L’expérience de douleur et la réponse à son traitement sont teintées par les facteurs psychologiques, parmi lesquels figurent les attentes. Cette thèse propose de raffiner la compréhension de l’effet des attentes sur la régulation de la douleur par l’entremise de deux études quantitatives. D'abord, une étude expérimentale explore l'impact des attentes sur l'analgésie induite par contre-stimulation. Des volontaires sains ont été assignés à une condition contrôle ou à l’un des trois groupes au sein desquels les attentes étaient évaluées (attentes a priori) ou manipulées par l’entremise de suggestions (hyperalgésie ou analgésie). La douleur, l’anxiété et le réflexe nociceptif de flexion en réponse à des stimulations électriques ont été mesurés avant, pendant et après l’application d’un sac de glace. Les résultats suggèrent que les attentes a priori prédisent l’amplitude de l’analgésie, tandis que les attentes suggérées parviennent à potentialiser ou à bloquer les mécanismes endogènes d'inhibition de la douleur déclenchés par la contre-stimulation, indépendamment du niveau d’anxiété. Ensuite, une étude clinique se penche sur l'apport des attentes aux issues thérapeutiques de patients traités en centres multidisciplinaires de gestion de la douleur chronique. Préalablement au traitement, les attentes des patients quant aux résultats anticipés après six mois de traitement ont été évaluées. Les changements dans l’intensité douloureuse, les symptômes dépressifs, l’interférence de la douleur et la dramatisation face à la douleur, ainsi que l’impression de changement et la satisfaction face au traitement ont été évalués au suivi de six mois. Les résultats d'analyses de modélisation par équations structurelles appuient la relation prédictive entre les attentes et les issues thérapeutiques et soulignent l’impression de changement du patient comme variable médiatrice de cette association. En plus de se montrer supérieur à un modèle alternatif, ce modèle s'est avéré pertinent à travers différents sous-groupes. Dans l'ensemble, cette thèse contribue à démontrer le rôle déterminant des attentes dans le contexte de la douleur, tant au niveau physiologique que thérapeutique. Les conclusions qui se dégagent de cet ouvrage entraînent des retombées non négligeables et réitèrent la nécessité de considérer la perspective du patient afin d'optimiser les soins destinés au soulagement de la douleur. / The experience of pain and response to pain treatments are influenced by psychological factors, such as expectations. This doctoral dissertation aims at refining the comprehension of the impact of expectations on pain regulation through two quantitative studies. First, an experimental study examined the impact of expectations on analgesia induced by heterotopic noxious counter-stimulation. Healthy volunteers were assigned to a control group or one of three experimental groups in which expectations were either assessed (a priori expectations) or manipulated using suggestions (hyperalgesia or analgesia). Acute shock-pain, shock-related anxiety and the nociceptive flexion reflex were measured in response to electrical stimulations before, during and after the application of a tonic cold pain. Results suggest that a priori expectations predict the magnitude of analgesia, while manipulated expectations either enhance or block counter-stimulation analgesia, independently of anxiety processes. Subsequently, a clinical study examined the association between expectations and clinical outcomes of chronic pain patients treated in multidisciplinary pain centers. Prior to their initial visit, patients' expected treatment outcomes were assessed. Six months after their initial visit, changes in pain intensity, depressive symptoms, pain interference and pain catastrophizing, along with satisfaction with treatment and impression of change were measured. Structural equations modeling analyses support the predictive association between expectations and all clinical outcomes as well as the mediating effect of patient’s impression of change. In addition to being superior to an alternative model, the proposed model was shown to be relevant across subgroups. Overall, this thesis contributes to the demonstration of the determinant role of expectations on physiological and therapeutic processes in the context of pain regulation. These findings reiterate the need to consider the patient's perspective and offer a valuable avenue towards the optimization of treatments intended at relieving pain.

<p>Uvod: Lumbalni bolni sindrom (LBS) podrazumeva tegobe u vidu bolova, u lumbalnom ili lumbosakralnom segmentu kičmenog stuba, sa ili bez iradijacije u donje ekstremitete, uz poremećaj funkcije umbosakralnog dela kičmenog stuba, za&scaron;titnu mi&scaron;ićnu reakciju na bol (spazam) uz moguće znake senzitivnog poremećaja. Laser male snage (LMS) ima &scaron;iroku primenu u fizikalnoj medicini i rehabilitaciji zbog analgetskog, antiinflamatornog, antiedematoznog i biostimulativnog dejstva. Cilj rada: Glavni ciljevi su bili da se utvrdi da li fizikalna terapija primenom LMS utiče na smanjenje bola, povećanje pokretljivost lumbalne kičme, smanjenje spazma pravertebralne muskulature, kao i na smanjenje funkcionalne osnesposobljenosti u subakutnom LBS. Materijal i metode: Sprovedena je prospektivna studija na 123 pacijenata (50 mu&scaron;karaca i 73 žene), različitih profesija, izabranih metodom slučajnog izbora, prosečne životne dobi 32.59&plusmn;5.67 godina (ispitivana grupa 31.87&plusmn;5.84, kontrolna grupa 33.31&plusmn;5.45, raspon od 19-45). U studiju su uključeni ispitanici koji su prvi put doživeli lumbalni bolni sindrom koji su pregledani u Odeljenju za fizikalnu medicinu i rehabilitaciju Doma zdravlja Novi Sad. Ispitivanu grupu je činio 61 ispitanik koji su uključeni u fizikalni tretman, primenom laseroterapije i kineziterapije uz medikamentoznu terapiju. Kontrolnu grupu je činilo 62 ispitanika koji koji su uključeni u fizikalni tretman primenom kineziterapije uz medikamentoznu terapiju. Svim ispitanicima je uzeta anamneza, obavljen klinički pregled, izvr&scaron;ena samoprocena bola i popunjavali su upitnike. Navedeno ispitivanje je sprovedeno na početku tretmana, nakon 6 nedelje i nakon sprovedenog tretmana. Kori&scaron;ćeni su sledeći upitnici: vizuelna analogna skala (VAS), standardizovani upitnici za merenje funkcionalnog ishoda - The Oswestry Disability Index (ODI), The Rolland&amp;Morris Disability Questionnaire (RMDQ) i SF-36 upitnik. Rezultati: Rezultati ukazuju da se intenzitet bola meren VAS skalom u obe ispitivane grupe značajno smanjivao tokom svih posmatranih perioda ispitivanja, pri čemu dobijena razlika između dve grupe nije statistički značajna (p=0.904). Pokretljivost lumbalne kičme u obe ispitivane grupe tokom posmatranog perioda se značajno povećala tokom svih posmatranih perioda ispitivanja, pri čemu dobijena razlika između dve grupe nije statistički značajna (p=0.798). U obe ispitivane grupe spazam paravertebralne muskulature se značajno smanjivao tokom svih posmatranih perioda ispitivanja, dok dobijena razlika između grupa nije statistički značajna (p=0.453). Funkcionalna onesposobljenost pacijenata (procenjivana smanjenjem funkcionalne onesposobljenosti ODI i RMDQ) se značajno smanjivala u obe ispitivane grupe pacijenata tokom svih posmatranih perioda ispitivanja. Dobijena razlika u skorovima procenjivana RMDQ između ispitivanih grupa pacijenata nije statistički značajna (p=0.648), kao i putem ODI skora između ispitivanih grupa (p=0.311). Procena funkcionalne onesposobljenosti putem procene kvaliteta života (SF-36), ukazuje da se kvalitet života značajno povećavao u svim ispitivanim skorovima u obe ispitivane grupe tokom svih posmatranih perioda ispitivanja. Nema razlika u funkcionalnoj onesposobljenost (SF-36), odnosno nema razlike u kvalitetu života u skorovima fizičko funkcionisanje, ograničenje zbog emocionalnih problema, socijalno funkcionisanje, mentalno zdravlje, telesni bol, energija i vitalnost, sumarni skor fizičkog i sumarni skor mentalnog zdravlja između ispitivanih grupa. Dimenzije kvaliteta života u skorovima ograničenje zbog fizičkog zdravlja je značajno bolje u kontrolnoj grupi ispitanika (p=0.028). Dimenzija kvaliteta života u skoru op&scaron;te zdravlje je značajno bolje u ispitivanoj grupi pacijenata (p=0.041). Zaključci. Primenom LMS u subakutnom LBS do&scaron;lo je statistički značajnog smanjenja intenziteta bola, povećanja pokretljivosti lumbalne kičme, smanjenja spazma paravertebralne muskulature, kao i smanjenja funkcionalne onesposobljenosti. S obzirom da ne postoji koncenzus oko primene LMS, kao ni drugih metoda fizikalne terapije u subakutnom stadijumu LBS, navedeni rezultati bi mogli doprineti usvajanju kliničkih smernica, odnosno dijagnostičkih i terapijskih protokola za subakutni LBS.</p> / <p>Introduction: Low back pain syndrome (LBP) implies pain in the lumbar or lumbosacral segment of the spine, with or without irradiation into the lower extremities, with a disorder to the function of the lumbosacral part of the spine, a protective muscular reaction to pain (spasm) and possible signs of a sensory processing disorder. Low-Level Laser Therapy (LLLT) has broad application in physical medicine and rehabilitation due to analgesic, antiinflammatory, anti-edematous and biostimulative effects. Objective: The main objective of this study was to determine whether physical therapy with a LLLT has an effect on reducing pain, increasing mobility in the lumbar spine, reducing spasms of the paravertebral muscle, as well as in reducing functional incapacity in subacute LBP. Material and methods: A prospective study was conducted on 123 patients (50 men and 73 women), of different professions, chosen through random selection, with a mean age of 32.59 &plusmn; 5.67 years (examined group 31.87 &plusmn; 5.84, control group 33.31 &plusmn; 5.45, range 19-45). The study included respondents who had experienced lumbar pain syndrome for the first time and who had been examined in the Department of Physical Medicine and Rehabilitation of the Novi Sad Health Center. The examined group consisted of 61 respondents undergoing physical treatment with the application of LLLT and kinesiotherapy with medication therapy. The control group consisted of 62 respondents undergoing physical treatment with the application of kinesiotherapy with medication therapy. All patients were subject to an anamnesis, a clinical examination, a selfassessment of pain and were required to complete questionnaires. The above study was carried out at the beginning of treatment, after 6 weeks, and after treatment was completed. The following questionnaires were used: Visual Analogue Scale (VAS), standardized questionnaires for assessing functional outcomes &ndash; The Oswestry Disability Index (ODI), The Rolland &amp; Morris Disability Questionnaire (RMDQ) and the SF-36 questionnaire. Results: Results indicate that pain intensity assessed using the VAS scale was significantly decreased, in both examined groups, during all observed study periods, where the difference between the two groups was not statistically significant (p = 0.904). Mobility of the lumbar spine was significantly increased, in both examined groups, during all observed study periods, where the obtained difference between the two groups was not statistically significant (p = 0.798). In both examined groups, spasm of the paravertebral musculature significantly decreased during all observed study periods, while the difference between the groups was not statistically significant (p = 0.453). Functional disability of patients (assessed by a reduction of functional disabilities of ODI and RMDQ) significantly decreased in both examined groups of patients during all observed examination periods. The obtained difference in scores assessed via the RMDQ, between the studied patient groups, was not statistically significant (p = 0.648), as well as via the ODI score between the researched groups (p = 0.311). Assessment of functional disability through the assessment of quality of life (SF-36) indicates that the quality of life increased significantly, for all examined scores in both examined groups, during all observed testing periods. There is no difference in functional disability (SF-36), that is, there is no difference in quality of life in score physical functioning, restrictions due to emotional problems, social functioning, emotional wellbeing, bodily pain, energy/vitality, physical and mental health, between the examined groups. The dimensions of quality of life in score role limitations due to physical health problems are significantly better in the control group (p = 0.028). The quality of life dimension in the general health perceptions is significantly better in the examination group (p = 0.041). Conclusions: The application of LLLT in subacute LBP resulted in a statistically significant reduction in pain intensity, increased lumbar spine mobility, decreased spasms of paravertebral musculature, and decreased functional disability. Given that there is no consensus on the use of LLLT, nor any other methods of physical therapy, during the subacute LBP, these results could contribute to the adoption of clinical guidelines, that is, diagnostic and therapeutic protocols for subacute LBP.</p>

<p>Uvod: U savremenom svetu koronarna arterijska bolest srca (KABS) je vodeći uzrok obolevanja i umiranja, a akutni koronarni sindrom (AKS) je jedna od njenih najče&scaron;ćih i najopasnijih kliničkih manifestacija. Dijastolna disfunckija leve komore često prati KABS i mogući je doprinosni faktor za lo&scaron; klinički tok i ishod. Postavlja se pitanje u kom obimu je dijastolna disfunkcija leve komore udružena sa koronarnom arterijskom bole&scaron;ću i da li savremeni programi ambulantne sveobuhvatne kardijalne rehabilitacije (ASKR) imaju uticaja na bolju prognozu ove grupe kardiolo&scaron;kih bolesnika. Uprkos &scaron;irokoj primeni revaskularizacionih procedura u svakodnevnoj kardiolo&scaron;koj praksi i brojnih studija koje su ukazale na pozitivne efekte programa SKR na funkcionalni status pacijenata nakon AKS, jo&scaron; uvek postoji mnogo kontroverzi o efektima fizičkog treninga, na srčanu funkciju i pobolj&scaron;anje funkcionalnog kapaciteta kod pacijenata sa KABS i pridruženom dijastolnom disfunkcijom. Cilj istraživanja: bio je da ispita uticaj superviziranih vežbi fizičkim opterećenjem (VFO) u okviru programa ambulantne sveobuhvatne kardijalne rehabilitacije (ASKR), na dijastolnu disfunkciju leve komore (DDLK) i funkcionalni status pacijenata (FS), nakon AKS, re&scaron;enog perkutanom koronarnom intervencijom (PCI), kao i da li, s druge strane, prisustvo i stepen dijastolne disfunkcije na početku istraživanja, utiče na funkcionalni status i pojavu neželjenih kardijalnih događaja, kod ove grupe pacijenata u okviru programa ASKR i van njega&nbsp; Materijal i metode: Istraživanjem je bilo obuhvaćeno ukupno 85 ispitanika, oba pola, starosti od 18-65 godina, koji su tokom indeksne hospitalizacije lečeni kao klinički dokazani AKS (APNS; NSTEMI; STEMI) i kod kojih je urađena neka od interventnih koronarnih procedura (pPCI; PCI; PTCA). Nakon 4 nedelje od otpusta sa hospitalizacije, zbog NSTEMI ili APNS, odnosno nakon 6 nedelja od otpusta sa hospitalizacije zbog STEMI, pacijenti sa EFLK &ge; 45%, bez značajnih valvularnih i drugih mana i sa nekim od poremećaja dijastolne funkcije, bili su kandidati za uče&scaron;će u istraživanju. Svi ispitanici su podvrgavani &bdquo;ulaznom&ldquo;ehokardiografskom pregledu (EHO) u cilju procene sistolne funkcije i stepena dijastolne disfunkcije leve komore, kao i &bdquo;ulaznom&ldquo; spiroergometrijskom testu (CPET) u cilju procene funkcionalnog statusa, na osnovu kojeg je vr&scaron;ena preskripcija vežbi fizičkim opterećenjem (VFO) u okviru programa ASKR. Program ASKR odvijao se u ukupnom trajanju od 12 nedelja, odnosno 36 pojedinačnih sesija VFO, 3 puta nedeljno u trajanju od po 30 minuta. Kontrolna grupa obuhvatila je grupu pacijenata koja nije živela u blizini IKVBV i koja nije bila u mogućnosti da dolazi redovno na VFO u sklopu ASKR. Njima je bilo pu&scaron;teno na volju da na osnovu urađenog EHO pregleda i CPET, određuju stepen VFO po sopstvenom nahođenju, uz primenu optimalnog medikamentnog lečenja i ostalih mera sekundarne prevencije. Nakon 3 meseca obe grupe pacijenata bile su podrvrgnute novom &ndash;&ldquo;izlaznom&rdquo; ehokardiografskom i CPET pregledu u cilju komparacije sa rezultatima na početku istraživanja. Rezultati:Istraživanje je pokazalo da nakon 3 meseca superviziranog treninga VFO, u okviru programa ASKR, kod bolesnika nakon AKS, lečenih perkutanom koronarnom intervencijom, dolazi do pobolj&scaron;anja stepena dijastolne disfunkcije leve komore, naročito kroz promene vrednosti ehokardiografskih parametara e&rsquo;l i E/e&rsquo; l. U kontrolnoj grupi e&rsquo;l se smanjio za (0,003 &plusmn; 0,025), a u osnovnoj se povećao za (0,011 &plusmn; 0,021). U kontrolnoj grupi e&rsquo;l se nije značajno promenio (p = 0,515), a u osnovnoj grupi se značajno povećao (p &lt; 0,0005). Na početku istraživanja u osnovnoj grupi e&rsquo;l je bio (0,097 &plusmn; 0,027 m/sec), a na kraju (0,108 &plusmn; 0,031 m/sec). E/e&rsquo;l se nije značajno promenio u kontrolnoj grupi (p = 0,226), a u osnovnoj grupi se značajno smanjio (p = 0,002). Na početku istraživanja u osnovnoj grupi E/e&rsquo;l je bio (8,02 &plusmn; 2,98), a na kraju (6,97 &plusmn; 2,17). Takođe je utvrđeno da nakon 3 meseca superviziranog treninga u okviru programa ASKR, dolazi do pobolj&scaron;anja funkcionalnog kapaciteta pacijenata sa KABS i dijastolnom disfunkcijom leve komore, kroz povećanje CPET parametara: peak VO2, VO2 predict i METs. U kontrolnoj grupi peak VO2 se smanjio za (1,79 &plusmn; 3,84), a u osnovnoj se povećao za (1,67 &plusmn; 4,29). U kontrolnoj grupi peak VO2 se značajno smanjio (p = 0,018), a u osnovnoj grupi se značajno povećao (p = 0,005).Na početku istraživanja u kontrolnoj grupi srednja vrednost peak VO2 iznosila je (23,01 &plusmn; 3,99 ml/kgTT/min), a u osnovnoj grupi je iznosila (23,15 &plusmn; 4,99 ml/kgTT/min). Na kraju istraživanja u osnovnoj grupi srednja vrednost peak VO2 iznosila (24,82 &plusmn; 5,77 ml/kgTT/min), dok je kod kontrolne grupe iznosila (21,21 &plusmn; 4,05 ml/kgTT/min). U kontrolnoj grupi ppVO2(%) se smanjio za (5,28 &plusmn; 14,39), a u ispitivanoj se povećao za (7,16 &plusmn; 18,51). U kontrolnoj grupi ppVO2(%) se nije značajno promenio (p = 0,058), dok se u osnovnoj grupi statistički značajno povećao (p = 0,005). Razlika srednjih vrednosti promena METs između osnovne i kontrolne grupe je bila statistički značajna (p &lt; 0,0005). U kontrolnoj grupi METs se smanjio za (0,55 &plusmn; 1,12), a u osnovnoj se povećao za (0,58 &plusmn; 1,12). U kontrolnoj grupi METs se značajno smanjio (p = 0,013), a u osnovnoj grupi se značajno povećao (p &lt; 0,0005). Zaključak: Program ambulantne sveobuhvatne kardijalne rehabilitacije, kod bolesnika nakon akutnog koronarnog sindroma, lečenih perkutanom koronarnom intervencijom, utiče na pobolj&scaron;anje faktora rizika kardiovaskularnih bolesti, značajno utiče na pobolj&scaron;anje stepena dijastolne disfunkcije leve komore i na pobolj&scaron;anje funkcionalnog statusa pacijenata, u odnosu na početak istraživanja.</p> / <p><!--[if gte mso 9]><xml> <o:DocumentProperties> <o:Author>mladen</o:Author> <o:Version>16.00</o:Version> </o:DocumentProperties> <o:OfficeDocumentSettings> <o:AllowPNG/> </o:OfficeDocumentSettings></xml><![endif]--><!--[if gte mso 9]><xml> <w:WordDocument> <w:View>Normal</w:View> <w:Zoom>0</w:Zoom> <w:TrackMoves/> <w:TrackFormatting/> <w:PunctuationKerning/> <w:ValidateAgainstSchemas/> <w:SaveIfXMLInvalid>false</w:SaveIfXMLInvalid> <w:IgnoreMixedContent>false</w:IgnoreMixedContent> <w:AlwaysShowPlaceholderText>false</w:AlwaysShowPlaceholderText> <w:DoNotPromoteQF/> 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<p>Uvod: Povezanost dijabetesa melitusa i&nbsp; tuberkuloze je odavno primećena i bila je predmet ispitivanja mnogih studija. Dijagnoza &scaron;ećerne bolesti pre otkrića insulina značila je smrtni ishod u roku od pet godina, a najče&scaron;ći uzrok smrti su bile infekcije, uključujući tuberkulozu. Poslednjih godina incidenca tuberkuloze je u padu, ali je i dalje prisutan značajan broj obolelih od tuberkuloze u zemljama u razvoju. Sa druge strane incidenca dijabetes melitusa je u porastu, pre svega zbog tendencije porasta broja gojaznih osoba. Procenjeno je da će prevalencija obolelih od dijabetes melitusa dostići 438 miliona obolelih do 2030, a 80% svih slučajeva će biti stanovnici zemalja u razvoju gde je i dalje visoka prevalencija tuberkuloze. Kao rezultat ovakve epidemiolo&scaron;ke situacije ove dve bolesti će se sve če&scaron;će javljati uporedo, modifikujući tok jedna drugoj. Preduslov za uspe&scaron;no lečenje dijabetičara obolelih od tuberkuloze je postizanje zadovoljavajuće metaboličke regulisanosti &scaron;ećerne bolesti. smrtni ishod u roku od pet godina, a najče&scaron;ći uzrok smrti su bile infekcije, uključujući tuberkulozu. Poslednjih godina incidenca tuberkuloze je u padu, ali je i dalje prisutan značajan broj obolelih od tuberkuloze u zemljama u razvoju. Sa druge strane incidenca dijabetes melitusa je u porastu, pre svega zbog tendencije porasta broja gojaznih osoba. Procenjeno je da će prevalencija obolelih od dijabetes melitusa dostići 438 miliona obolelih do 2030, a 80% svih slučajeva će biti stanovnici zemalja u razvoju gde je i dalje visoka prevalencija tuberkuloze. Kao rezultat ovakve epidemiolo&scaron;ke situacije ove dve bolesti će se sve če&scaron;će javljati uporedo, modifikujući tok jedna drugoj. Preduslov za uspe&scaron;no lečenje dijabetičara obolelih od tuberkuloze je postizanje zadovoljavajuće metaboličke regulisanosti &scaron;ećerne bolesti. Cilj istraživanja: Cilj rada je bilo ispitivanje uticaja dijabetesa melitusa na tok plućne tuberkuloze, prvenstveno na bakteriolo&scaron;ki status, radiolo&scaron;ku prezentaciju bolesti, dužinu terapijskog režima i učestalost recidiva bolesti. Materijal i metode: Ispitivanjem su obuhvaćene dve grupe od po pedeset bolesnika koji su hospitalizovani u Institutu za plućne bolesti Vojvodine. Prvu grupu činili su bolesnici sa plućnom tuberkulozom i pridruženom &scaron;ećernom bole&scaron;ću, a drugu grupu bolesnici sa plućnom tuberkulozom bez pridružene &scaron;ećerne bolesti. Svi bolesnici su analizirani po sledećim karakteristikama: starost, pol, klinička slika, bakteriolo&scaron;ki status, radiolo&scaron;ka prezentacija, prisustvo neželjenih efekata antituberkulotika, prisustvo rezistencije M. tuberculosis na lekove, trajanje terapijskog režima, ishod lečenja, pojava recidiva i dužina hospitalizacije. Oboleli od &scaron;ećerne bolesti bili su dodatno analizirani prema: tipu bolesti, dužini trajanja bolesti, metaboličkoj regulisanosti bolesti i prisustvu komplikacija. Svi bolesnici obuhvaćeni ispitivanjem bili su podvrgnuti standardnom dijagnostičkom algoritmu koji obuhvata: anamnezu i fizikalni pregled, direktnu mikroskopiju sputuma, kultivaciju sputuma, radiogram grudnog ko&scaron;a, CT grudnog ko&scaron;a u slučaju postavljenih kliničkih indikacija. Invazivna dijagnostika će se sprovesti kod bolesnika kod kojih dijagnoza nije mogla biti postavljena prethodno sprovedenom neinvazivnom dijagnostikom. Terapijski režim će biti započet tokom hospitalizacije u Institutu za plućne bolesti Vojvodine, a nastavljen ambulantno pod kontrolom Dispanzera za plućne bolesti. Po zavr&scaron;etku terapijskog režima predviđena je kontrola u Institutu za plućne bolesti Vojvodine koja obuhvata procenu kliničke slike, bakteriolo&scaron;kog statusa, radiolo&scaron;kog nalaza i eventualnu potrebu za produženjem terapijskog režima. Rezultati: Istraživanje je pokazalo da je u grupi obolelih od tuberkuloze bez pridruženog dijabetes melitusa bio sličan broj bolesnika mu&scaron;kog i ženskog pola, a veći broj ispitanika se nalazio u starosnim kategorijama do 50 godina starosti, dok je u grupi obolelih od tuberkuloze sa dijabetes melitusom bio značajno vi&scaron;e zastupljen mu&scaron;ki pol i značajno vi&scaron;e ispitanika se nalazilo u starosnim kategorijama preko 50 godina starosti. Beleži se statistički značajno veći broj recidiva u grupi obolelih od tuberkuloze sa dijabetes melitusom (p=0,001). Između ispitvanih grupa se ne beleži statistički značajna razlika u kliničkoj prezentaciji bolesti. U grupi obolelih od tuberkuloze sa dijabetes melitusom, statistički značajno je veći broj direktno pozitivnih nalaza sputuma (p=0,046). Utvrđeno je postojanje statistički značajne razlike u prosečnoj dužini vremena potrebnoj za direktnu konverziju sputuma (p=0,000) i prosečnoj dužini vremena potrebnoj za konverziju kulture sputuma (p=0,000). U oba slučaja je grupa obolelih od tuberkuloze sa pridruženim dijabetes melitusom imala duže prosečno vreme potrebno za konverziju. U grupi obolelih od tuberkuloze sa pridruženim dijabetes melitusom bilo je statistički značajno vi&scaron;e bolesnika sa prisustvom kaverne (p=0,006) i lokalizacijom promena u sva tri režnja (p=0,000). Nije zapažena statistički značajna razlika u trajanju terapijskog režima, ispoljavanju neželjenih efekata lekova, pojavi rezistencije na lekove i ishodu lečenja između dve ispitivane grupe. Grupa obolelih od tuberkuloze sa pridruženim dijabetesom imala je statistički značajno veći broj bolničkih dana (p=0,000). Poređenjem grupa obolelih od tuberkuloze sa pridruženim zadovoljavajuće regulisanim dijabetesom i grupe obolelih od tuberkuloze sa lo&scaron;e regulisanim dijabetesom uočeno je statistički značajno duže trajanje terapijskog režima kod dijabetičara sa lo&scaron;e regulisanom bole&scaron;ću (p=0,018). Nije bilo statistički značajne razlike u zastupljenosti recidiva, kliničke prezentacije bolesti, bakteriolo&scaron;kog i radiolo&scaron;kog statusa, ispoljavanju neželjenih efekata lekova, pojavi rezistencije na lekove, ishoda lečenja i broja bolničkih dana između dve ispitivane grupe. Dodatnim poređenjem grupa (oboleli od tuberkuloze bez pridruženog dijabetesa, oboleli od tuberkuloze sa pridruženim zadovoljavajuće regulisanim dijabetesom i oboleli od tuberkuloze sa pridruženim lo&scaron;e regulisanim dijabetesom) primećeno je da je grupi bolesnika obolelih od tuberkuloze sa lo&scaron;e regulisanim dijabetesom potrebno najduže vreme za direktnu konverziju i konverziju kultura sputuma na MT i da imaju najveći broj bolničkih dana. U grupi obolelih od tuberkuloze sa pridruženim lo&scaron;e regulisanim dijabetesom je bilo statistički značajno veći broj bolesnika koji su lečeni osam meseci u odnosu na druge dve grupe (p=0,011). Poređenjem grupa obolelih od tuberkuloze sa tipom 1 dijabetesa tipom 2 dijabetesa nije uočena statističk značajna razlika između grupa po svim ispitivanim varijablama. U grupi dijabetičara sa dobro regulisanim dijabetesom nalazi se veći broj onih koji imaju tip 2 bolesti, u odnosu na grupu bolesnika sa lo&scaron;e regulisanim dijabetesom. Grupa dijabetičara sa lo&scaron;e regulisanom bolesti ima statistički značajno veći broj komplikacija &scaron;ećerne bolesti. Zaključak: Dokazano je da &scaron;ećerna bolest značajno utiče na bakteriolo&scaron;ki status, radiolo&scaron;ku prezentaciju, dužinu terapijskog režima, učestalost recidiva tuberkuloze i broj bolničkih dana obolelih od tuberkuloze,kao i da je regulisanost &scaron;ećerne bolesti imala značajan uticaj na dužinu terapijskog režima.</p> / <p>Introduction: The association of diabetes mellitus and tuberculosis has long been observed and has been the subject of many studies. The diagnosis of diabetes before the discovery of insulin meant death within five years, a leading cause of death were infections, including tuberculosis. Last years the incidence of tuberculosis has declined, but there is still a significant number of TB patients in developing countries. On the other hand, the incidence of diabetes is on the rise, primarily due to the tendency of an increasing number of obese people. It is estimated that the prevalence of patients with diabetes will reach 438 million sufferers by 2030, and 80% of all cases will be people in developing countries where it is still a high prevalence of tuberculosis. As a result of the epidemiological situation, these two diseases will increasingly occur in parallel, modifying the current one another. Aim: The aim of this study was to investigate the influence of diabetes mellitus on the course of pulmonary tuberculosis, primarily in the bacteriological status, radiological presentation of disease, duration of the treatment regimen and the frequency of disease relapse. Materials and Methods: The study included two groups of fifty patients who were hospitalized at the Institute for pulmonary diseases. The first group consisted of patients with pulmonary tuberculosis and concomitant diabetes mellitus, a second group consisted of patients with pulmonary tuberculosis without associated diabetes. All patients were analyzed by the following characteristics: age, gender, clinical picture, bacteriological status, radiological presentation, the presence of side effects of antituberculosis drugs, the presence of M. tuberculosis resistant to the drugs, the duration of the therapeutic regimen, treatment outcome, recurrence and length of hospitalization. Diabetics were further analyzed with respect to: the type of disease, duration of disease, a metabolic disease and the regulation for the presence of a complication. All patients completed this study were subjected to a diagnostic algorithm comprising: history and physical examination, direct microscopy of sputum, cultivation of sputum, radiographs of the chest, chest CT scan in case positioned on clinical indications. Invasive diagnostic will be performed in patients in whom the diagnosis could not be set previously conducted noninvasive diagnostics. The treatment regimen will be started during the hospitalization in the Institute of pulmonary diseases and is set under the control of ambulatory pulmonary dispensaries. Results: The study showed that in the group of TB patients without concomitant diabetes mellitus was a similar number of patients male and female, a greater number of respondents was in the age groups up to the age of 50, while in the group of TB patients with diabetes mellitus was significantly more frequent male half and significantly more respondents were in the age groups over 50 years of age. Significantly higher number of relapses is recorded in a group of TB patients with diabetes mellitus (p = 0,001). Between the two study groups was not significant difference in the clinical presentation of the disease. In the group of TB patients with diabetes mellitus, is statistically significant higher number of smear positive findings (p = 0,046). There is a statisticaly significant difference in the average length of time required for the smear conversion (p = 0,000) and average length of time needed for the conversion of sputum cultures (p = 0,000). In both cases, the group of TB patients with associated diabetes mellitus had a longer average time needed for the conversion. In the group of patients with tuberculosis associated with diabetes mellitus was statistically significantly more patients with the presence of the cavern (p = 0,006), and the localization of the pulmonary changes in all three lobes (p = 0,000). Between the two study groups was not observed a statistically significant difference in duration of the treatment regimen, the expression of adverse drug effects, develop resistance to the drugs, and the outcome of the treatment. Group of patients with tuberculosis associated with diabetes had a statistically significantly greater number of hospital days (p = 0,000). Between the groups of patients with tuberculosis associated with satisfactory controlled diabetes and the group of TB patients with poorly controlled diabetes was statistically significantly longer duration of the therapeutic regimen in diabetic patients with poor regulation of the disease (p = 0,018). There was no significant difference in the appearance of relapses, the clinical presentation of disease, the bacteriological status, radiology, the expression of adverse drug effects, develop resistance to the drugs, outcome of the treatment, number of hospital days between the two study groups. Comparing the three groups (tuberculosis without associated diabetes mellitus, TB patients with associated satisfactorily controlled diabetes and TB patients with associated poorly controlled diabetes), it was observed that the group of patients suffering from tuberculosis with poorly controlled diabetes takes the longest time to smear conversion and conversion of sputum culture and to have the highest number of hospital days. In the group of patients with tuberculosis associated with poorly controlled diabetes was significantly greater number of patients who were treated for eight months compared to the other two groups (p = 0,011). Comparing the group of TB patients with type 1 diabetes and type 2 diabetes is not a statistically significant difference between the groups in all variables. In the group of diabetic patients with satisfactorily controlled diabetes, there are a large number of those with type 2 disease, in comparison to the group of patients with poorly controlled diabetes. Group of diabetics with poorly regulated disease has a significantly greater number of diabetes comlications. Conclusion: It has been shown that diabetes mellitus has a significant effect on the bacteriological status, radiological presentation, the length of the treatment regimen, the frequency of recurrence of tuberculosis and the number of hospital days of patients with tuberculosis, and that the adjustment of diabetes had a significant effect on the length of the treatment regimen.</p>

INTRODUÇÃO: Pacientes com rigidez pós-traumática do cotovelo que falharam à fisioterapia convencional têm como possibilidades de tratamento protocolos de reabilitação associado ao uso de órtese ou à liberação cirúrgica do cotovelo. Na literatura não existem artigos comparativos entre essas duas formas de tratamento. O objetivo primário deste estudo foi comparar a amplitude de movimento de flexoextensão do cotovelo entre os pacientes submetidos ao tratamento cirúrgico ou à reabilitação. Os objetivos secundários foram comparar os resultados clínicos, de acordo com a escala \"Mayo Elbow Performance Score\", o questionário \"Disability of Arm, Shoulder and Hand\" e a escala visual analógica de dor, além de comparar o ganho absoluto e relativo da flexoextensão, a flexão e extensão máxima, a amplitude de pronossupinação e a taxa de complicações. MÉTODOS: Estudo clínico randomizado, com avaliador cego, de pacientes com rigidez póstraumática do cotovelo que apresentaram falha ao tratamento fisioterápico convencional. Os pacientes foram alocados aleatoriamente em dois grupos de tratamento: conservador e cirúrgico. O grupo conservador foi submetido ao protocolo de reabilitação envolvendo a equipe de terapia ocupacional, com exercícios e alongamentos associados ao uso de órteses estáticas seriadas de extensão, dinâmicas de flexão, além de sessões de movimentação contínua passiva. O grupo cirúrgico foi submetido à liberação cirúrgica por via posterior, seguido do mesmo protocolo de reabilitação do grupo conservador. As escalas clínicas foram aplicadas pré-operatoriamente, aos 3 e 6 meses de seguimento. A amplitude de movimento foi avaliada nos mesmos períodos e adicionalmente com 6 semanas. As complicações foram avaliadas até os 6 meses de tratamento. O desfecho primário do estudo foi a amplitude de movimento de flexoextensão aos 6 meses de seguimento. RESULTADOS: Trinta pacientes foram incluídos no estudo, sendo 15 em cada grupo. A amplitude de movimento de flexoextensão do cotovelo, ao final dos 6 meses de seguimento, foi de 108,4º para o grupo cirúrgico e de 88,1º para o grupo conservador (p=0,002). O ganho absoluto e relativo da flexoextensão do cotovelo aos 6 meses foram respectivamente de 17,2º e 26,8% para o grupo conservador e de 40,8º e 58,8% para o grupo cirúrgico (p < 0,001). A pontuação da escala visual analógica de dor, escala \"Mayo Elbow Performance Score\" e o questionário \"Disability of Arm, Shoulder and Hand\" foram respectivamente de 4,4, 70,6 e 35,3 para o grupo conservador e de 3,9, 77,3 e 27,6 para o grupo cirúrgico (p=0,486, p=0,342 e p=0,361). O grupo conservador apresentou uma complicação, enquanto o grupo cirúrgico quatro (p=0,598). CONCLUSÕES: A liberação cirúrgica do cotovelo associada ao protocolo de reabilitação resultou em uma maior amplitude de flexoextensão, além de um maior ganho absoluto e relativo quando comparada à reabilitação isolada após 6 meses. A extensão máxima obtida foi superior no grupo cirúrgico, sem diferença para a flexão máxima e amplitude de movimento de pronossupinação. Os grupos não diferiram nas escalas funcionais e na taxa de complicações / INTRODUCTION: Patients with post-traumatic elbow stiffness who have failed conventional physiotherapy have two options of treatment: rehabilitation protocols associated with the use of bracing or surgical elbow release. In the literature there are no comparative studies between those forms of treatment. The primary objective of this study was to compare the elbow flexion-extension range of motion between patients submitted to surgical treatment or rehabilitation. The secondary objectives were to compare the clinical outcomes according to the Mayo Elbow Performance Score, the Disability of Arm, Shoulder and Hand questionnaire and the visual analogue pain scale, in addition to comparing the absolute and relative gain of elbow flexion-extension, maximal flexion and extension, pronosupination range of motion and complications rate. METHODS: Randomized clinical trial with blind evaluator of patients with post-traumatic elbow stiffness who presented failure to conventional physiotherapeutic treatment. Patients were randomly assigned to two treatment groups: non surgical and surgical. The non surgical group was submitted to a rehabilitation protocol involving the occupational therapy team, with exercises and stretching associated with the use of serial extension static braces, dynamics braces and continuous passive movement sessions. The surgical group was submitted to surgical release, followed by the same protocol of rehabilitation of the non surgical group. The clinical scales were applied preoperatively, at 3 and 6 months of follow-up. The range of motion was assessed at the same periods and additionally at 6 weeks. Complications were assessed up to 6 months of treatment. The study primary outcome was the flexion-extension range of motion at 6 months of follow-up. RESULTS: Thirty patients were included in the study, 15 in each group. The elbow flexion-extension range of motion at 6 months of follow-up was 108.4º for the surgical group and 88.1º for the non surgical group (p=0.002). The absolute and relative gain of elbow flexion-extension at 6 months were 17.2º and 26.8% for the non surgical group and 40.8º and 58.8% for the surgical group (p < 0.001). The visual analogue pain scale, the Mayo Elbow Performance Score and the Disability of Arm, Shoulder and Hand questionnaire were respectively 4.4, 70.6 and 35.3 for the non surgical group and 3.9, 77.3 and 27.6 for the surgical group (p=0.486, p=0.342 and p=0.361). The non surgical group presented one complication, while the surgical group had four (p=0.598). CONCLUSIONS: The elbow surgical release associated with the rehabilitation protocol resulted in a greater flexion-extension range of motion and greater absolute and relative gain when compared to the isolated rehabilitation after 6 months. The maximal extension obtained was superior in the surgical group, with no difference for maximal flexion and pronosupination range of motion. The groups did not differ on functional scales and complication rates

INTRODUÇÃO: As fraturas do terço médio da clavícula representam 80% das fraturas claviculares e seu tratamento é motivo de discussão na literatura ortopédica. Estudos prévios relativos ao tratamento cirúrgico têm demonstrado bons resultados clínicos com o uso das placas de reconstrução ou a fixação intramedular elástica estável com hastes flexíveis de titânio. O objetivo deste estudo foi a comparação desses métodos no tratamento das fraturas do terço médio da clavícula, quanto aos resultados funcionais, parâmetros radiográficos, dor pós-operatória, taxa de satisfação e taxa de complicações. MÉTODOS: Neste ensaio clínico comparativo, prospectivo e randomizado, 59 pacientes com fratura desviada do terço médio da clavícula foram alocados aleatoriamente para receberem osteossíntese com placa de reconstrução (33 pacientes - grupo Placa) ou haste flexível de titânio (26 pacientes - grupo Haste). O desfecho primário do estudo foi a avaliação funcional pelo escore DASH aos 6 meses de pós-operatório. Os desfechos secundários foram: o escore DASH aos 12 meses; o escore de Constant- Murley aos 6 e 12 meses; o tempo de consolidação da fratura; o encurtamento residual; o nível de dor pela escala visual analógica no 1º pósoperatório; a taxa de pacientes satisfeitos e a taxa de complicações. RESULTADOS: Cinquenta e quatro pacientes completaram o seguimento, sendo 29 do grupo Placa e 25 do grupo Haste. O escore DASH médio aos 6 meses foi de 9,9 pontos no grupo Placa e 8,5 no grupo Haste, sem diferença estatisticamente significante (p = 0,329). Da mesma forma, não houve diferenças significantes no escore DASH aos 12 meses ou no escore de Constant aos 6 e 12 meses. O tempo de consolidação foi equivalente entre os grupos (p = 0,352), enquanto o encurtamento residual foi maior no grupo Placa, com significância estatística (p = 0,032), mas sem relevância clínica (0,4 cm). Os resultados da escala visual analógica para dor no 1º pósoperatório e a taxa de pacientes satisfeitos foram similares entre os grupos. O grupo Placa apresentou mais casos com angulação do implante (11 casos) do que o grupo Haste (um caso) (p = 0,003), enquanto o grupo Haste foi mais associado à dor relacionada ao implante (10 casos), em comparação ao grupo Placa (4 casos) (p = 0,035). Não houve diferenças significantes entre os grupos quanto às complicações maiores, incluindo falha do implante, infecção pós-operatória, pseudoartrose e reoperação. CONCLUSÕES: A osteossíntese das fraturas desviadas do terço médio da clavícula com placa de reconstrução ou haste flexível de titânio produzem resultados semelhantes quanto aos escores funcionais, tempo de consolidação, dor pós-operatória, satisfação dos pacientes e complicações maiores. As placas de reconstrução são mais suscetíveis à angulação do implante, enquanto as hastes flexíveis de titânio causam mais dor relacionada ao implante / INTRODUCTION: Midshaft clavicle fractures represent 80% of all clavicular fractures, and their treatment is controversial in the literature. Previous studies have shown good clinical results in patients with midshaft clavicular fractures treated with reconstruction plate fixation or elastic stable intramedullary nailing (ESIN). The objective of this study was to compare these methods in terms of functional results, radiographic parameters, postoperative pain, satisfaction rates and complication rates. METHODS: In this prospective, randomized, controlled trial, 59 patients with displaced midshaft clavicular fractures were randomly assigned to receive either reconstruction plate (33 patients - Plate group) or ESIN fixation (26 patients - ESIN group). The primary outcome was the DASH score at 6 months. The secondary outcomes were the following: DASH score at 12 months; Constant-Murley scores at 6 and 12 months; time to fracture union; residual shortening; visual analog scale for pain on the first post-operative day; percentage of satisfied patients; and complications rates. RESULTS: Fifty-four patients completed the follow-up, 29 in the Plante group and 25 in the ESIN group. The mean DASH score at 6 months was 9.9 in the plate group and 8.5 in the ESIN group, with no significant difference (p = 0.329). Similarly, there were no differences in the DASH score at 12 months or the Constant-Murley scores at 6 and 12 months. The time to union was equivalent between the groups (p = 0.352), whereas the residual shortening was significantly greater in the plate group (p = 0.032) but was not clinically relevant (0.4 cm). The visual analog scale scores for pain and the percentage of satisfied patients were similar between the groups. Implant bending was significantly more common in the plate group (eleven patients) than in the ESIN group (one patient) (p = 0.003), whereas hardware-related pain was more frequent in the ESIN group (10 patients vs. 4 patients) (p = 0.035). There were no differences in terms of major complications, including implant failure, postoperative infection, nonunion and reoperation. CONCLUSIONS: Reconstruction plates and ESIN yielded similar results in terms of functional results, time to union, post-operative pain, patient satisfaction and major complications in patients with displaced midshaft clavicular fractures. Reconstruction plates are more susceptible to implant bending, whereas ESIN causes more hardwarerelated pain

No Brasil a principal causa de hipertensão portal é a esquistossomose mansônica na sua forma hepato-esplênica, classificada como pré-sinusoidal. Esta doença adquire grande importância epidemiológica, por acometer indivíduos jovens, com função hepática preservada, e por atingir uma grande parcela da população (cerca de 1 milhão de indivíduos). Destes, cerca de 12 a 52% irão apresentar hemorragia digestiva por ruptura de varizes de esôfago. Não existe até o momento nenhum tratamento que se estabeleça como de consenso para esta enfermidade, porém há uma preferência dos autores para o tratamento cirúrgico e, no Brasil, esta recai sobre a desconexão ázigo-portal e esplenectomia geralmente associada a escleroterapia endoscópica das varizes no pós-operatório. Não estão bem estabelecidas as alterações hemodinâmicas portais decorrentes do tratamento cirúrgico da hipertensão portal e sua influência no resultado deste tratamento. Com o objetivo de avaliar o impacto imediato da desconexão ázigo-portal e esplenectomia (DAPE) na pressão portal e os resultados do tratamento cirúrgico da hipertensão portal no que se refere à recidiva hemorrágica e ao calibre das varizes de esôfago, foram estudados 19 pacientes portadores de esquistossomose hepato-esplênica e hipertensão portal com história de hemorragia digestiva alta por ruptura de varizes esofágicas, com idade média de 37,9 anos. Durante a cirurgia foi avaliada a pressão portal, no início e no final do procedimento através da cateterização da veia porta por cateter de polietileno introduzido por veia jejunal. Todos os pacientes foram submetidos à endoscopia no pré e pós-operatório para avaliar a variação do calibre das varizes esofágicas. Os pacientes foram acompanhados ambulatorialmente e o tempo médio de seguimento foi de 26 meses. Como resultado obteve-se uma queda na pressão portal média de 31,3% após a DAPE (p=0,0001). No acompanhamento pós-operatório houve redução significativa do calibre das varizes esofágicas quando comparadas com a avaliação pré-operatória (p < 0,05). Apenas um paciente (8,3%) apresentou, durante o acompanhamento, recidiva hemorrágica porém, esta foi decorrente de úlcera gástrica e não de varizes esofágicas. Por fim chegou-se à conclusão de que a desconexão ázigo-portal e esplenectomia promoveu queda imediata na pressão portal, com conseqüente diminuição do calibre das varizes esofágicas, tendo sido eficaz no tratamento da hipertensão portal destes pacientes / The main cause of portal hypertension in Brazil is the hepato-splenic form of mansonic schistosomiasis, which is classified as pre-sinusoidal. It acquires major epidemiological importance because it occurs in young individuals and affects a huge parcel of the population (around 1 million people), 12 to 52% of whom will present digestive hemorrhage due to rupture of esophageal varices. There is no consensus treatment for this disease up to the moment, but there is a predilection for the surgical approach. In Brazil, the most employed technique is the esophagogastric devascularization with splenectomy (EGDS), generally associated to late postoperative endoscopical sclerotherapy of the esophageal varices. The hemodynamic alterations in the portal flow resulting from the surgery and their possible influences on the outcome are not well established. With the aim of evaluating the immediate impact of the EGDS upon the portal pressure as well as the results of the surgical treatment on the digestive hemorrhage recurrence and the caliber of the esophageal varices, 19 patients (11males, aged between 18 and 61 years) with hepato-splenic schistosomiasis, presenting portal hypertension and previous episodes of digestive hemorrhage were studied. None of the patients had received any treatment prior to the surgery. The portal pressure was assessed at the beginning and the end of the EGDS through catheterization of the portal vein with a polyethylene catheter introduced through a branch of a jejunal vein. All the patients were submitted to digestive endoscopy before and after the surgery (2 months), in order to classify the caliber of the esophageal varices according to Palmer\'s classification. They also entered the continuous program of endoscopical evaluation and sclerotherapy. The mean clinical follow up period was 26 months. Our results showed that the portal pressure had diminished in all the patients, with a mean decrease of 31.3% after the EGDS. In the postoperative follow up (1 month), the esophageal varices showed a statistically significant reduction in their calibers, when compared to the pre-surgical measurements (p=0.004). Only one patient presented digestive hemorrhage during the follow up period, but it was due to gastric ulcer and not to rupture of esophageal varices. These results have demonstrated that the EGDS promotes an immediate decrease in the portal pressure and a reduction in the caliber of the esophageal varices, thus contributing to the good results of this technique. With the association of EGDS and sclerotherapy of the esophageal varices, no hemorrhagic episodes were observed in this series, during the study

Introdução: A terapia de ressincronização cardíaca (TRC) é um tratamento recomendado pelas principais diretrizes mundiais para pacientes com insuficiência cardíaca congestiva (ICC), disfunção ventricular esquerda (FE <= 35%), com tratamento otimizado e distúrbio da condução intraventricular, principalmente pelo ramo esquerdo. Entretanto, 30%-40% dos pacientes selecionados não respondem ao tratamento. As razões desse insucesso não são completamente conhecidas. Existe, portanto, necessidade de desenvolvimento de índices multifatoriais para melhor selecionar e acompanhar a evolução e o prognóstico destes pacientes. Objetivo: Elaborar modelos preditores de risco de óbito cardíaco ou transplante (Tx), em diferentes fases da TRC. Métodos e Casuística: Estudo observacional, prospectivo e analítico, com inclusão de 116 pacientes, entre 01/2008 a 03/2013, sendo 69,8% do sexo masculino, com CF III (68,1%) e IV ambulatorial (31,9%), com BRE em 71,55% e com idade de 64,89 ± 11,18 anos e fração de ejeção (FE) de 29%. Avaliações foram feitas no período pré-implante (tempo 1), 6-12 meses (tempo 2) e 18-24 meses (tempo 3) e correlacionadas com a mortalidade cardíaca/Tx no final do seguimento. Foram estudadas variáveis clínicas, eletrocardiográficas e ecocardiográficas e realizadas análises de regressão de Cox e regressão logística, com a construção da curva ROC. As curvas de sobrevidas foram realizadas pelo método de Kaplan-Meier e comparadas pelo log-rank. Modelos e escores foram elaborados pelas pontuações do \"hazard ratio\", utilizado como variável independente no modelo de regressão logística. Resultados: Ocorreram 29 (25%) óbitos/Tx durante o seguimento de 34,09 ± 17,9 meses. A mortalidade cardíaca/Tx foi de 16,3 % (19 pacientes). Seis pacientes foram transplantados durante o tempo do estudo. No período préimplante (tempo 1), a presença de disfunção de ventrículo direito (VD), FE < 25% e o uso de altas doses de diuréticos (dois ou mais comprimidos de furosemida) mostraram-se com valor independente, com aumento de risco de óbito cardíaco/Tx de 3,9; 4,8 e 5,9 vezes, respectivamente. No tempo 2 (1° ano), as variáveis disfunção de VD, altas doses de diuréticos e internações por ICC foram as variáveis significativas, com aumento de risco 3,5; 5,3 e 12,5 respectivamente. No tempo 3 (2° ano), as variáveis disfunção de VD e classe funcional III/IV foram significativas no modelo multivariado de Cox, com aumento de risco de 12,1 e 7,7. As acurácias dos modelos foram 84,6%; 93% e 90,5%, respectivamente. Conclusão: Os modelos preditores de óbito cardíaco desenvolvidos a partir de variáveis clínicas e ecocardiográficas, obtidas em diferentes fases da TRC, mostraram boa acurácia e podem ajudar na seleção, seguimento, definição de resposta e aconselhamento destes pacientes / Introduction: Cardiac resynchronization therapy (CRT) is indicated for patients with congestive heart failure (CHF), ejection fraction (EF) <= 35%, and bundle branch block. However, 30%-40% do not respond to CRT. Therefore, there is a need to develop multifactorial indexes to better select and follow these patients. Objective: This work aims to develop predictive models for the risk of cardiac death or transplantation (Tx) at different stages of CRT. Methods: We performed a prospective observational study of 116 patients, 69.8% males, functional class (FC) III (68.1%) and IV (31.9%), LBBB in 71.55%, age 64.89 ± 11.18 years. We studied clinical, electrocardiographic, and echocardiographic variables and performed Cox and logistic regression with ROC and Kaplan- Meier curves. Results: The cardiac mortality was 16.3% (19 patients) in the 34.09 ± 17.9 follow-up months. Pre-implantation, the right ventricular dysfunction (RVD), EF <25%, and the use of high doses of diuretics (HDD) increased risk of cardiac death or Tx of 3.9, 4.8, and 5.9 fold, respectively, and in the first year, the variables RVD, HDD, and hospitalizations for CHF increased risk of death of 3.5, 5.3, and 12.5, respectively. In the 2nd year, the variables RVD and FC III / IV (NYHA) were significant in the multivariate Cox model. The accuracies of the models were 84.6%, 93%, and 90.5%, respectively. Conclusions: Cardiac death predictive models were developed in different stages of CRT, and were based on the analysis of simple clinical and echocardiographic variables. The models showed good accuracy and can help in the selection and follow-up of these patients

Introdução: Programas de exercícios para pacientes lombálgicos tem sido amplamente descritos na literatura; contudo a efetividade de programas de exercícios para esta condição clínica ainda encontra-se controversa. Objetivo: Avaliar a efetividade de um programa de exercícios baseado em abordagem postural e funcional sobre a capacidade funcional e a qualidade de vida de pacientes com lombalgia crônica. Desenho Experimental: Randomized Controlled Trial. Amostra: 30 pacientes do sexo feminino com lombalgia crônica não-específica. Instrumentos de Análise: Capacidade Funcional (Roland-Morris Disability Questionnaire), Qualidade de Vida (SF-36) e intensidade de dor (Escala Numérica de Dor). Métodos: As pacientes foram divididas em Grupo Controle (GC) e Grupo Experimental (GE). Pacientes em ambos os grupos foram submetidas a três avaliações durante seis semanas, em intervalos de três semanas envolvendo o preenchimento dos questionários Roland-Morris, SF-36 e Escala Numérica de Dor. O grupo experimental foi submetido a um programa de exercícios durante seis semanas objetivando a melhora do recrutamento muscular para melhor manutenção postural e treino de funcionalidade. O grupo controle, após o período de observação, recebeu intervenção idêntica à recebida pelo grupo experimental. Grupos controle e experimental foram comparados através do teste t – student. Resultados: O grupo experimental apresentou melhora significativa na capacidade funcional (p= 0,0), qualidade de vida (SF 36;escalas variando com p = 0,0 até 0,02) e intensidade de dor (p= 0,0) ao ser comparado com o grupo controle. Após a intervenção em ambos os grupos, a melhora manteve-se significativa. Conclusão: O programa de exercícios baseado em abordagem postural e funcional mostrou-se eficiente na melhora da dor, capacidade funcional e qualidade de vida de pacientes com lombalgia crônica. / Background: Exercise programs for low back pain have been largely studied; however its effectiveness on this clinical condition is still controversial. Purpose: To assess the effects of a postural and functional approach-based exercise program on functional capacity, quality of life and pain condition of subjects with chronic low back pain (CLBP). Study Design: Randomized Controlled Trial. Patient Sample: 30 women with nonspecific CLBP. Outcome Measures: functional capacity (RMQ, Roland-Morris Disability Questionnaire), quality of life (SF-36 subscales) and pain condition (NRS, Numerical Rating Scale). Methods: Patients were randomly assigned to control (CG) and treatment groups (TG). Patients from both groups were submitted to a three-week interval evaluation involving the completion of RMQ, SF-36 and NRS. TG was submitted to a six-week program of treatment addressing improvement of muscular recruitment for better postural maintenance and functional training. The CG was submitted to the same intervention program, after six weeks of no intervention. CG and TG were compared by applying t student test to the variables. Results: TG showed significant improvement in functional capacity (p= 0.0), quality of life (SF 36 subscales with p ~ 0.0 to 0.02) and pain condition (p= 0.0) compared to CG. The refferences remained significant when the results of intervention in the control group were added to the treatment group and compared to the control group baseline. Conclusions: The postural and functional approach-based exercise program showed efficient in improving the functional capacity, quality of life and pain condition of CLBP patients.

INTRODUÇÃO: As fraturas da extremidade proximal do úmero são frequentes, com incidência crescente no idoso e com impacto na qualidade de vida e na função do ombro. Para os casos com desvio, a placa bloqueada é o método mais utilizado de osteossíntese. Bons resultados clínicos são obtidos tanto com a placa bloqueada como com a haste intramedular bloqueada. O objetivo do estudo foi a comparação desses métodos no tratamento das fraturas da extremidade proximal do úmero quanto aos resultados clínicos, radiográficos e à taxa de complicações. MÉTODOS: Nesse estudo clínico prospectivo e randomizado, 72 pacientes com fraturas desviadas da extremidade proximal do úmero, classificadas como em 2 ou 3 partes de Neer, foram alocados para receberem osteossíntese com placa bloqueada (36 pacientes - Grupo Placa) ou haste intramedular bloqueada (36 pacientes - Grupo Haste). Os desfechos clínicos foram avaliados aos 3, 6 e 12 meses e incluíram as escalas de Constant e Murley, Universidade da Califórnia em Los Angeles modificada (UCLA), escala visual analógica de dor (EVA) e o questionário \"Disability of Arm, Shoulder and Hand\"(DASH) e a amplitude de movimento passiva. Os desfechos radiográficos consistiram na avaliação da consolidação e do ângulo cabeça-diáfise. As complicações foram avaliadas até os 12 meses e incluíram a avaliação do manguito rotador pela ultrassonografia. O desfecho primário do estudo foi a avaliação pela escala de Constant e Murley, aos 12 meses de pós-operatório. RESULTADOS: Sessenta e cinco pacientes completaram 12 meses de seguimento, sendo 32 no Grupo Haste e 33 no Grupo Placa. A escala de Constant aos 12 meses foi de 70,3 pontos para o Grupo Haste e de 71,5 pontos para o Grupo Placa (p = 0,750). A escala de Constant Relativa Individual foi de 81% para o Grupo Haste e de 85% para o Grupo Placa (p = 0,400). Também não houve diferença entre os grupos aos 3 e 6 meses para a escala de Constant. A escala EVA e o questionário DASH também não apresentaram diferença aos 3, 6 e 12 meses, assim como os resultados radiográficos. A escala UCLA apresentou diferença de 4,0 pontos aos 3 meses, com melhores resultados para o Grupo Haste (p = 0,005), mas sem diferença significante aos 6 e 12 meses. A amplitude de movimento apresentou diferença de 2,1 pontos favorável ao Grupo Haste para a rotação medial aos 6 meses (p = 0,042), sem diferença para os demais planos de movimento nos diferentes momentos de avaliação. Foram registradas 38 complicações, sendo 28 no Grupo Haste e 10 no Grupo Placa, com diferença estatística (p = 0,001). As complicações ocorreram em 18 pacientes, sendo 11 (34%) do Grupo Haste e sete (21%) do Grupo Placa, sem diferença estatística (p = 0,137). CONCLUSÕES: A osteossíntese das fraturas da extremidade proximal do úmero com placa bloqueada ou haste intramedular bloqueada produziram resultados clínicos e radiográficos semelhantes. A fixação com haste intramedular bloqueada apresentou maior taxa de complicações e reoperações / INTRODUCTION: Fractures of the proximal humerus are common, with an increasing incidence in the elderly and with a high impact on quality of life and shoulder function. For displaced fractures, the locking plate is the most used method of osteosynthesis. Studies have shown good clinical results with the use of locking plates, but also with the fixation with locking intramedullary nail. The aim of this study was to compare the clinical outcomes, radiographic results and the complications between these two methods in patients with displaced proximal humerus fractures. METHODS: In this prospective, randomized clinical trial, 72 patients with displaced fractures of the proximal humerus, classified as Neer 2- or 3-part, were randomly assigned to receive osteosynthesis with either locking plate (36 patients - Plate Group) or locking intramedullary nail (36 patients - Nail Group). The clinical outcomes were evaluated at 3, 6 and 12 months and included the Constant and Murley, University of California at Los Angeles (UCLA) and Disability of Arm, Shoulder and Hand (DASH) scores, visual analog scale (VAS) and the passive range of motion. Radiographic findings (consolidation and head shaft angle) and complications, which included the evaluation of rotator cuff by ultrasound, were also evaluated. The primary outcome was the Constant and Murley score at 12 months. RESULTS: Sixty-five patients completed 12 months of follow-up, 32 in the Nail Group and 33 in the Plate Group. The mean Constant score at 12 months was 70.3 points for the Nail Group and 71.5 points for the Plate Group (p = 0.750) and the mean Relative Constant score was 81% for the Nail Group and 85% points for the Plate Group (p = 0.400). There was also no difference at 3 and 6 months for the Constant score. VAS, DASH and radiographic findings also did not differ at 3, 6 and 12 months. Range of motion showed a 2.1 points difference in favor of the Nail Group for medial rotation at 6 months (p = 0.042), with no difference for the other motions at 3, 6 and 12 months. The UCLA score presented a difference of 4.0 points at 3 months, with better results for the Nail Group (p = 0.005), but no significant difference at 6 and 12 months. Thirty-eight complications were recorded, 28 in the Nail Group and 10 in the Plate Group, with significant difference (p = 0.001). Complications occurred in 18 patients, 11 (34%) of the Nail Group and seven (21%) of the Plate Group, with no significant difference (p = 0.137). CONCLUSIONS: Locking plates and locking intramedullary nail yielded similar clinical and radiographic results. Locking intramedullary nail fixation has a higher risk for complications and reoperations