrease the tension of the Iliotibial Band, however, the evidence is still limited about what exercises would be more appropiate. The purpose of our study was to determine the level of activation of the hip abductor muscle in two exercise used in clinical practice. The sample included 22 women, healthy and physically active (age 23 ± 2 years). We analyzed the electromyographic signal amplitude of the Gluteus Medius and Tensor Fascia Latae muscles in Pelvic Drop and Wallbanger exercises, being expressed as a percentage of maximum voluntary isometric contraction. The results were analyzed with the program IBM SPSS Statistics 20, by testing Wilcoxon. The Gluteus Medius activation was 23,946% ± 11,321 (mean ± SD) in the Pelvic Drop exercise and 18,197% ± 9,61 in the Wallbanger exercise. The Tensor Fascia Latae activation was 26,581% ± 19,264 in the Pelvic Drop exercise and 12,953% ± 11,129 in the Wallbanger exercise. In both cases, the differences were statistically significant, as that obtained between the activation of the Gluteus Medius and Tensor Fascia Latae in the Wallbanger exercise. We conclude that Pelvic Drop exercise achieve greater activation of the hip abductor muscles, however, is Wallbanger exercise which achieves a differential activation, causing a lower activation in the Tensor Fascia Latae than in Gluteal Medius muscle. It is hoped that the information found contribute to knowledge on the treatment and prevention of various diseases of lower limb, serve as a basis for further studies to optimize the recovery time of patients.

El Síndrome de la banda iliotibial es la principal causa de dolor lateral de rodilla en corredores. Se asocia a debilidad en la musculatura abductora de cadera, entre otras causas que siguen siendo investigadas. El presente estudio consistió en determinar el tiempo de activación muscular del glúteo medio y tensor de la fascia lata en atletas sanos y con síndrome de la banda iliotibial, durante la carrera. La población estudio se compuso de atletas fondistas y triatletas pertenecientes a distintos clubes de corredores de la Región Metropolitana, de edades promedio de 26,31 ±7,47años. La muestra se conformó de 16 sujetos de género masculino; 9 sanos y 7 lesionados. El protocolo de estudio se llevó a cabo en el laboratorio de análisis de movimiento de la Escuela de Kinesiología de la Universidad de Chile. Cada sujeto realizó una prueba de carrera en cinta rodante, a una velocidad de 10 km/h, con 2 grados de inclinación. Se realizó un registro electromiográfico de superficie del músculo tensor de la fascia lata y del glúteo medio en ambas extremidades. Se aplicó una prueba t de student (95% intervalo de confianza) para muestras relacionadas (p<0.05). Los resultados obtenidos mostraron gran variabilidad en los tiempos de activación entre sujetos, sin embargo, se mantienen relativamente constantes para un mismo sujeto. En sujetos sanos, el tiempo de activación del glúteo medio fue -0,087±0,059 segundos y el tiempo de activación del tensor de la fascia lata fue 0,02±0,025 segundos, en donde la activación del glúteo medio precedió a la del tensor de la fascia lata, y a su vez al contacto inicial del pie, a diferencia del tensor de la fascia lata, que se activa después del contacto inicial del pie. En los individuos con síndrome de la banda iliotibial, el tiempo de activación del glúteo medio correspondió a -0,074± 0,046 segundos, y el correspondiente al tensor de la fascia lata fue de -0,005±0,038 segundos. Se concluyó que las diferencias entre los tiempos de activación de ambos grupos no fueron significativas. Tampoco lo fueron para los valores de tiempo de activación en relación al porcentaje de la fase de apoyo. / The iliotibial band syndrome is the leading cause of lateral knee pain in runners. It is associated with weakness in the hip abductor muscles, among other causes are being investigated. The present study was to determine the activation time of gluteus medius and tensor fascia lata in healthy and iliotibial band syndrome athletes during the race. The study population consisted of distance runners and triathletes from different running clubs in the metropolitan region, average age 26.31 ± 7.47 years. The sample consisted of 16 male subjects, 9 healthy and 7 injured. The study protocol was carried out in the motion analysis laboratory of the School of Kinesiology, University of Chile. Each subject performed a test of treadmill running at a speed of 10 km / h, with 2 degrees of inclination. A record was made of surface electromyography from tensor fascia lata and gluteus medius on both ends. We applied a Student's t test (95% confidence interval) for related samples (p <0.05). The results showed great variability in activation times between subjects, however, remain relatively constant for a given subject. In healthy subjects, the activation time of the gluteus medius was -0.087 ± 0.059 seconds and the activation time of the tensor fascia lata was 0.02 ± 0.025 seconds, where activation of the gluteus medius preceded the tensor fascia lata, and in turn the initial foot contact, unlike the tensor fascia lata, which is activated after initial contact of the foot. In individuals with iliotibial band syndrome, the time of activation of the gluteus medius corresponded to ± 0.046 -0.074 seconds, and for the tensor fascia lata was -0.005 ± 0.038 seconds. It was concluded that the differences between the activation times of both groups were not significant. Neither were the values for activation time relative to the percentage of the stance phase.

The Gluteus Medius and the Tensor Fascia Lata are two of the main muscles involved in the action of hip abduction. This action is important for both dynamic movements in athletic pursuits and in every day ambulation. Weakness in these muscles has been connected to multiple injuries in the lower limb, but the question of the casual relationship between gait change, hip abductor weakness, and lower limb injury is still up for debate. As presented by the current research, younger populations tend to have overuse injuries with females having a greater susceptibility for injuries connected to hip abductor weakness, and older populations tend to have injures related to atrophy and degeneration of either the hip abductor muscles or the joint surrounding the hip. Research in this field has increasingly focused on sub-sets of the populations, such as just females or just males, trying to pinpoint the role that hip abductor weakness plays in these injuries. By trying to minimize or even eliminate the confounding variables that have previously made it difficult to determine the role hip abductor weakness plays in these gait changes and injuries, these studies have been able to make more clear conclusions at the expense of making a broader generalization. Similarities and differences between how the sub-groups present with hip abductor weakness are discussed, as well as discrepancies observed within the research done on similar cohorts. Future directions for research in this field are discussed, as well as implications for clinical implementation of targeted rehabilitation programs to ensure the best possible outcomes.

Afecções ortopédicas são freqüentes em pequenos animais e dentre essas afecções destaca-se a luxação coxofemoral – a mais freqüente dentre as luxações. Devido a tal incidência, a luxação coxofemoral tornou-se objeto de inúmeras pesquisas em medicina veterinária, sendo o tratamento cirúrgico o mais efetivo para sua correção. Ainda não foi, no entanto, desenvolvida uma técnica cirúrgica preferencial, amplamente difundida nas rotinas hospitalares. O presente trabalho avalia comparativamente o implante de fáscia lata bubalina e de pino de Steinmann transarticular para a estabilização de articulações coxofemorais luxadas. Foram utilizados 26 cães, separados em dois grupos que foram também, por sua vez, subdivididos. O primeiro grupo foi denominado “grupo Experimental” e reuniu 16 animais: oito pertencentes ao subgrupo “pino” e oito ao subgrupo “fáscia”. O segundo grupo foi denominado “grupo Rotina” e constituído por dez animais provenientes da rotina de atendimentos do Hospital de Clínicas Veterinárias da Universidade Federal do Rio Grande do Sul (UFRGS), sendo igualmente subdividido nos subgrupos “pino” e “fáscia”, com cinco animais cada um. Os cães foram submetidos às respectivas técnicas de estabilização e acompanhados clínica e radiograficamente durante 60 dias, findos os quais os animais do grupo Experimental passaram por avaliação macroscópica direta das articulações, além da histopatologia e teste de tensiometria. A principal vantagem da fáscia respeita à deambulação dos animais, que apresentaram evolução pós-operatória significativamente precoce em relação ao grupo submetido ao implante do pino de Steinmann transarticular, além de menor grau de atrofia muscular. Os testes de tensiometria, avaliações radiográficas e exames histopatológicos não apresentaram diferenças estatisticamente significativas entre os grupos, evidenciando também que ambas as técnicas não geraram alterações deletérias à articulação operada. Destarte, conclui-se que a técnica de estabilização da articulação coxofemoral com implante de fáscia lata é eficaz e vantajosa quando comparada à técnica do pino transarticular. / The orthopedics disorders are very frequent in small animals and among them we can find the coxofemoral luxation as the most frequent disease. Because of a high incidence it became an important subject for veterinary researches. Surgery is the most effective treatment in cases of coxofomoral luxation, although the techniques that already exist are not so used in the clinics routine because of some difficulties these techniques present. In this paper the bubaline fascia lata implant and Steinmann transarticular pin were compared in surgeries for coxofemoral luxation. Twenty-six animals were used, divided into two groups that were subdivided. The first group was called “Grupo Experimental” and was formed by 16 animals, 8 animals in the subgroup called “pino” and the other 8 animals in the subgroup “fáscia”. The second group was called “Rotina” because these animals came from the routine of the clinic sector of Universidade Federal do Rio Grande do Sul Veterinary Hospital, and these groups were also subdivided in the subgroups “pino” and “fáscia”, with 5 animal each. These groups were submitted to the mentioned above stabilization techniques and after that, they were observed clinically and radiografically during 60 days. After that, it was realized a macroscopic study in the articulations of “Grupo Experimental”, besides an histopatological exam and a tensiometry test. The results showed that the technique with the bubaline fascia lata implant proved to be really efficient and it has some advantages comparing to the transarticular pin technique. The most important advantage is related to the deambulation, where the animals in this group showed a better evolution after the surgery. The level of muscular atrophy in this group was less marked. The tensiometry tests, the radiographic and histopatological exams did not present important differences between the two groups, but they were useful to show that the two techniques did not cause bad alterations in the worked articulation. In this sense it can be concluded that the stabilization of the coxofemoral articulation using bubaline fascia lata implant is a better technique comparing to the transarticular pin technique due to its advantages, mainly related to the deambulation and the muscular atrophy.

Afecções ortopédicas são freqüentes em pequenos animais e dentre essas afecções destaca-se a luxação coxofemoral – a mais freqüente dentre as luxações. Devido a tal incidência, a luxação coxofemoral tornou-se objeto de inúmeras pesquisas em medicina veterinária, sendo o tratamento cirúrgico o mais efetivo para sua correção. Ainda não foi, no entanto, desenvolvida uma técnica cirúrgica preferencial, amplamente difundida nas rotinas hospitalares. O presente trabalho avalia comparativamente o implante de fáscia lata bubalina e de pino de Steinmann transarticular para a estabilização de articulações coxofemorais luxadas. Foram utilizados 26 cães, separados em dois grupos que foram também, por sua vez, subdivididos. O primeiro grupo foi denominado “grupo Experimental” e reuniu 16 animais: oito pertencentes ao subgrupo “pino” e oito ao subgrupo “fáscia”. O segundo grupo foi denominado “grupo Rotina” e constituído por dez animais provenientes da rotina de atendimentos do Hospital de Clínicas Veterinárias da Universidade Federal do Rio Grande do Sul (UFRGS), sendo igualmente subdividido nos subgrupos “pino” e “fáscia”, com cinco animais cada um. Os cães foram submetidos às respectivas técnicas de estabilização e acompanhados clínica e radiograficamente durante 60 dias, findos os quais os animais do grupo Experimental passaram por avaliação macroscópica direta das articulações, além da histopatologia e teste de tensiometria. A principal vantagem da fáscia respeita à deambulação dos animais, que apresentaram evolução pós-operatória significativamente precoce em relação ao grupo submetido ao implante do pino de Steinmann transarticular, além de menor grau de atrofia muscular. Os testes de tensiometria, avaliações radiográficas e exames histopatológicos não apresentaram diferenças estatisticamente significativas entre os grupos, evidenciando também que ambas as técnicas não geraram alterações deletérias à articulação operada. Destarte, conclui-se que a técnica de estabilização da articulação coxofemoral com implante de fáscia lata é eficaz e vantajosa quando comparada à técnica do pino transarticular. / The orthopedics disorders are very frequent in small animals and among them we can find the coxofemoral luxation as the most frequent disease. Because of a high incidence it became an important subject for veterinary researches. Surgery is the most effective treatment in cases of coxofomoral luxation, although the techniques that already exist are not so used in the clinics routine because of some difficulties these techniques present. In this paper the bubaline fascia lata implant and Steinmann transarticular pin were compared in surgeries for coxofemoral luxation. Twenty-six animals were used, divided into two groups that were subdivided. The first group was called “Grupo Experimental” and was formed by 16 animals, 8 animals in the subgroup called “pino” and the other 8 animals in the subgroup “fáscia”. The second group was called “Rotina” because these animals came from the routine of the clinic sector of Universidade Federal do Rio Grande do Sul Veterinary Hospital, and these groups were also subdivided in the subgroups “pino” and “fáscia”, with 5 animal each. These groups were submitted to the mentioned above stabilization techniques and after that, they were observed clinically and radiografically during 60 days. After that, it was realized a macroscopic study in the articulations of “Grupo Experimental”, besides an histopatological exam and a tensiometry test. The results showed that the technique with the bubaline fascia lata implant proved to be really efficient and it has some advantages comparing to the transarticular pin technique. The most important advantage is related to the deambulation, where the animals in this group showed a better evolution after the surgery. The level of muscular atrophy in this group was less marked. The tensiometry tests, the radiographic and histopatological exams did not present important differences between the two groups, but they were useful to show that the two techniques did not cause bad alterations in the worked articulation. In this sense it can be concluded that the stabilization of the coxofemoral articulation using bubaline fascia lata implant is a better technique comparing to the transarticular pin technique due to its advantages, mainly related to the deambulation and the muscular atrophy.

Afecções ortopédicas são freqüentes em pequenos animais e dentre essas afecções destaca-se a luxação coxofemoral – a mais freqüente dentre as luxações. Devido a tal incidência, a luxação coxofemoral tornou-se objeto de inúmeras pesquisas em medicina veterinária, sendo o tratamento cirúrgico o mais efetivo para sua correção. Ainda não foi, no entanto, desenvolvida uma técnica cirúrgica preferencial, amplamente difundida nas rotinas hospitalares. O presente trabalho avalia comparativamente o implante de fáscia lata bubalina e de pino de Steinmann transarticular para a estabilização de articulações coxofemorais luxadas. Foram utilizados 26 cães, separados em dois grupos que foram também, por sua vez, subdivididos. O primeiro grupo foi denominado “grupo Experimental” e reuniu 16 animais: oito pertencentes ao subgrupo “pino” e oito ao subgrupo “fáscia”. O segundo grupo foi denominado “grupo Rotina” e constituído por dez animais provenientes da rotina de atendimentos do Hospital de Clínicas Veterinárias da Universidade Federal do Rio Grande do Sul (UFRGS), sendo igualmente subdividido nos subgrupos “pino” e “fáscia”, com cinco animais cada um. Os cães foram submetidos às respectivas técnicas de estabilização e acompanhados clínica e radiograficamente durante 60 dias, findos os quais os animais do grupo Experimental passaram por avaliação macroscópica direta das articulações, além da histopatologia e teste de tensiometria. A principal vantagem da fáscia respeita à deambulação dos animais, que apresentaram evolução pós-operatória significativamente precoce em relação ao grupo submetido ao implante do pino de Steinmann transarticular, além de menor grau de atrofia muscular. Os testes de tensiometria, avaliações radiográficas e exames histopatológicos não apresentaram diferenças estatisticamente significativas entre os grupos, evidenciando também que ambas as técnicas não geraram alterações deletérias à articulação operada. Destarte, conclui-se que a técnica de estabilização da articulação coxofemoral com implante de fáscia lata é eficaz e vantajosa quando comparada à técnica do pino transarticular. / The orthopedics disorders are very frequent in small animals and among them we can find the coxofemoral luxation as the most frequent disease. Because of a high incidence it became an important subject for veterinary researches. Surgery is the most effective treatment in cases of coxofomoral luxation, although the techniques that already exist are not so used in the clinics routine because of some difficulties these techniques present. In this paper the bubaline fascia lata implant and Steinmann transarticular pin were compared in surgeries for coxofemoral luxation. Twenty-six animals were used, divided into two groups that were subdivided. The first group was called “Grupo Experimental” and was formed by 16 animals, 8 animals in the subgroup called “pino” and the other 8 animals in the subgroup “fáscia”. The second group was called “Rotina” because these animals came from the routine of the clinic sector of Universidade Federal do Rio Grande do Sul Veterinary Hospital, and these groups were also subdivided in the subgroups “pino” and “fáscia”, with 5 animal each. These groups were submitted to the mentioned above stabilization techniques and after that, they were observed clinically and radiografically during 60 days. After that, it was realized a macroscopic study in the articulations of “Grupo Experimental”, besides an histopatological exam and a tensiometry test. The results showed that the technique with the bubaline fascia lata implant proved to be really efficient and it has some advantages comparing to the transarticular pin technique. The most important advantage is related to the deambulation, where the animals in this group showed a better evolution after the surgery. The level of muscular atrophy in this group was less marked. The tensiometry tests, the radiographic and histopatological exams did not present important differences between the two groups, but they were useful to show that the two techniques did not cause bad alterations in the worked articulation. In this sense it can be concluded that the stabilization of the coxofemoral articulation using bubaline fascia lata implant is a better technique comparing to the transarticular pin technique due to its advantages, mainly related to the deambulation and the muscular atrophy.

Orientador: Agricio Nubiato Crespo / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciencias Medicas / Made available in DSpace on 2018-08-06T13:38:08Z (GMT). No. of bitstreams: 1 Carvalho_EduardoGeorgeBaptistade_M.pdf: 6583260 bytes, checksum: c2467f978ca8069f79000308c237d538 (MD5) Previous issue date: 2006 / Resumo: A correção de alterações da lâmina própria nas pregas vocais, como sulcos, cicatrizes e degenerações senis, ainda é um desafio à fonocirurgia. Materiais implantáveis e métodos de implantação são continuamente investigados. Este trabalho avaliou a utilização de enxerto de fragmento da faseia lata na lâmina própria da prega vocal de cães, estudando as alterações histológicas conseqüentes, quanto à reação inflamatória aguda e crônica, à fibrose e ã neovascularização. Doze cães adultos foram submetidos à enxertia de um fragmento de 0,3 X 0,3 cm da faseia lata na lâmina própria da prega vocal direita. Na prega vocal esquerda, o mesmo acesso cirúrgico foi reproduzido, sem colocação do enxerto. Após dois e seis meses, os animais foram sacrificados e suas pregas vocais estudadas histologicamente. A faseia não induziu resposta inflamatória, aguda ou crônica, em qualquer animal, nem desencadeou fibrose além da conseqüente ao procedimento cirúrgico, como observado no lado controle. Em todos os casos, identificou-se o tecido enxertado sem evidências de reabsorção e com aumento da neovascularização, demontrando que a faseia lata apresenta integração tecidual boa na camada superficial da lâmina própria de prega vocal de cão / Abstract: Satisfactory corrective treatment for sulcus, scar and senile alterations in the lamina propria of vocal folds is still under development. This study assessed the utilization of a fascia lata graft in the vocal fold lamina propria of dogs by analyzing the histological alterations induced by acute and chronic inflammatory reactions as well as the fibrosis triggered by graft procedure and persistence. A fragment measuring 0.3 X 0.3 cm of the fascia lata was grafted in the right vocal old lamina propria of 12 adult dogs. Identical surgical access in the left vocal fold was reproduced without introducing the graft. After periods of two and six months, the animals were sacrificed and a histological study of their vocal cords was performed. Besides the reactions resulting from the surgical procedure in the control side, the fascia did not induce an acute or chronic inflammatory reaction or trigger fibrosis in any of the animals. In all the cases, the grafted tissue did not show evidence of resorption, demonstrating that the superficial layer of the lamina propria in dogs presents good tolerance to fascia lata grafting / Mestrado / Otorrinolaringologia / Mestre em Ciências Médicas

Orientador: Agrício Nubiato Crespo / Tese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-17T15:39:14Z (GMT). No. of bitstreams: 1 Carvalho_EduardoGeorgeBaptistade_D.pdf: 1487097 bytes, checksum: 8b21a6026c0fd35ff39cc175609d11d7 (MD5) Previous issue date: 2011 / Resumo: A correção de sulcos e cicatrizes de pregas vocais permanece como grande desafio à fonocirurgia. Substâncias que promovam a reestruturação da lâmina própria parecem ser a melhor opção. Esta pesquisa avaliou a influência do fator de crescimento de fibroblastos na integração tecidual de enxerto de fragmento de fáscia superficial na lâmina própria de prega vocal de coelhos associado à injeção de FGF, quanto às alterações histológicas induzidas como reação inflamatória aguda e crônica, fibrose desencadeada pelo procedimento e presença de neovascularização. Doze coelhos adultos foram submetidos ao enxerto de fragmento de 0,1 X 0,1 cm de fáscia cervical superficial na lâmina própria de ambas as pregas vocais. Na prega vocal direita foi injetado fator de crescimento de fibroblastos. Após um e doze meses, os animais foram sacrificados e suas pregas vocais submetidas a estudo histológico. O fator de crescimento de fibroblastos induziu resposta inflamatória em todos os animais após um mês do experimento inicial. Desencadeou fibrose além da causada pelo procedimento cirúrgico na prega vocal direita em todos os animais após 12 meses do experimento inicial. Fato que demonstra que o fator de crescimento de fibroblastos não representa uma boa opção terapêutica na correção das alterações da lâmina própria de pregas vocais quando associado ao enxerto de fáscia. / Abstract: The correction of sulcus and scars of vocal cords remains as a major challenge to fonosurgery. Substances which promote the restructuring the lamina propria seem to be the best option. This study evaluated the influence of fibroblasts growth factor in integration fragment of fascia grafted in the vocal fold lamina propria of rabbits associated with the injection FGF, regarding the histological alterations , acute and chronic inflammatory reaction, fibrosis, presence of neovascularization and the density of collagen. Twelve adult rabbits were submitted to grafting of fragment of 0.1 X 0.1 cm cervical fascia in the vocal fold lamina propria. Fibroblasts growth factor was injected in the right vocal fold. After a month and 12 months, the animals were sacrificed and their vocal folds submitted to histological study. The fibroblasts growth factor induced acute inflammatory response in all animals after one month of initial experiment. It induced fibrosis in addition to the caused by surgical procedure on the right vocal fold in all animals after 12 months of initial experiment. Fact which demonstrate that the fibroblasts growth factor with fascia grafting is not a good therapeutic option in correction of alterations of the vocal fold lamina propria. / Doutorado / Otorrinolaringologia / Doutor em Ciências Médicas