Estudo quanti-qualitativo realizado no Centro Educativo de Enfermagem para Adultos e Idosos, em 2004, com os objetivos de identificar os fatores que influenciam o comportamento de pessoas diabéticas acerca dos cuidados essenciais com os pés, com vista à prevenção do pé diabético e verificar a discrepância entre conhecimento e comportamento acerca destes cuidados essenciais com os pés. O referencial metodológico baseou-se no modelo Predisponing, Reinforcing and Enabling Causes in Educational Diagnosis and Evoluation – PRECEDE. Participaram 55 pessoas diabéticas, que atenderam os critérios de inclusão e exclusão. Utilizou-se para a coleta de dados formulário, questionários e entrevista semiestruturada. Em relação ao diagnóstico social e epidemiológico obtivemos que a maioria dos sujeitos é do sexo feminino; na faixa etária de 60 a 79 anos; com diabetes do tipo 2; o tempo de diagnóstico variou de 6 a 10 anos; com grau de instrução e poder aquisitivo baixos; e condições de moradia satisfatórias. Quanto ao tratamento, todos os sujeitos referiram seguir um plano alimentar; 65% realizavam atividade física; 74,5% utilizavam agente oral e 36,4% insulina. No que se refere as comorbidades 70,9% apresentavam hipertensão arterial; 50,9% catarata; 23,6% retinopatia; 30,9% doença vascular periférica e 63,4% obesidade. Os valores de glicemia, colesterol, triglicérides e hemoglobina glicada A1c estavam acima do limite superior do método. As alterações neuropáticas, circulatórias e dermatolocais mais significativas foram: o ressecamento, a fissura, o dedo em garra; a acentuação do arco plantar; a elevação do dorso plantar; os calos; a cãibra, o adormecimento; o formigamento; a ausência de sensibilidade; a alteração da mobilidade articular; as varizes; o edema; a onicomicose; a unha encravada e corte inadequado das unhas. Em relação ao diagnóstico comportamental e educacional houve discrepância entre o comportamento e o conhecimento em relação aos cuidados essenciais com os pés. Os comportamentos adequados foram: secagem dos espaços interdigitais; uso de calçados macios e confortáveis; não utilização de bolsa de água quente; verificação do calçado antes de usá-los; não andar descalço. Os conhecimentos corretos mostraram que os sujeitos reconhecem a importância: do exame diário dos pés; do corte de unhas adequado; de lavar os pés diariamente; de não andar descalço e de secar os espaços interdigitais. A análise qualitativa dos dados possibilitou identificar três categorias analíticas a percepção das pessoas diabéticas frente às complicações nos pés advindas do diabetes, o significado da descoberta e vivência do diabetes; e a influência dos referentes sociais. Estas categorias nos permitiram identificar as crenças comportamentais e normativas que influenciam o comportamento de pessoas diabéticas acerca dos cuidados essenciais com os pés. Entre as crenças encontramos: retardo na cicatrização de feridas; o diabetes leva ao desequilíbrio emocional, psicológico e físico; o homem é mais descuidado que a mulher; a amputação é o fim da vida; a expressão pé diabético é uma alerta constante;hidratar os pés é coisa de mulher; grupo de educação em diabetes como fonte de aprendizado; os pares ajudam e encorajam e a família (cônjuge, filhos, parceiros) interfere positiva e negativamente. / This quanti-qualitative study was carried out at a Nursing Education Center for Adults and Elderly in 2004 and aimed to identify what factors influence diabetic patients’ essential foot care behavior, with a view to diabetic foot prevention, as well as to verify the discrepancy between knowledge and behavior related to essential foot care. The methodological reference framework was based on the PRECEDE model - Predisposing, Reinforcing and Enabling Causes in Educational Diagnosis and Evaluation. Study participants were 55 diabetes patients who met inclusion criteria. Data were collected by means of forms, questionnaires and semistructured interviews. In terms of social and epidemiological diagnosis, most subjects were women between 60 and 79 years old; type 2 diabetes patients; diagnosis time ranged from 6 to 10 years; education level and purchasing power were low; and housing conditions were satisfactory. All subjects mentioned they followed a food plan; 65% did physical activity; 74.5% used an oral agent and 36.4% insulin. With respect to comorbidities, 70.9% suffered from arterial hypertension; 50.9% cataract; 23.6% retinopathy; 30.9% peripheral vascular disease and 63.4% obesity. Glucose, cholesterol, triglycerides and glycated hemoglobin A1c levels exceeded upper limits. The most important neuropathic, circulatory and dermatological alterations were: dry skin, fissure, claw toe; plantar arch accentuation; plantar dorsum elevation; calluses; cramp, numbness; formication; lack of sensitivity; articular mobility alteration; varicose veins; edema; a onychomycosis; ingrown nails and inadequate nail cutting. What the behavioral and educational diagnosis is concerned, we found a discrepancy between essential foot care behavior and knowledge. Adequate behavior included: drying the area between toes; using soft and comfortable shoes; not using hot-water bottle; checking shoes before wearing them; not walking barefoot. Correct knowledge showed that the participants recognize the importance of: daily foot examination; adequate nail cutting; washing feet daily; not walking barefoot and drying the skin between toes. Qualitative data analysis allowed us to identify three analytic categories: diabetes patients’ perception of foot complications as a result of diabetes, the meaning of discovering and living with diabetes; and the influence of social relations. Through these categories, we managed to identify the behavioral and normative beliefs that influence diabetes patients’ essential foot care behavior. These beliefs include delayed wound healing; diabetes leads to emotional, psychological and physical unbalance; men take less care than women; amputation means the end of life; the term diabetic foot is a constant alert; only women hydrate their feet; diabetes education group as a source of learning; peers help and encourage and the family (husband/wife, children, partners) interfere positive and negatively.

O valgo dinâmico de joelho é amplamente relacionado à disfunção e ao mau alinhamento postural e membros inferiores. No entanto, não está estabelecido como o valgo dinâmico de joelho está associado às adaptações cinemáticas de tornozelo e pé e ao comportamento das cargas plantares durante atividades funcionais. Objetivo: Comparar a amplitude articular de dorsiflexão do tornozelo, adução e abdução de retropé, pronação e supinação de subtalar, bem como avaliar a área e a pressão plantar total e do mediopé em diferentes tarefas funcionais utilizadas na avaliação do valgo dinâmico de joelho em indivíduos clinicamente saudáveis de ambos os sexos a partir da avaliação cinemática e baropodométrica. O objetivo foi correlacionar o valor do pico de valgo dinâmico de joelho com as amplitudes de tornozelo, com a área e pressão plantar do pé nestas tarefas. Materiais e métodos: Foram incluídos 30 voluntários sem histórico de lesão ou trauma nos membros inferiores, sendo 15 homens e 15 mulheres. Os voluntários tiveram o membro inferior dominante avaliado na realização de cinco diferentes tarefas funcionais: descida de degrau, single leg step down, agachamento unipodálico, aterrissagem unipodálica e drop vertical jump. Para a avaliação cinemática foi utilizado o sistema Vicon (Centennial, CO, EUA) com um total de 34 marcadores refletivos bilateralmente, para observação das variáveis cinemáticas tridimensionais de joelho, tornozelo e pé. A área e a pressão plantar foram obtidas do Baropodômetro Matscan System (Tekscan®. South Boston, MA, EUA). Para as análises dos dados cinemáticos e baropodométricos foram considerados o momento do pico de valgo de joelho nas diferentes tarefas funcionais realizadas. Resultados: As amplitudes de dorsiflexão de tornozelo (P = 0,489), adução e abdução do retropé (P = 0,0791), pronação e supinação de retropé (P = 0,163) e pronação e supinação da articulação subtalar (P = 0,305) não foram diferentes entre nenhuma das tarefas realizadas. Quanto as variáveis de área e pressão plantar total do pé, as tarefas de agachamento unipodálico e a descida de degrau apresentaram os maiores valores em comparação as tarefas de aterrissagem unipodálica (p = 0,005 e 0,027; ES = 0,66), drop vertical jump (p = 0,001 e p = 0,001; ES = 0,38) e single leg step down (p = 0,01 e p = 0,007; ES = 0,43). Os menores valores foram observados na tarefa de drop vertical jump com diferenças observadas para todas as tarefas (p<0,05). Já para as variáveis de pressão plantar do mediopé, a maior pressão foi observada na tarefa de descida de degrau que foi diferente de todas as tarefas (p<0,005), exceto a tarefa de agachamento unipodálico (p=0,13 es= 0,306) e as menores pressões foram encontradas na tarefa do drop vertical jump que apresentou diferenças para a tarefa de agachamento unipodálico (p=0,028 es= 0,485), aterrissagem unipodálica (p=0,006 es= 0,687) e descida de degrau (p=0,001 es= 0,257), porém não apresentou diferenças quando comparada a tarefa de single leg step down (p=0,374 es= 0,170). As variáveis de pico de valgo dinâmico de joelho apresentaram baixa correlação com as variáveis de pronação da articulação subtalar, área e pressão total e do mediopé. Conclusão: As tarefas funcionais avaliadas não apresentam diferença na cinemática de tornozelo e pé. A tarefa de descida de degrau levou a uma maior área de contato e maior pressão plantar do pé e a tarefa de drop vertical jump apresentou menor área de contato e menor pressão plantar do pé. Não houve correlação do pico de valgo dinâmico de joelho, com as amplitudes de tornozelo e pé, bem como a área e a pressão plantar do pé. / Dynamic knee valgus is largely related to the dysfunction and poor postural alignment of this articulation. However, isn\'t established how dynamic knee valgus can be associated with ankle and foot kinematic adaptations and the behavior of the plantar loads during functional activities. Objective: To compare the joint amplitude of ankle dorsiflexion, adduction and abduction of rearfoot, pronation and supination of midfoot, as well as to evaluate the total and midfoot area and pressure in different functional tasks used in the evaluation of dynamic knee valgus in clinically healthy individuals of both sexes from the kinematic and baropodometric evaluation. Besides that, the goal was to correlate the value of the dynamic knee valgus peak with the ankle amplitudes, with the foot area and foot pressure in these tasks. Materials and methods: It included 30 volunteers with no history of injury or trauma in the lower limbs, 15 men and 15 women. The volunteers had the dominant lower limb evaluated in performing five different functional tasks: step descent, single leg step down, single leg squat, unipodal landing and drop vertical jump. For the kinematic evaluation, the Vicon system (Centennial, CO, USA) with a total of 34 markers were used bilaterally to observe the three-dimensional knee, ankle and foot kinematics variables. The area and plantar pressure were obtained from the Matscan System Baropodometer (Tekscan®, South Boston, MA, USA). For the analysis of the kinematic and baropodometric data, the moment of the knee valgus peak was considered in the different functional tasks performed. Results: Results: The amplitudes of ankle dorsiflexion (P = 0.489), adduction and abduction of the rearfoot (P = 0.0791), pronation and supination of the rearfoot (P = 0.163) and pronation and supination of the subtalar joint (P = 0.305) did not Were different between any of the tasks performed. Regarding the variables of area and total foot pressure of the foot, the tasks of unipodal squatting and stair descent presented the highest values in comparison to the tasks of unipodal landing (p = 0.005 and 0.027; ES = 0.66), drop vertical jump (P = 0.001 and p = 0.001, ES = 0.38) and single leg step down (p = 0.01 and p = 0.007, ES = 0.43). The lowest values were observed in the drop vertical jump task with differences observed for all tasks (p <0.05). For the midfoot plantar pressure variables, the greatest pressure was observed in the task of stair descent that was different from all tasks (p <0.005), except for the one-legged squat task (p = 0.13 and 0.306) (P = 0.028 es = 0,485), unipodal landing (p = 0,006 es = 0,687), and lowering of the step (p = 0.001 es = 0.257), but did not present differences when compared to single leg step down task (p = 0.344 es = 0.170). The variables of dynamic knee dynamic valgus presented a low correlation with the variables of pronation of the subtalar joint, area and total pressure and midfoot.Conclusion: The functional tasks evaluated don\'t present differences in ankle and foot kinematics. The task of step descent led to a greater area of contact and greater plantar pressure and the task of drop vertical jump had a lower area of contact and lower foot pressure of the foot. There was not a correlation of the dynamic knee valgus peak with the ankle and foot amplitudes, as well as foot area and pressure.

Background / Hand, foot, and mouth disease (HFMD), in particular those associated with enterovirus 71 (EV71), has caused large outbreaks in the Western Pacific and Southeast Asian countries in the past three decades. There is currently no effective chemoprophylaxis or vaccination for HFMD or EV71 infection. Public health strategies rest on good understanding of the epidemiological features of HFMD. The present series of studies examined the epidemiological characteristics of HFMD in Hong Kong, with a view to better understand the disease epidemiology so as to guide public health actions. / Methods and results of individual studies / Study (1)--characterizing the changing epidemiological features identified from various surveillance systems for HFMD / The trend of HFMD activities from 2001-2009 was analyzed using the sentinel surveillance statistics and HFMD outbreaks. The type of institutions reporting HFMD over time, incidences of outbreaks in 18 districts, and age and sex distribution of affected persons of HFMD outbreaks were analyzed. The clinical presentation, hospitalization rate, complication rate and case fatality of outbreaks were examined. The circulating enterovirues each year were determined by laboratory surveillance findings from 2001-2009 and test for morbidity caused by EV71. Seasonal peak was detected from warmer months of May through July but a smaller winter peak was found from October to December since 2006. An increasing trend of more older children aged above 5 years were infected, from 25.4% in 2001 to 33.0% in 2009 (p=0.01, Mantel-Haenszel Chi-square test). Laboratory surveillance detected a cyclical high activity of EV71 in every 3 to 4 years, which was associated with a higher average hospitalization rate among patients of the HFMD outbreaks reported in corresponding year, although it was only marginally significant (p=0.09, linear regression test). / Study (2)--analyzing the characteristics of EV71 epidemic in 2008 / All EV71 cases diagnosed by PHLC from 1998-2008 were analyzed. The complication and case fatality rates, percentage requiring hospitalization, median duration of hospital care, and the likelihood of being associated with an HMFD outbreak in institution in 2008 were compared with the corresponding rates calculated from cases reported from 1998-2007. Phylogenetic tree was constructed by using the neighbour-joining method and the molecular epidemiology of EV71 detected in 2008 was compared with the past years’ trends. Ninety-eight EV71 cases were reported in 2008, highest in the past decade. The annual incidence was 1.4/100 000 in general population, with highest incidence reported in children aged 0-4 years old (27.9/100 000). 11.2% had complications including meningitis or encephalitis (6.1%), pneumonia (3.1%), acute flaccid paralysis (1.0%), and shock (1.0%). There was only one fatal case (CFR: 1.0%) attributed to interstitial pneumonitis. 45.9% had concurrent HFMD outbreaks in their schools or institutions, and six schools required temporarily class suspension for 14 days. Both the complication rate and CFR werenot significantly different from the corresponding rates of the past 10 years (p=0.12 and 1.00 respectively). Phylogenetic analysis found that most cases reported in 2008 were C4 strains, which were the predominant circulating strains in the past ten years. / Study (3)--examining the association between meteorological parameters and HFMD activity / The sentinel consultation rate of HFMD was tested for any association with the meteorological parameters obtained from the Hong Kong Observatory from 2000-2004. Different regression models were examined to find the best model for predicting HFMD consultation rates from 2005-2009. In multivariate regression analysis, model M2 (in which mean temperature, diurnal difference in temperature, relative humidity and wind speed were positively associated with HFMD) was found to have a higher R2 (0.119) than M0 and M1 models with an R2 of 0.079 and 0.062 respectively, indicating that HFMD consultation rates were better explained using meteorological parameters measured 2 weeks earlier. The predicted trend of HFMD consultation rates for 2005 to 2009 matched well with the observed one (Spearman’s rank correlation coefficient=0.276, P=0.000). Sensitivity analysis showed that the estimated HFMD consultation rates were mostly affected by varying the relative humidity and least affected by wind speed. / Study (4)--determining the basic reproduction number of coxsackievirus A16 and enterovirus 71 using mathematical model / The basic reproduction numbers (R0) of EV71 and CoxA16 from laboratory confirmed HFMD outbreaks reported to DH from 2004-2009 were determined using mathematical model. Thirty four outbreaks were analyzed, 27 due to CoxA16 and seven due to EV71. The median R0 of EV71 was 5.48 with an inter-quartile range of 4.206.51 while median R0 of CoxA16 was 2.50 with an inter-quartile range of 1.963.67. In the sensitivity analysis, R0 of EV71 was significantly higher than that of CoxA16 in whole range of incubation periods, p≦0.025. R0was not associated with outbreak setting, size of the institution or number of persons affected. / Study (5)--assessing the impact of SARS and pandemic influenza H1N1 on transmission of HFMD in Hong Kong / I compared the observed HFMD consultation rates and the projected rates, which were constructed using mathematical model, in defined periods of 2003 and 2009 during which territory-wide public health interventions (including school closure) against Severe Acute Respiratory Syndrome (SARS) and pandemic influenza H1N1 were implemented. There was a reduction of 57.2% (95% C.I.:53.0-60.7%) in observed HFMD consultation rates during SARS period in 2003 and a reduction of 26.7% (95% C.I.:19.5-32.7%) during pandemic influenza H1N1 period in 2009. In 2003, the projected rates were still lower than the observed rates beyond week 31 until almost the end of the year. On the contrary, in 2009, the observed HFMD consultation rates became comparable to that of the projected rates in August, before the end of the defined intervention period. / Conclusions / This thesis bridges the knowledge gaps regarding epidemiological characteristics of HFMD. The changing epidemiology of HFMD, including the cyclical high activity of EV71 warrants vigilant surveillance of its activity in order to guide preventive measures. I have demonstrated that climate parameters may help predict HFMD activity, which could assist in explaining the winter peak detected in recent years and issuing early warning in the future. The R0 of EV71 and CoxA16 were first determined in the literature and I found that R0 of EV71 was higher than R0 of CoxA16. The reduction of transmission of HFMD during the SARS and H1N1 periods suggested that public health measures are effective in reducing the transmission of enteroviruses. / Ma, Siu Keung. / Thesis (M.D.)--Chinese University of Hong Kong, 2013. / Includes bibliographical references (leaves 121-149). / Electronic reproduction. Hong Kong : Chinese University of Hong Kong, [2012] System requirements: Adobe Acrobat Reader. Available via World Wide Web. / Table of content --- p.ii / Acknowledgements --- p.iv / Abbreviations --- p.v / Caption for Tables --- p.vi / Caption for Figures --- p.viii / Précis --- p.1 / Chapter PART I: --- LITERATURE REVIEW ON HFMD --- p.5 / Chapter Chapter 1. --- Current Understanding of Epidemiology of HFMD --- p.6 / Chapter 1.1 --- Causative agents and virology --- p.6 / Chapter 1.2 --- Clinical presentation and management --- p.8 / Chapter 1.3 --- Geographical distribution and past epidemics --- p.14 / Chapter 1.4 --- Host susceptibility and molecular determinants of neruovirulence --- p.26 / Chapter 1.5 --- Routes of transmission and transmission dynamics --- p.27 / Chapter 1.6 --- Knowledge gap identified from literature review --- p.29 / Chapter PART II: --- STUDIES ON EPIDEMIOLOGY OF HFMD IN HONG KONG --- p.33 / Chapter Chapter 2. --- Study Objectives and Main data source for analysis --- p.34 / Chapter 2.1 --- Aim and objectives of this thesis --- p.34 / Chapter 2.2 --- Sentinel surveillance system for monitoring HFMD activity --- p.35 / Chapter 2.3 --- Institutional outbreaks of HFMD reported to DH . --- p.37 / Chapter 2.4 --- EV 71 infection reported to Department of Health --- p.37 / Chapter 2.5 --- Laboratory surveillance for monitoring enteroviruses --- p.37 / Chapter Chapter 3. --- Study (1)--Characterizing the changing epidemiological features identified from various surveillance systems for HFMD --- p.38 / Chapter Chapter 4. --- Study (2)--Analyzing the epidemic of enterovirus 71 in 2008 and its public health implication to Hong Kong --- p.52 / Chapter Chapter 5. --- Study (3)--Examining the association between meteorological parameters and HFMD activity --- p.67 / Chapter Chapter 6. --- Study (4)--Determining the basic reproduction number of coxsackievirus A16 and enterovirus 71 using mathematical model --- p.85 / Chapter Chapter 7. --- Study (5)--Impact of SARS and Pandemic Influenza H1N1 on transmission of HFMD in Hong Kong --- p.100 / Chapter Chapter 8. --- Conclusion --- p.111 / List of publications related to this thesis --- p.119 / References --- p.121

For individuals with type 2 diabetes, diabetic foot ulcers represent a significant health issue and the wound care cost is quite high. Currently, clinicians and nurses mainly base their wound assessment on visual examination of wound size and the status of the wound tissue. This method is potentially inaccurate for wound assessment and requires extra clinical workload. In view of the prevalence of smartphones with high resolution digital camera, assessing wound healing by analyzing of real-time images using the significant computational power of today’s mobile devices is an attractive approach for managing foot ulcers. Alternatively, the smartphone may be used just for image capture and wireless transfer to a PC or laptop for image processing. To achieve accurate foot ulcer image assessment, we have developed and tested a novel automatic wound image analysis system which accomplishes the following conditions: 1) design of an easy-to-use image capture system which makes the image capture process comfortable for the patient and provides well-controlled image capture conditions; 2) synthesis of efficient and accurate algorithms for real-time wound boundary determination to measure the wound area size; 3) development of a quantitative method to assess the wound healing status based on a foot ulcer image sequence for a given patient and 4) design of a wound image assessment and management system that can be used both in the patient’s home and clinical environment in a tele-medicine fashion. In our work, the wound image is captured by the camera on the smartphone while the patient’s foot is held in place by an image capture box, which is specially design to aid patients in photographing ulcers occurring on the sole of their feet. The experimental results prove that our image capture system guarantees consistent illumination and a fixed distance between the foot and camera. These properties greatly reduce the complexity of the subsequent wound recognition and assessment. The most significant contribution of our work is the development of five different wound boundary determination approaches based on different computer vision algorithms. The first approach employs the level set algorithm to determine the wound boundary directly based on a manually set initial curve. The second and third approaches are the mean-shift segmentation based methods augmented by foot outline detection and analysis. These two approaches have been shown to be efficient to implement (especially on smartphones), prior-knowledge independent and able to provide reasonably accurate wound segmentation results given a set of well-tuned parameters. However, this method suffers from the lack of self-adaptivity due to the fact that it is not based on machine learning. Consequently, a two-stage Support Vector Machine (SVM) binary classifier based wound recognition approach is developed and implemented. This approach consists of three major steps 1) unsupervised super-pixel segmentation, 2) feature descriptor extraction for each super-pixel and 3) supervised classifier based wound boundary determination. The experimental results show that this approach provides promising performance (sensitivity: 73.3%, specificity: 95.6%) when dealing with foot ulcer images captured with our image capture box. In the third approach, we further relax the image capture constraints and generalize the application of our wound recognition system by applying the conditional random field (CRF) based model to solve the wound boundary determination. The key modules in this approach are the TextonBoost based potential learning at different scales and efficient CRF model inference to find the optimal labeling. Finally, the standard K-means clustering algorithm is applied to the determined wound area for color based wound tissue classification. To train the models used in the last two approaches, as well as to evaluate all three methods, we have collected about 100 wound images at the wound clinic in UMass Medical School by tracking 15 patients for a 2-year period, following an IRB approved protocol. The wound recognition results were compared with the ground truth generated by combining clinical labeling from three experienced clinicians. Specificity and sensitivity based measures indicate that the CRF based approach is the most reliable method despite its implementation complexity and computational demands. In addition, sample images of Moulage wound simulations are also used to increase the evaluation flexibility. The advantages and disadvantages of three approaches are described. Another important contribution of this work has been development of a healing score based mechanism for quantitative wound healing status assessment. The wound size and color composition measurements were converted to a score number ranging from 0-10, which indicates the healing trend based on comparisons of subsequent images to an initial foot ulcer image. By comparing the result of the healing score algorithm to the healing scores determined by experienced clinicians, we assess the clinical validity of our healing score algorithm. The level of agreement of our healing score with the three assessing clinicians was quantified by using the Kripendorff’s Alpha Coefficient (KAC). Finally, a collaborative wound image management system between the PC and smartphone was designed and successfully applied in the wound clinic for patients’ wound tracking purpose. This system is proven to be applicable in clinical environment and capable of providing interactive foot ulcer care in a telemedicine fashion.

Submitted by Angela Maria de Oliveira (amolivei@uepg.br) on 2018-11-30T15:19:09Z No. of bitstreams: 2 license_rdf: 811 bytes, checksum: e39d27027a6cc9cb039ad269a5db8e34 (MD5) Divonei Gibala.pdf: 716715 bytes, checksum: 62013137c73366e29317e7a5788692e3 (MD5) / Made available in DSpace on 2018-11-30T15:19:09Z (GMT). No. of bitstreams: 2 license_rdf: 811 bytes, checksum: e39d27027a6cc9cb039ad269a5db8e34 (MD5) Divonei Gibala.pdf: 716715 bytes, checksum: 62013137c73366e29317e7a5788692e3 (MD5) Previous issue date: 2018-08-14 / Introdução: atualmente sabe-se que a ulceração do pé diabético é uma das principais complicações do diabetes, pois apresenta importância médica, social e econômica. Diversos fatores interferem na correta cicatrização dessas feridas, sendo um deles o estresse oxidativo. Diante dessa situação buscam-se medidas que atuem nessas vias, tendo o selênio como componente importante na defesa antioxidativa do organismo. Objetivo: analisar a evolução do processo cicatricial da úlcera no pé diabético após a suplementação com selênio. Métodos: Ensaio clínico, aberto, não-randomizado, com 19 pacientes com feridas diabéticas do ambultatório de feridas do HURCG. Foi realizada suplementação com selênio 100mcg por 60 dias e realizado biópsia cutânea antes e depois da suplementação com selênio. Avaliou-se histomorfologicamente essas lesões. Resultados: Houve predominância do sexo masculino e da faixa etária de 60 anos. Após o uso de selênio, a congestão vascular, tecido de granulação e fibrose diminuíram, não havendo diferenças estatísticas nos demais parâmetros (neutrófilos, edema e monomorfonucleares). As bordas das úlceras apresentaram hiperqueratose e acantose, as quais não sofreram influência do selênio. Conclusão: a suplementação com selênio apresentou melhora no quadro de congestão, além de diminuir componentes inflamatórios, como a formação de tecido de granulação e a fibrose. / Introduction: It is now known that diabetic foot ulceration is one of the main complications of diabetes, because it is of medical, social and economic importance. Several factors interfere in the correct healing of these wounds, one of them being oxidative stress. In view of this situation, measures are sought that act in these pathways, with selenium as an important component in the antioxidative defense of the organism. Objective: to analyze the evolution of the cicatricial process of the ulcer in the diabetic foot after the supplementation with selenium. Methods: An open, non-randomized clinical trial of 19 patients with diabetic wounds from the HURCG wound ambiance. Selenium supplementation was 100mcg for 60 days and skin biopsy was performed before and after selenium supplementation. These lesions were histomorphologically evaluated. Results: There was a predominance of males and 60-year-olds. After the use of selenium, vascular congestion, granulation tissue and fibrosis decreased, and there were no statistical differences in the other parameters (neutrophils, edema and monomorphonuclear cells). The edges of the ulcers presented hyperkeratosis and acanthosis, which were not influenced by selenium. Conclusion: supplementation with selenium improved congestion and decreased inflammatory components, such as granulation tissue formation and fibrosis.

Chronic diabetic foot ulcers, venous leg ulcers and pressure ulcers affect a large subset of the United State population yet they remain a challenge for physicians to treat. There are many different types of products on the market for the treatment of chronic wounds. Some use living cells but only two are FDA approved to heal chronic wounds. A new type of product recently garnered attention in the wound care market because it also contains living cells: hypothermically stored amniotic tissue products. Hypothermically stored amniotic tissue is unique because it maintains living cells and offers the benefits of containing signaling molecules and maintaining an intact extra cellular matrix. While there are other types of amniotic or placental tissue products in the wound care market, they are processed by dehydration or cryopreservation which limits their capacities for maintaining living cells. This thesis will explore the potential for hypothermically processed amniotic tissue products to treat chronic wounds.

A maioria dos casos de pé torto congênito tratados pelo método de Ponseti requer a secção do tendão calcâneo para correção do equino residual. Evidências clínicas sugerem que há completa cicatrização entre os cotos tendíneos, mas este processo reparativo ainda não foi suficientemente estudado. Esta investigação teve como objetivo avaliar o processo de reparação que ocorre após a secção percutânea do tendão calcâneo para a correção do equino residual no pé torto congênito idiopático tratado pelo método de Ponseti. Por meio de estudo prospectivo, foram analisadas 37 tenotomias em 26 pacientes com pé torto congênito idiopático tratados pelo método de Ponseti, com seguimento mínimo de um ano após a secção. A tenotomia foi realizada percutaneamente com agulha biselada de grosso calibre, sob sedação e anestesia local. O exame ultrassonográfico foi feito logo após a secção tendínea para assegurar que ela tenha sido completa e mensurar o afastamento entre os cotos. A reparação foi estudada por meio da ultrassonografia realizada três semanas, seis meses e um ano após a tenotomia. A ultrassonografia, realizada imediatamente após o procedimento, mostrou que, em alguns casos, feixes tendíneos residuais persistiam entre os cotos, mas foram completamente seccionados, em seguida, sob controle ultrassonográfico. Houve afastamento médio de 5,65 mm ± 2,26 (2,3 a 11,0 mm) entre os cotos tendíneos logo após a secção. Em um caso ocorreu sangramento maior que o habitual, que foi controlado com pressão local e não provocou interferência no tratamento. Após três semanas, a ultrassonografia mostrou regeneração tendínea com preenchimento do espaçamento entre os cotos por tecido hipoecoico com ecotextura irregular e com restituição da continuidade entre os cotos demonstrada dinamicamente pela transmissão de movimentos do músculo tríceps sural para o calcanhar. Seis meses após a tenotomia, o exame ultrassonográfico evidenciou que o tecido de reparação apresentava ecotextura de aspecto fibrilar e, quando comparado ao tendão normal, havia leve ou moderada hipoecogenicidade e espessamento cicatricial. Um ano após a tenotomia, o exame ultrassonográfico mostrou estrutura fibrilar na região de reparação, com ecogenicidade semelhante ao tendão normal, mas ainda apresentando espessamento tendíneo cicatricial. Em termos gerais, ocorreu rápida cicatrização após a secção percutânea do tendão calcâneo, que restabeleceu a continuidade entre os cotos. Ao final do período de observação, o tecido de reparação tendínea apresentou aspecto ultrassonográfico semelhante ao lado normal, exceto por leve espessamento, o que sugere um mecanismo de reparação predominantemente intrínseco. / Most cases of congenital clubfoot treated by the Ponseti technique require percutaneous Achilles tenotomy in order to correct the residual equinus. Clinical evidences suggest that complete healing occurs between the cut tendon stumps, but there have not yet been any detailed studies investigating this reparative process. This study was performed to assess the Achilles tendon repair after percutaneous sectioning to correct the residual equinus of clubfoot treated by the Ponseti method. A prospective study analyzed 37 tenotomies in 26 patients with clubfoot treated by the Ponseti technique, with a minimum follow-up of one year after the section. The tenotomy was performed percutaneously with a large-bore needle bevel with patient sedation and local anesthesia. Ultrasonographic scanning was performed after section to ascertain that the tenotomy had been completed and to measure the stump separation. In the follow-up period, the reparative process was followed ultrasonographically at three weeks, six months and one year post-tenotomy. The ultrasonography performed immediately after the procedure showed that in some cases, residual strands between the tendon ends persisted, and these were completely sectioned under ultrasound control. A mean retraction of 5.65 mm ± 2.26 (range, 2.3 to 11.0 mm) between tendon stumps after section was observed. Unusual bleeding occurred in one case and was controlled by digital pressure, with no interference with the final treatment. After three weeks, ultrasonography showed tendon repair with the tendon gap filled with irregular hypoechoic tissue, and also with transmission of muscle motion to the heel. Six months after tenotomy, there was structural filling with a fibrillar aspect, mild or moderate hypoechogenicity, and tendon scar thickening when compared to a normal tendon. One year after tenotomy, ultrasound showed a fibrillar structure and the echogenicity at the repair site that was similar to a normal tendon, but with persistent mild tendon scarring thickness. It was observed that there was a fast reparative process after Achilles tendon percutaneous sectioning that reestablished continuity between stumps. The reparative tissue evolved to tendon tissue with a normal ultrasonographic appearance except for mild thickening, suggesting a predominantly intrinsic repair mechanism

Diabetic foot ulceration (DFU) is a known major complication of diabetes mellitus which contributes to lower extremities amputation. This study aimed to investigate the use of interventional devices either as a preventative or therapeutic strategy to improve clinical management of this pathology, as well as investigating the impaired function of endothelial progenitor cells in the diabetic condition. The first element targeted plantar callus formation among diabetic neuropathic (NRP) patients through the use of a SurroSenseRxTM biofeedback device. Reducing foot pressure with improved walking strategy in the 6 months study in diabetic neuropathy patients (n=20) appeared to minimise the size of non-ulcerative plantar callus (p < 0.05), potentially reducing future ulcer recurrence. The 2nd study focused on the use of a GekoTM electrical stimulation device to enhance DFU healing in 24 patients. Wounds were characterised as being neuroischaemic (NRI) or neuropathic (NRP) based on standard parameters adopted in the Manchester diabetes clinic. The device was worn by 11 intervention subjects and compared to 13 controls without any electrical stimulus. Results suggested healing and wound closure have potentially increased in participants with electrical stimulation. In addition, Neuropathy Disability Score (NDS) was improved among intervention patients compared to control (p < 0.0001). The 3rd, in vitro and mechanistic study focuses on the outgrowth of endothelial cells (OECs), abnormal angiogenic responses and inflammatory microenvironment which could contribute to impaired wound healing in diabetic patients. OECs were isolated from diabetic patients and healthy controls (HCs), characterised by immunohistochemistry and Polymerase Chain Reaction (PCR). The functions of the three OEC groups from NRI, NRP diabetic patients and healthy controls respectively were compared using in vitro proliferation, transwell migration and wound healing scratch assays, together with matrigel tube formation assays. Scratch assays showed 100% closure in HCs over 24 hours, while 86.6% closure was apparent in NRI vs 38.1% in NRP. Seahorse mitochondrial stress test was conducted and demonstrated mitochondrial dysfunction in NRP vs NRI vs HCs (p < 0.05). Western blot analysis showed a lack of ERK phosphorylation by NRP OECs and an up-regulation of plasma inflammatory cytokines (TNFa and IL-6) in diabetic samples vs HC (p < 0.0001), while the angiogenic factors ang-2, FGF-2, VEGF-D, HGF and IL-8, and nitric oxide bioavailability were all significantly reduced in diabetic samples vs HC (p < 0.05). The functional defects of the diabetic OECs were partially restored through glycomimetic (synthesis compounds for endothelial damage protection) treatment (p < 0.05). In summary, this study has highlighted areas worthy of future development both in terms of preventative and therapeutic strategies. With improvements in digital technology and the need to empower patients to take responsibility of their health and well-being as well as greater understanding of the cellular and molecular biological repair processes that may be exploited, there may be potentials to reduce the risk of future ulceration among patients using these novel approaches in the future.

Submitted by Fabíola Silva (fabiola.silva@famerp.br) on 2017-02-24T19:38:53Z No. of bitstreams: 1 denilsonpereirajose_dissert.pdf: 1394022 bytes, checksum: 45ff80cb00c7924473059901b8f4ed4f (MD5) / Made available in DSpace on 2017-02-24T19:38:53Z (GMT). No. of bitstreams: 1 denilsonpereirajose_dissert.pdf: 1394022 bytes, checksum: 45ff80cb00c7924473059901b8f4ed4f (MD5) Previous issue date: 2014-10-13 / Introduction: Diabetes mellitus is a chronic disease evidenced by hyperglycemia and one of the main symptoms includes the diabetic foot, which can lead to amputation thereby decreasing the survival of patients with diabetes. Objective: Identify sociodemographic and clinical factors of patients with diabetes types one and two who were seen at the diabetic foot outpatient clinic at a University Hospital in São José do Rio Preto/SP. Methods: Descriptive study with a quantitative approach which the data was collected from 121(100%) electronic patient records with diabetes type 1 and 2 who were seen at the diabetic foot outpatient clinic at a University Hospital in São José do Rio Preto/SP from July 2010 to July 2012. Results: Of the 121 patients, 80(66,12%) were male,50(41,32%) were from São José do Rio Preto,46(38,02%) had incomplete primary education and, 86(71,07%) consensual marriage, with a mean age of 54,17 (DP=15,37) years old, since the age ranges from 21 to 84 years old.. As for the clinical characteristics, there is a majority of type 2 DM with 68(72,34%), showed presence of wounds 61(6,19%), 53(43,80%) of Wagner classification grade 0 (high risk, but no lesions). And yet the first degree of injury is directly related to type 2 diabetes and patients who have nephropathy, hypertension, neuropathy, dyslipidemia and related diseases, as well as having risk factors such as smoking and alcoholism. Conclusion: Greater investments are needed in health education strategies, strengthening planned investments by a multidisciplinary healthcare team. / Introdução: A diabetes mellitus (DM) é uma doença crônica, caracterizada pela hiperglicemia e uma das principais complicações é o pé diabético, que pode evoluir para amputações com isso diminuindo a sobrevida do paciente com diabetes. Objetivo: Identificar os fatores sóciodemográficos e clínicos dos pacientes com diagnóstico de diabetes tipo1 e 2 atendidos no ambulatório do pé diabético de um hospital de ensino de São José do Rio Preto/SP e associar estes fatores ao tipo de diabetes e classificação de Wagner. Casuística e Métodos: Pesquisa descritiva com abordagem quantitativa, cujos dados foram obtidos por meio de pesquisa de 121(100%) prontuários eletrônicos de pacientes com diagnóstico de diabetes tipo1 e 2 atendidos no ambulatório do pé diabético de um hospital de ensino de São José do Rio Preto/SP no período de julho de 2010 a julho de 2012. Resultados: Dos 121 pacientes, 80(66,12%) eram do gênero masculino,50(41,32%) eram de São José do Rio Preto,46(38,02%) tinham ensino fundamental incompleto,86(71,07%) apresentavam com conjugue, com idade média de 54,17 anos (DP=15,37), sendo que a faixa etária que variou de 21 a 84 anos. Quanto às características clinicas, verificou-se a predominância do DM do tipo 2 com 68(72,34%), apresentaram presença de feridas 61(56,19%),53(43,80%) a Classificação de Wagner de grau 0 (risco elevado, porém ausência de úlcera) e ainda de grau 1 apresentou associação com o diabetes tipo 2 e com pacientes que apresentava nefropatia, HAS, neuropatia, dislipidemia como doenças associadas, além de apresentar fatores de risco como tabagismo e alcoolismo. Conclusão: Faz-se necessário maiores investimentos em estratégias de educação em saúde, intensificando os programados por equipe multidisciplinar da área da saúde.

Bakgrund: Diabetes mellitus är en kronisk folksjukdom som drabbar miljoner människor över hela världen. Denna långvariga sjukdom kan leda till komplikationer som svårläkta fotsår som medför lidande för patienten, begränsar vardagen och sänker livskvaliten, vilket i svåra fall kan leda till amputation. Dessa svårläkta fotsår kostar samhället massor vilket är ett bekymmer. Syfte: Syftet med denna litteraturstudie var att beskriva sjuksköterskans arbete i förebyggandet av fotsår hos personer med diabetes mellitus samt att beskriva de ingående artiklarnas undersökningsgrupp. Metod: En beskrivande litteraturstudie som baserats på tio vetenskapliga artiklar, åtta med kvantitativ ansats, en med kvalitativ ansats samt en med mixad ansats. Artiklarna söktes i sökmotorn PubMed samt databasen Cinahl. Resultat: Det finns några punkter som spelar stor roll i förebyggandet av diabetes fotsår. Detta är att sjuksköterskor ska identifiera risker hos personer med diabetes. Detta görs med hjälp av olika instrument för att upptäcka neutrovaskulärpati. Det andra sättet i förebyggandet är att öka kunskap hos personer med diabetes och vägleda dem till egenvård. Detta möjliggörs genom att ge fotvårdsutbildning till patienter för att sköta sina fötter och på så sätt förhindra uppkomsten av fotsår och fotkomplikationer. Det sista resultatet som kom fram i den här litteraturstudien är att ett samarbete mellan olika vårdprofessioner krävs i det förebyggande arbetet. Framför allt är ett bra samarbete mellan sjuksköterskor och undersköterskor som är angeläget.   Slutsats: Olika faktorer kan påverka positivt på förebyggandet av fotsår hos personer med diabetes. Dessa faktorer är att identifiera risker, upptäcka neurovaskulärpati i tid, öka kunskap hos dessa personer och vägleda dem till egenvård samt skapa en bra kommunikation mellan olika vårdprofessioner. / Background: Diabetes mellitus is a chronic disease that affects millions of people worldwide. This long-lasting disease may have bad complications like chronic foot ulcers that causes suffering for the patient, limits the everyday life and lowers quality of life and severe cases can lead to amputations. The slow-healing foot ulcers costs society a lot, which is a concern. Purpose: The purpose of this study was to describe the nurse's work in the prevention of foot ulcers in people with diabetes mellitus and to describe the depth of the articles study group. Method: A descriptive literature study based on ten scientific articles, eight of the quantitative approach, a qualitative approach and a mixed approach. Articles were searched in the databases CINAHL and PubMed. Results: There are some points that play a major role in the prevention of diabetic foot ulcers. This is nurses to identify risks in people with diabetes. This is done using a variety of instruments to detect neutrovaskulärpati. The other way of prevention is to increase the knowledge of the person with diabetes and to guide the self-care. This made real by providing foot care training patients to manage their feet and so prevent the formation of ulcers and foot complications. The final results came in this literature is that cooperation between different health care professions needed in preventive work. Above all, a good collaboration between nurses and assistant nurses are set location. Conclusion: Various factors can affect positively on the prevention of foot ulcers in people with diabetes. These factors are to identify risks and detect neurovaskulärpati in time, increase the knowledge of these people and guide them to self-care and good communication between various health care professions.