O desenvolvimento de um método eficiente de avaliação prognóstica precoce seria de grande utilidade na seleção de lactentes com plexopatia braquial obstétrica para cirurgias de reconstrução do plexo braquial. Realizamos estudos de condução motora em 54 pacientes entre 10 e 60 dias de vida. Foram comparadas lado a lado as amplitudes dos potenciais de ação musculares compostos dos nervos axilar (músculo deltóde), musculocutâneo (músculo bíceps), radial proximal (músculo tríceps), radial distal (músculo extensor comum dos dedos), mediano (eminência tenar) e ulnar (eminência hipotenar). A relação entre a amplitude do potencial motor do lado lesado sobre o lado são foi chamada de Índice de Viabilidade Axonial (IVA), sendo este calculado tanto a partir da amplitude negativa como da amplitude pico-a-pico. Os pacientes foram seguidos clinicamente e classificados em três grupos: Grupo A, com recuperação total até os seis meses de vida; Grupo B, recuperação satisfatória até os doze meses de vida, e Grupo C, recuperação insatisfatória até os doze meses de vida. Analisamos a curva ROC (Receive Operator Characteristic Curve) de cada IVA para definir o melhor ponto de corte para detecção dos pacientes do Grupo C (mau prognóstico). Para o nervo axilar, o ponto de corte ideal foi IVA menor que 10%, com sensibilidade de 88,2% e especificidade de 89,2% ou 91,9%. Para o nervo musculocutâneo, o ponto de corte foi a ausência de potencial de ação motor, com sensibilidade de 88,2% e especificidade de 73,0%. Para o nervo radial proximal, o ponto de corte foi IVA menor que 20%, com sensibilidade de 82,4% ou 94,1% e especificidade de 97,3% ou 100%. Para o nervo radial distal, o ponto de corte foi IVA menor que 50%, com sensibilidade de 76,5% ou 82,4% e especificidade de 97,3%. Para o nervo ulnar, o ponto de corte foi IVA menor que 50%, com sensibilidade de 58,8% e especificidade de 97,3% ou 100%. O IVA do nervo mediano teve um desempenho ruim e seu uso não pode ser recomendado. Os IVAs dos nervos radial proximal, radial distal e ulnar apresentaram maior especificidade do que o critério clínico mais utilizado para a avaliação prognóstica, ou seja, ausência de função bicipital aos três meses de vida. A sensibilidade dos IVAs dos nervos axilar, musculocutâneo, radial proximal e radial distal foram equivalentes à do critério clínico. A utilização do estudo de condução motora entre 10 e 60 dias de vida forneceu uma avaliação prognóstica mais precoce e mais específica do que o critério clínico, podendo ser utilizada para indicação cirúrgica destes pacientes. / Early prognostic assessment of obstetric brachial plexopathies would be a major step for rational selection of infants for brachial plexus surgery. We performed nerve conduction studies in 54 patients from 10 to 60 days of life. We compared sideto-side the compound muscle action potentials amplitudes from the axillary (deltoid muscle), musculocutaneous (biceps), proximal radial (triceps), distal radial (extensor digitorum communis), median (thenar eminence) and ulnar nerves (hypothenar eminence). The ratio between the amplitude of the affected limb and that of the healthy side was called Viability Axonal Index (VAI), which was calculated using both the negative and the peak-to-peak amplitudes. The patients were followed-up and classified in three groups: Group A, with full recovery at six months of age; Group B, with satisfactory recovery at twelve months of age, and Group C, with poor recovery at twelve months of age. We analyzed the ROC (Receive Operator Characteristic) curve of each VAI to define the best cut-off point for detection of Group C patients (bad prognosis). The best cut-off point for the axillary nerve was a VAI of less than 10%, whith sensibility of 88.2% and specificity of 89.2% or 91.9%. For the musculocutaneous nerve, the cut-off point was an absent motor action potential, with sensibility of 88.2% and specificity of 73.0%. For the proximal radial nerve, the cut-off point was a VAI of less than 20%, with sensibility of 82.4% or 94.1% and specificity of 97.3% or 100%. For the distal radial nerve, the cut-off point was a VAI of less than 50%, with sensibility of 76.5% or 82.4% and specificity of 97.3%. For the ulnar nerve, the cut-off point was a VAI of less than 50%, which sensibility of 58.8% and specificity of 97.3% or 100%. The VAI from the median nerve had a poor performance and its use could not be recommended. The VAIs from proximal radial, distal radial and ulnar nerves had better specificities compared to the most used clinical criterion: absence of biceps function at three months of age. The VAIs sensitivities from axillary, musculocutaneous, proximal radial and distal radial nerves were equivalent to the clinical criterion. The use of motor conduction studies between 10 and 60 days of age yielded an earlier and more specific prognostic estimation than the clinical criterion, and could be used for indication of surgery in these patients.

A Anatomia comparativa de mamíferos vem sendo tema de pesquisas, nas áreas biomédica e biológica com o objetivo de se buscar conhecimentos que possam auxiliar na busca sobre o entendimento do binômio unidade-variedade, dentre os símios tem sido particularmente enfocados o Babuíno e o Rhesus que, entretanto, não são próprios do Novo Mundo. O Cebus apella, animal das matas do continente Sul-americano, distribuindo-se geograficamente por quase todo o Brasil, apresenta satisfatória adaptação à vida em cativeiro condição em que, inclusive, se reproduz com facilidade. Assim, é de nosso interesse focalizar, o Cebus apella, analisando a origem, a composição e os nervos resultantes de seu plexo braquial. O objetivo imediato deste trabalho é, dar seqüência ao conhecimento de sua Anatomia, visando também o fornecimento de subsídios para interpretações anatómo-funcionais do Cebus apella, comparativamente a outros animais. O objetivo a médio e a longo prazos é o estabelecimento do padrão anatômico deste animal, culminando com a elaboração de um Atlas - texto sobre a Anatomia do macaco Cebus apella. Utilizamos 20 animais, sendo 10 machos e 10 fêmeas, adultos, pertencentes ao acervo de pesquisas da Universidade Federal de Uberlândia. A preparação das peças anatômicas foi feita segundo a metodologia usual em estudos anatômicos. Os principais nervos oriundos do plexo braquial são: supraescapular, subescapular, musculocutâneo, radial, mediano, ulnar, axilar, toracodorsal, peitoral maior e peitoral menor. Em 57% dos espécimes dissecados o plexo braquial do Cebus está constituído por raízes de C5 a T1, em 21,4% de C5 a T2, em 14,3% de C4 a T1 e em 7,3% de C4 a T2. O plano dorsal do plexo braquial contribui para a formação dos nervos: frênico, peitoral maior e peitoral menor. O plano médio origina os nervos musculocutâneo, mediano, ulnar e cutâneo medial do antebraço, enquanto o plano ventral dá origem aos nervos supraescapular, subescapular, axilar, radial e torácico longo. Discute-se a ocorrência de pré e de pós-fixação do plexo, bem como a de seu deslocamento cranial e caudal. Em conclusão o plexo braquial do Cebus apella está constituído por raízes de C5 a T1 e é organizado em um plano ventral mais simples, um médio de complexidade intermediária e um dorsal mais complexo. / Comparative Anatomy of mammals has been a relevant theme of researches in the biomedical and biological areas with the objective of looking for more information that can aid for searching on the understanding of the unit-variety complex. Among the simians, Baboon and Rhesus have been particularly focused, although they are not from the New World. The monkey Cebus apella, animal of the forests of the South American continent, being geographically distributed for almost the whole Brazil, presents satisfactory adaptation to the captive life showing a great easiness of reproduction. Thus, we intended to study the monkey Cebus apella, analyzing the origin, the composition and the resulting nerves of its brachial plexus. The immediate objective of this study was to add information to the knowledge of its Anatomy, seeking the supply of subsidies for anatomo-functional interpretations of Cebus apella comparatively to humans and domestic animals. Further, we propose to establish the anatomical pattern of this animal, culminating with the elaboration of an Atlas - text on the Anatomy of the monkey Cebus apella. Twenty adult animals, 10 male and 10 female, belonging to the collection of anatomical pieces of the Anatomy Laboratory of the Federal University of Uberlândia were obtained and prepared through fixation and dissection. The major nerves originating from the brachial plexus were: the suprascapular, the subscapular, the musculo-cutaneous, the radial, the median, the ulnar, the axillary, the thoraco-dorsal, the pectoralis major and the pectoralis minor. In the dissected specimens, the brachial plexus of Cebus apella was constituted by the roots from C5 to T1 (55,00 ± 11,12%), from C5 to T2 (25,00 ± 9,68%), from C4 to T1 (15,00 ± 7,98%) and from C4 to T2 (5,00 ± 4,87%). The ventral plan of the brachial plexus contributed for the formation of the following nerves: the phrenic, the subclavius, the pectoralis major, and the pectoralis minor. The medium plan originated the musculo-cutaneous, the median, the ulnar, and the forearm medial cutaneous nerves, while the dorsal plan originated the suprascapular, the subscapular, the axillary, the radial, thoraco-dorsal and the long thoracic nerves. In addition, the occurrence of pre- and post- fixation of the plexus as well as its cranial and caudal displacement have been discussed. In conclusion, the brachial plexus of Cebus apella constituted by the roots from C5 to T1 is organized in a simpler ventral plan, a medium plan of intermediate complexity and a more complex dorsal plan.

Estudos de prognóstico clínico consistem na predição do curso de uma doença em pacientes e são utilizados por profissionais da saúde com o intuito de aumentar as chances ou a qualidade de sua recuperação. Sob a perspectiva computacional, a criação de um modelo prognóstico clínico é um problema de classificação, cujo objetivo é identificar a qual classe (dentro de um conjunto de classes predefinidas) uma nova amostra pertence. Este projeto visa a criar modelos prognósticos de lesões traumáticas do plexo braquial, um conjunto de nervos que inervam os membros superiores, utilizando dados de pacientes adultos com esse tipo de lesão. Os dados são provenientes do Instituto de Neurologia Deolindo Couto (INDC) da Universidade Federal do Rio de Janeiro (UFRJ) e contêm dezenas de atributos clínicos coletados por meio de questionários eletrônicos. Com esses modelos prognósticos, deseja-se identificar de maneira automática os possíveis preditores do curso desse tipo de lesão. Árvores de decisão são classificadores frequentemente utilizados para criação de modelos prognósticos, por se tratarem de um modelo transparente, cujo resultado pode ser examinado e interpretado clinicamente. As Florestas Aleatórias, uma técnica que utiliza um conjunto de árvores de decisão para determinar o resultado final da classificação, podem aumentar significativamente a acurácia e a generalização dos modelos gerados, entretanto ainda são pouco utilizadas na criação de modelos prognósticos. Neste projeto, exploramos a utilização de florestas aleatórias nesse contexto, bem como a aplicação de métodos de interpretação de seus modelos gerados, uma vez que a transparência do modelo é um aspecto particularmente importante em domínios clínicos. A estimativa de generalização dos modelos resultantes foi feita por meio de métodos que viabilizam sua utilização sobre um número reduzido de instâncias, uma vez que os dados relativos ao prognóstico são provenientes de 44 pacientes do INDC. Além disso, adaptamos a técnica de florestas aleatórias para incluir a possível existência de valores faltantes, que é uma característica presente nos dados utilizados neste projeto. Foram criados quatro modelos prognósticos - um para cada objetivo de recuperação, sendo eles a ausência de dor e forças satisfatórias avaliadas sobre abdução do ombro, flexão do cotovelo e rotação externa no ombro. As acurácias dos modelos foram estimadas entre 77% e 88%, utilizando o método de validação cruzada leave-one-out. Esses modelos evoluirão com a inclusão de novos dados, provenientes da contínua chegada de novos pacientes em tratamento no INDC, e serão utilizados como parte de um sistema de apoio à decisão clínica, de forma a possibilitar a predição de recuperação de um paciente considerando suas características clínicas. / Studies of prognosis refer to the prediction of the course of a disease in patients and are employed by health professionals in order to improve patients\' recovery chances and quality. Under a computational perspective, the creation of a prognostic model is a classification task that aims to identify to which class (within a predefined set of classes) a new sample belongs. The goal of this project is the creation of prognostic models for traumatic injuries of the brachial plexus, a network of nerves that innervates the upper limbs, using data from adult patients with this kind of injury. The data come from the Neurology Institute Deolindo Couto (INDC) of Rio de Janeiro Federal University (UFRJ) and they are characterized by dozens of clinical features that are collected by means of electronic questionnaires. With the use of these prognostic models we intended to automatically identify possible predictors of the course of brachial plexus injuries. Decision trees are classifiers that are frequently used for the creation of prognostic models since they are a transparent technique that produces results that can be clinically examined and interpreted. Random Forests are a technique that uses a set of decision trees to determine the final classification results and can significantly improve model\'s accuracy and generalization, yet they are still not commonly used for the creation of prognostic models. In this project we explored the use of random forests for that purpose, as well as the use of interpretation methods for the resulting models, since model transparency is an important aspect in clinical domains. Model assessment was achieved by means of methods whose application over a small set of samples is suitable, since the available prognostic data refer to only 44 patients from INDC. Additionally, we adapted the random forests technique to include missing data, that are frequent among the data used in this project. Four prognostic models were created - one for each recovery goal, those being absence of pain and satisfactory strength evaluated over shoulder abduction, elbow flexion and external shoulder rotation. The models\' accuracies were estimated between 77% and 88%, calculated through the leave-one-out cross validation method. These models will evolve with the inclusion of new data from new patients that will arrive at the INDC and they will be used as part of a clinical decision support system, with the purpose of prediction of a patient\'s recovery considering his or her clinical characteristics.

Ultrasound-guided selective C5 nerve root blocks have been described in several case reports as a safe and effective means to anesthetize the distal clavicle while maintaining innervation of the upper extremity and preserving diaphragmatic function. In this study, cadavers were injected with 5 mL of 0.5% methylene blue dye under ultrasound guidance to investigate possible proximal and distal spread of injectate along the brachial plexus, if any. Following the injections, the specimens were dissected and examined to determine the distribution of dye and the structures affected. One injection revealed dye extended proximally into the epidural space, which penetrated the dura mater and was present on the spinal cord and brainstem. Dye was noted distally to the divisions in 3 injections. The anterior scalene muscle and phrenic nerve were stained in all 4 injections. It appears unlikely that local anesthetic spread is limited to the nerve root following an ultrasound-guided selective C5 nerve root injection. Under certain conditions, intrathecal spread also appears possible, which has major patient safety implications. Additional safety measures, such as injection pressure monitoring, should be incorporated into this block, or approaches that are more distal should be considered for the acute pain management of distal clavicle fractures.

BACKGROUND: Recent studies indicate that the use of ankle-brachial index (ABI) measurements helps identify patients with peripheral arterial disease. Previous research also reveals a relationship between peripheral arterial disease and higher incidence of cardiac mortality and morbidity. PURPOSE: The purpose of this study was to investigate the correlation of a low ABI (<0.90 mm Hg) with coronary artery disease, diabetes, hypercholesterolemia, body mass index greater than 25, a sedentary lifestyle, smoking, and carotid artery disease. METHODS: A descriptive correlational design was used to study a population (N = 810) of fairly healthy women who self-selected to undergo cardiovascular screening that they paid for out of pocket. Cardiac disease and most of the data on risk factors were obtained using questionnaires. Carotid artery stenosis was determined by ultrasound. Hypotheses were tested using χ and independent t test. RESULTS: A statistically significant relationship was found between a low ABI and the presence of moderate to severe carotid artery stenosis (χ = 5.90, P = .015). A low ABI (<0.90 mm Hg) was not significantly related to cardiac disease (χ = 0.83, P = .362), diabetes (χ = 1.82, P = .177), hypercholesterolemia (χ = 0.01, P = .930), claudication (χ = 2.06, P = .151), physical activity (χ = 1.17, P = .884), or body mass index (t = 1.12, P = .270). CONCLUSION: The significant relationship between low ABI and carotid artery stenosis illustrates that atherosclerosis occurs in multiple arterial beds simultaneously. The lack of association between ABI and the other variables probably reflects the self-report nature of the data collected on these variables. Ankle-brachial index measurements may be useful in future research as a tool for early recognition of cardiovascular disease.

Gallstones have been linked to dyslipidemia, metabolic syndrome and cardiovascular disease. Arterial stiffness is an indicator of subclinical atherosclerosis. The aim of this study was to prospectively examine the relationship between gallstone disease and arterial stiffness progression in 347 men and 454 women. These subjects were followed for 7 years. Arterial stiffness progression was measured based on increases in brachial-ankle pulse wave velocity. Changes in brachial-ankle pulse wave velocity during the study period were significantly greater in patients with gallstones than in subjects without gallstones. After adjusting for multiple risk factors, gallstone disease was found to be a significant and independent predictor of brachial-ankle pulse wave velocity progression (β=0.189; P<0.001). In conclusion, gallstone disease is an independent predictor of arterial stiffness progression, even after adjusting for other cardiovascular risk factors.

No description available.

京都大学 / 0048 / 新制・課程博士 / 博士(医学) / 甲第18132号 / 医博第3852号 / 新制||医||1001(附属図書館) / 30990 / 京都大学大学院医学研究科医学専攻 / (主査)教授 戸口田 淳也, 教授 髙橋 良輔, 教授 宮本 享 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

No description available.

<p> Increased arterial stiffness and vascular endothelial dysfunction have been identified as independent risk factors for the development and progression of cardiovascular disease. Traditional endurance training has been associated with elevated levels of central arterial compliance and an attenuation of cardiovascular events. As well, the positive benefits of aerobic-based training have been acknowledged as effective modulators of vascular endothelial function. To date, the impact of sprint interval training on cardiovascular health has not been evaluated. Furthermore, the mechanisms responsible for previously observed enhancements in endurance (750 kJ) performance following two weeks of sprint interval training remain unclear, but may be related to changes in vascular structure and function.</p> <p> Nine young healthy males [age: 22 ± 0.5 (mean± SEM)] participated in a two week sprint interval training program consisting of 4-6 30 second maximum effort exercise bouts performed every other day on a cycle ergometer. In addition, each participant was required to complete a 750 kJ time trial on a cycle ergometer as a measure of aerobic exercise performance before (PRE) and after (POST) training. Measurements of supine, resting carotid pulse pressure, carotid cross-sectional compliance, and brachial vascular endothelial function (using flow mediated dilation) were also acquired PRE and POST training.</p> <p> Resting pulse pressure did not show any significant changes with exercise training (PRE= 48.6±1.6, POST= 52.4±2.5 mmHg, p>0.05). Mean brachial artery diameter was not changed with sprint interval training (PRE= 4.29±0.17, POST= 4.38±0.18 mm, p>0.05); however, mean carotid artery diameter increased significantly PRE to POST (PRE= 6.40±0.15, POST= 6.49±0.14 mm, p=0.008). Carotid cross-sectional compliance did not change PRE to POST training (PRE= 0.164±0.010, POST= 0.162±0.007 mm^2/mmHg, p>0.05). Brachial vascular endothelial function measured using flow-mediated dilation did not show a significant change with sprint interval training, however a trend towards improvement was noted (PRE= 4.6±1.8, POST= 6.4±1.0 %, p=0.296). When normalized for shear rate (which was also unaltered with sprint interval training) there were no changes in endothelial function (PRE = 0.158±0.068, POST= 0.198 ± 0.034 %/S^-1, p>0.05). Average brachial post-occlusion blood flow was significantly enhanced following training possibly revealing enhanced resistance vessel function (PRE= 296.0±37.4, POST= 324.8±38.8 ml/min, p=0.04), despite no change in peak brachial blood flow (PRE= 332.0±42.3, POST= 362.6±45.7 ml/min, p>0.05). 750 kJ time trial performance was significantly enhanced with training (PRE = 62.8±4.9; POST= 55.84±3.55 min; p=0.006).</p> <p> In conclusion, sprint interval training did not change resting carotid compliance or brachial endothelial function, despite significant improvements in aerobic performance (750 kJ). However, carotid resting diameters and brachial post occlusion blood flow were significantly increased PRE to POST and a trend towards improvement was seen for brachial flow mediated dilation. The exact mechanisms responsible for such changes remain unknown and require further investigation.</p> / Thesis / Master of Science (MSc)