Background: Peripheral arterial disease (PAD) affects over 8 million people in the United States and has been found to be associated with an increased incidence of coronary and carotid artery disease. The ankle brachial index (ABI) measurement is a highly specific noninvasive screening and diagnostic test for PAD, but is rarely performed in primary care office settings. This study sought to determine the actual performance time involved in completing an ABI in a primary care office. Methods: Data were collected by one provider on a convenience sample of women who met the inclusion criteria. The time was recorded at the beginning and upon the completion of the ABI procedure for each patient. Analysis of the time data was completed and barriers to performing the ABI were recorded by the provider. Results: The average time to complete an ABI was 5 minutes, with a range of 3-11 minutes. In 83.8% of patient encounters, the ABI procedure took less than 6 minutes to complete. Barriers identified by the provider included the additional time needed to explain the test and assist patients into the proper testing position. Conclusions: The actual performance time for an ABI in a primary care setting takes an average of 5 minutes, but additional time may be required for patient preparation and education. With proper scheduling and training, the ABI can be completed in a timely manner. The ABI is an important screening/diagnostic test that can be performed in primary care and potentially impact patient treatment plans.

Background and objectives: Coronary artery disease (CAD) is the leading cause of death among women both nationally and internationally. Despite increased knowledge regarding CAD in women, early diagnosis remains a difficult clinical task. A correlation between peripheral arterial disease (PAD) and CAD has been noted in previous research; however, these studies were either retrospective or did not focus on women. This research investigates the correlation of ankle brachial index (ABI), measurements used to diagnose PAD, and presence of CAD in women, in an effort to determine the predictive value of ABI specifically in women. Subjects and methods: A prospective correlation design was used to study women (n = 30) who were undergoing a diagnostic cardiac catheterization. Ankle brachial index readings were obtained prior to the catheterization procedure. Catheterization findings were grouped according to absence of CAD or presence of 1-vessel or multivessel CAD and coupled with each woman's ABI and recorded cardiovascular risk factors. Results: Peripheral arterial disease (based on ABI of <0.90 mm Hg) was found in 13.3% of the women. A significant correlation was found between ABI of less than 0.90 mm Hg and increasing age (t = -2.30, P =.029). Coronary artery disease was found in 82.1% of the women; more than half (57.1%) had multivessel disease. Absence of CAD was noted in 17.9%. Women with CAD were older than women without CAD (F = 3.86, P =.035). No significant differences were found between presence or absence of PAD based on ABI and diagnosis of no coronary disease or 1-vessel or multivessel coronary disease. Conclusions: This study failed to show the expected correlation between ABI of less than 0.90 mm Hg and CAD, but did show a significant correlation of age with presence of both PAD and CAD. Further research that focuses specifically on women is needed and should include a larger sample, additional unique cardiovascular risk factors, and innovative diagnostic tests to determine presence of CAD in women early in the disease process.

The development of atherosclerotic lesions and endothelial cell damage can originate during early childhood. Endothelial cells produce and release vasodilatory chemicals, which dictate the artery’s ability to vasodilate or vasoconstrict. Brachial artery FMD is a non-invasive, reproducible and a sensitive technique used to detect changes in arterial diameter and is correlated with coronary artery endothelial function. Cross-sectional studies have indicated increases in arterial diameter in children between the ages of 6-18 years however, a longitudinal, observational design study has not been conducted to understand how arterial diameters and FMD change over time in children, with considerations for the influences of physical activity and sex. The purpose of this study was to understand the impact of age and sex on arterial diameter and FMD and investigate the effects of habitual moderate-to-vigorous physical activity (MVPA) during both the school-age and preschool years on endothelial function trajectories during the school-age years. Over three years, 418 children between 3-5 years old participated in the HOPP study annually, and 279 of these children attended the lab when they were between 6-12 years old for an additional 3 annual visits in the SKIP study. Habitual MVPA was measured for 7 days in both the HOPP and SKIP studies each year, and FMD was measured each year during SKIP. Linear mixed-effects modeling was implemented to study the trend in FMD and the influence of chronological and biological age, sex and MVPA on arterial function; effects are reported as unstandardized estimates (Est). Boys had larger baseline and peak brachial artery diameters compared to girls (p<0.001). Girls had larger brachial artery FMD compared to boys (6.82±3.39 vs. 6.23±3.50 %, p<0.001). There was an effect of MVPA in the SKIP study on allometrically scaled FMD (Est. -0.017, p=0.03), but not on relative FMD (Est. -0.01, p=0.17). MVPA in the preschool years did not predict school-aged scaled FMD (Est. 0.11, p=0.24) or FMD (Est. -0.003, p=0.64). The observed trends in brachial artery diameter and FMD are in-line with expected changes in growth and maturation in children. Children who engaged in more habitual MVPA during the childhood years, but not the preschool years, demonstrated changes endothelial function during the school-age years. / Thesis / Master of Science (MSc) / It is clear that preliminary signs of atherosclerosis begin during the early years of childhood, and typically precede the development of future cardiovascular disease. Engaging in habitual physical activity at higher intensities, has been shown to positively influence cardiovascular health, specifically in central and peripheral arteries. This study sought to investigate the trends in vascular heath over time in children and examine the effect of moderate-to-vigorous physical activity engagement during the preschool years on vascular health during the school-age years. Our results suggest that as children age, their arteries get bigger in size and that school-aged girls have elevated vascular function when compared to boys. Children who engage in greater amounts of moderate-to-vigorous physical activity during their school-age years does not influence measures of vascular health. Additionally, engagement in habitual moderate to vigorous physical activity during the preschool years does not impact these vascular health relationships during the school-age years.

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La paralysie obstétricale du plexus brachial (POPB) est une parésie d’un ou des membres supérieurs causée le plus souvent par un étirement excessif des racines nerveuses à la naissance. Les enfants sans récupération complète garderont des séquelles à vie, comprenant une diminution de force et des mouvements, des déformations osseuses, impactant leurs activités quotidiennes. L'atteinte de l’épaule est la principale cause de morbidité. Les muscles gléno-huméraux sont au coeur de la pathologie de l’épaule. L’IRM permet l’évaluation de l’atteinte des muscles de l’épaule. Les volumes musculaires, intéressants du fait de leur corrélation avec la force, peuvent être obtenus par différentes techniques de segmentation dont les propriétés métrologiques sont inégales. Chez l’enfant avec POPB, l’utilisation d’une technique de segmentation sur un grand nombre de coupes a montré une atrophie variable des muscles glénohuméraux menant à des déséquilibres musculaires dans les trois plans de l’espace. Des corrélations entre les volumes musculaires et la force, significatives mais plus faibles que chez les enfants à développement typique étaient retrouvées. Du fait de l’atteinte osseuse et musculaire, la mobilité de l’articulation gléno-humérale est limitée. Dans une étude utilisant l’analyse quantifiée du mouvement, cette limitation, majeure en rotation externe d’épaule ainsi que des compensations au niveau de l’ensemble du membre supérieur ont été objectivées. La performance du mouvement était bonne. A partir des résultats obtenus différents objectifs et cibles thérapeutiques sont discutés. La lutte contre le déséquilibre musculaire rotateurs internes-externes apparaît comme une priorité. / Obstetric Brachial Plexus Palsy (OBPP) is the paralysis of one or both upper limbs. It is most often caused by excessive traction on cervical nerve roots during a difficult birth. The children without incomplete recovery will have long-term impairment, including loss of active and passive mobility, loss of strength, bony deformities, activity limitation and participation restriction. The loss of shoulder function is the main cause of morbidity in this population.Glenohumeral muscles involvement is a key element of the pathology of the shoulder. MRI allows evaluation of the shoulder muscle involvement. Muscle volumes in particular, well correlated with muscle strength, can be modified by different segmentation techniques whose metrological properties are unequal.In children with OBPP, the use of a segmentation technique on a large number of slices has shown a variable atrophy of the gleno-humeral muscles leading to three-dimensional muscular imbalances.Correlations between muscle volumes and strength were significant but lower than in children with typical development.Because of the bone deformity and muscle involvement, the mobility of the glenohumeral joint is limited. In a study using 3D motion analysis of the movement, this limitation, which is large in external shoulder rotation, as well as compensations on the whole upper limb, were shown. The performance of the movement was good.From these results, different objectives and therapeutic targets are discussed. Internal-external rotator muscular imbalance correction appears as a priority.

La radiculopathie cervicale caudale a été identifiée comme cause de boiterie affectant le membre antérieur chez le cheval. Les affections dégénératives des articulations intervertébrales des processus articulaires entraînent un remodelage périarticulaire pouvant comprimer les racines du nerf spinal ou leur rameau ventral. Les objectifs de l’étude étaient de décrire la réalisation d’injections échoguidées périneurales du rameau ventral des nerfs spinaux cervicaux 7 et 8 (RV7 et RV8), d’évaluer sur des cadavres de chevaux par dissection la diffusion péri-nerveuse d’une solution colorée ainsi que de décrire chez des chevaux sains les signes cliniques associés à une anesthésie périneurale échoguidée du RV7 et RV8 individuellement. Dans l’étude post-mortem, 5 RV7 et 5 RV8 ont été visualisés échographiquement et colorés par une injection de 7 ou 14 ml de solution colorée. Une portion du tronc nerveux a été trouvée coloré pour chaque injection. La coloration était uniforme transversalement sur toute la largeur du nerf et couvrait une longueur supérieure à 2 cm pour 8 RV alors qu’une coloration de la moitié crâniale du RV sur une longueur de moins de 2 cm pour un RV7 et un RV8. L’étude sur cheval sain portait sur 4 chevaux sains sans image radiographique anormale de la colonne cervicale. Six RV7 et 8 RV8 ont été anesthésiés de la Lidocaïne 2% mélangés à du iohexol. Toutes les injections ont entraîné boiterie antérieure ipsilatérale de l’injection. Les boiteries les plus sévères correspondaient à une parésie du nerf suprascapulaire pour RV7 et à une parésie radiale pour RV8. Cette étude a montré qu’il était possible de réaliser une injection périneurale des RV 7 et RV8 chez le cheval et que l’anesthésie tronculaire des deux racines provoque une atteinte motrice essentiellement de la fonction nerveuse. Ces résultats contribuent à mieux comprendre la symptomatologie des compressions nerveuses cervicales chez le cheval. / Caudal cervical radiculopathy has been identified as a cause of frontlimb lameness in horses. Degenerative conditions of articular process joint result in periarticular remodeling responsible for compression of spinal nerve roots or their ramus ventralis (RV). The objectives of the study were to describe how to perform perineural RV injection under ultrasonographic guidance, to evaluate on cadaver perineural RV staining after a dye solution injection, as well as describe clinical signs associated with a perineural ultranosonography-guided anesthesia of RV7 and RV8 respectively. In the post-mortem study, the RV of the spinal cervical nerves was visualized in all cadavers. Eight RV had a uniform transversal staining of the nerve trunk that covered longitudinally a distance greater than 2 cm. One C7 and one C8 RV showed incomplete transversal staining with a more concentrated color on its half cranial aspect and a longitudinal coverage of less than 2 cm. The in vivo study included 6 RV7 and 8 RV8 perineural injections of a local anesthetic agent, performed on 4 horses that had no abnormal finding on cervical radiographs. All anesthetic injections (lidocaine 2% and iohexol) resulted in modifications of the locomotion with variable degree of lameness on the ipsilateral frontlimb. Severe lameness was characteristic of a suprascapular paresis for RV7 and a radial paresis for RV8. Mild to moderate lameness on the ipsilateral frontlimb included decreased anterior phase of the stride, intern circumduction of the limb and sometimes stumbling for that same frontlimb. Signs of ataxia on the hindlimbs were encountered for 3 injections. This study showed that it is possible to perform perineural injections of RV7 and RV8 in horses and that perineural anesthesia of RV7 and RV8 results in motor dysfunction. These findings constitute a contribution to understanding clinical signs associated with cervical nerve compression in horses.

Methods of regional anaesthesia and regional postoperative analgesia are common in perioperative management of patients in traumatology-orthopaedics. One of most challenging fields of traumatology-orthopaedics is shoulder surgery. Shoulder surgery is associated with intense and long-lasting postoperative pain. It affects patients’ well-being, limits limb function and worsens results of surgical treatment. Determination of optimal methods for postoperative pain relief is very important in clinical practice. Several modern studies compared methods of systemic analgesia with continuous interscalene infusion of bupivacaine 0,15 - 0,25 % solution. Application of these concentrations of bupivacaine resulted in sufficient analgesia but profound motor blockade and anaesthetic toxicity were observed. There are few studies on interscalene infusions of small concentrations of bupivacaine. Data on effects of small doses of bupivacaine on intensity of motor blockade and adjuvant drugs on postoperative analgesia is lacking. AIM OF THE STUDY: to evaluate the quality of post-operative pain treatment after shoulder surgery using continuous perineural infusions of different concentrations (0.1% and 0.15%) of bupivacaine and bupicacaine (0.1%) in combination with adjuvant clonidine and effects on operated hand motor function. To assess clinical advisability of interscalene brachial plexus identification and catheterization using G. Meier’s technique. 159 patients scheduled for elective... [to full text]

The most frequent sequelae following an obstetric brachial plexus lesion without complete functional recovery concern the impaired shoulder rotation movements and the associated structural changes of the growing glenohumeral joint. <p>This pathology is often unrecognized and may lead to a limitation in active movements, a pathologic and less efficient motion pattern in the affected limb, and the development of a severely incongruent and dysplastic glenohumeral joint prone to further arthrosis.<p><p>Hypothesis<p><p>Glenohumeral dysplasia after obstetric brachial plexus lesion has multiple etiologies: A hypothetic obstetric trauma may precede the motor imbalance, due to the initial palsy and prevalent recovery of the medial rotators of the shoulder.<p>The correction of the muscular imbalance, by neurotization of the lateral rotators (supra- and infraspinatus muscle) using a local nerve transfer or by a later muscle transfer surgery, improves function, seems to prevent the development of joint dysplasia and limits the articular deformities once they are present. <p>The early (peripartal) glenohumeral subluxation must be recognized and treated immediately to prevent the development of a severe joint contracture and dysplasia.<p> <p>Material and methods<p><p>Two retrospective and one prospective study evaluate how surgery may correct the muscular imbalance.<p>In a first series of 65 children, we analyse the recovery of the supra- and infraspinatus muscle after a nerve transfer onto the suprascapular nerve.<p>In a second retrospective analysis on 114 children, we study the outcome after secondary surgery (anterior joint release, modified Hoffer muscle transfer) dedicated to improve active and passive lateral rotation of the shoulder.<p>A prospective study of 50 magnetic resonance (MRI) scans of the glenohumeral joint describes the articular deformities.<p>Finally, 10 children presenting a very early glenohumeral subluxation have undergone a closed orthopaedic reposition and plaster immobilisation and were followed for a minimum of 2 years.<p><p>Results<p><p>In the first group, neurotization of the suprascapular nerve has been performed either by a dorsal or a ventral approach at a mean age of 14 months. The mean follow up is of 3 years and the improvement in aLR(ABD) is 68°and only 25°in aLR(ADD). None of these children with improved active lateral rotation of the shoulder developed clinical signs of a glenohumeral dysplasia within the follow up period.<p><p>Among the 114 children operated between 6 months and 44 years with a shoulder release, 74 had an isolated release procedure, 40 an associated tendon transfer or a suprascapular neurotization. The mean improvement in passive lateral rotation with the arm adducted (pLR (ADD)) was 60°. Active lateral rotation was possible in 63 % of children who underwent an isolated joint release.<p>The Hoffer muscle transfer was performed in 29 children and improved the aLR (ABD) by 60° (mean postoperative follow-up of 30 months). No signs of severe glenohumeral dysplasia developed in these children later on.<p><p>The prospective study of 50 consecutive MRI scans in children presenting at the consultation with a rotatory imbalance of their shoulder, as a sequel from obstetric brachial plexus palsy (Bahm et al. 2007) shows 37 congruent joints, 10 dorsal subluxations, 2 dorsal luxations and one complete dislocation associated with the formation of an independent neoglenoid. The humeral head was deformed in 12 cases; the glenoid in 34 children (flat in 23, biconcave 7 times, convex 3 times).<p><p>The follow up of 2 years in 10 children who underwent an immediate closed reposition shows evidence of joint congruence with a limited (30°) pLR (ADD), definitely lower than after a surgical release.<p><p>Conclusion<p><p>Some osteo-articular deformities secondary to neuromuscular diseases are well described ;those following an obstetric brachial plexus lesion are insufficiently recognized. Their etiology is unclear.<p>At the level of the shoulder joint, these sequels might be very important.<p>Our neuroorthopaedic hypothesis concerning a multifactorial etiology and treatment strategy raises the need of an early and precise screening of the deforming forces to render normal biomechanics and function.<p>The surgical strategy includes the reconstruction of the responsible motor nerve and the improvement of the passive and active range of motion of the shoulder in lateral rotation<p>It seems to be efficient to limit the progression to severe glenohumeral dysplasia and further arthrosis.<p> / Doctorat en Sciences médicales / info:eu-repo/semantics/nonPublished

No description available.

Purpose The objective of this thesis is to establish an evidence-based clinical practice guideline for the primary management of obstetrical brachial plexus injury (OBPI). Four gaps are identified for management of OBPI in Canada: 1) The historic poor use of evidence, 2) Timing of referral to multidisciplinary care, 3) Indications and timing of operative nerve repair, and 4) Distribution of expertise in Canada. Methods The guideline is intended for all providers delivering perinatal care, and all specialists delivering care to OBPI patients. The consensus group was composed of clinicians representing each of Canada’s ten multidisciplinary centres. An original systematic review comparing the effectiveness of primary operative versus nonoperative management, and a review of Canadian OBPI epidemiology were completed. Quality indicators for referral to a multidisciplinary centre were established. Recommendations were based on best evidence, and interpretation of this evidence by clinical experts. An electronic modified Delphi approach was used for consensus, with agreement criteria defined a priori following RAND procedures. Results Nerve repair reduces functional impairment in OBPI versus nonoperative management of similar patients, and modern microsurgery has low incidence of major adverse events. The quality of evidence was low. Residual impairment is underestimated and uncharacterized in nonoperative literature. OBPI incidence was at least 1.24 per 1000 births in Canada, and consistent over the study period. The strongest risk factors for OBPI were comorbid humerus fracture, shoulder dystocia and comorbid clavicle fracture. Most patients were not referred to a multidisciplinary centre. The guideline group approved seven recommendations. Discussion Recommendations address the identified gaps in care, and guide identification, referral, treatment and outcome assessment for OBPI. The process established a new network of opinion leaders and researchers for further guideline development, and multicentre research. The next step is to facilitate the implementation of the recommendations. / Thesis / Master of Science (MSc)