published_or_final_version / Anatomy / Master / Master of Medical Sciences

Introdução: O transplante autólogo de células progenitoras hematopoéticas é indicado para tratamento de várias doenças neoplásicas e não-neoplásicas, tais como linfoma, mieloma múltiplo e doenças autoimunes. Para isso, é imprescindível coletar as células progenitoras hematopoéticas (CPHs), em geral mobilizadas para o sangue periférico, por meio de equipamentos de aférese e acesso venoso adequado, seja de veia periférica seja de veia central quando a primeira não for adequada. Usualmente, o acesso periférico se dá por veia da fossa cubital. Entretanto, a veia jugular externa também poderia ser uma opção em pacientes em que a veia cubital não proporcionar fluxo sanguíneo adequado, uma possibilidade ainda muito pouco explorada nesse contexto. Objetivos: Avaliar a viabilidade de coletar CPHs pela veia jugular externa em pacientes que não tem acesso por meio da veia da fossa cubital.Métodos: Trata-se de estudo observacional do tipo transversal, com coleta retrospectiva dos dados por meio da análise das fichas médicas arquivadas no Hemonúcleo do Hospital de Câncer de Barretos. A amostra foi composta de 26 indivíduos, sendo que 13 (50%) dos participantes tiveram a punção da veia jugular externa e os outros 13 (50%) foram extraídos aleatoriamente do conjunto de 913 pacientes que tiveram a punção da veia da fossa cubital para equilíbrio numérico das amostras, no período de 2007 a 2014. Resultados: Dos 26 participantes do estudo, 19 (76,9%) foram do sexo masculino e 7 (23,1%) do sexo feminino. Entre as doenças, o mieloma foi a mais prevalente, não houve diferença quanto ao diagnóstico entre os dois grupos fossa cubital e jugular. As médias de células CD34+ coletadas no grupo fossa cubital e no grupo jugular foram de 10,0 x 106/kg e 5,1 x 106/kg, respectivamente (p=0,20). As volemias processadas foram de 4,2 e 4,4 para os grupos fossa cubital de jugular (p=0,12). O fluxo médio de aspiração do sangue foi de 69±17 mL/minuto e 62±17 mL/minuto (p=0,29). Conclusão: Há viabilidade da coleta de CPH por via jugular externa / Introduction: Autologous hematopoietic progenitor cell transplantation is indicated for the treatment of various neoplastic and non-neoplastic diseases, such as lymphoma, multiple myeloma, and autoimmune diseases. For this, it is essential to collect the hematopoietic progenitor cells (CPHs), usually mobilized into the peripheral blood, by means of apheresis devices and adequate venous access, either peripheral vein or central vein when the former is not adequate. Usually, the peripheral access is by the ulnar fossavein. However, the external jugular vein could also be an option in patients where the ulnar vein does not provide adequate blood flow, a possibility still very little explored in this context. Objectives: To evaluate the feasibility of collecting CPHs through the external jugular vein in patients who do not have access through the ulnar fossa vein. Methods: It is an observational cross-sectional study, with retrospective data collection through the analysis of the medical records filed at the Barretos Cancer Hospital. The sample consisted of 26 individuals; 13 (50%) of the participants had external jugular vein puncture and the other 13 (50%) were randomly extracted from a set of 913 patients who had ulnar fossa vein puncture to numerical equilibrium of the samples from 2007 to 2014. Results: Of the 26 participants in the study, 19 (76.9%) were male and 7 (23.1%) were female. Among the diseases, myeloma was the most prevalent; there was no difference in diagnosis between the two groups of ulnar and jugular fossa. The mean CD34 + cells collected in the cubital fossa group and in the jugular group were 10.0 x 106/kg and 5.1 x 106/kg, respectively (p=0.20). The blood volumes processed were 4.2 and 4.4 for the jugular fossa group (p=0.12). The mean blood aspiration flow was 69 ± 17 mL/min and 62 ± 17 mL/min (p=0.29). Conclusion: there is viability of the collection of CPHs by external jugular vein

Introdução: O transplante autólogo de células progenitoras hematopoéticas é indicado para tratamento de várias doenças neoplásicas e não-neoplásicas, tais como linfoma, mieloma múltiplo e doenças autoimunes. Para isso, é imprescindível coletar as células progenitoras hematopoéticas (CPHs), em geral mobilizadas para o sangue periférico, por meio de equipamentos de aférese e acesso venoso adequado, seja de veia periférica seja de veia central quando a primeira não for adequada. Usualmente, o acesso periférico se dá por veia da fossa cubital. Entretanto, a veia jugular externa também poderia ser uma opção em pacientes em que a veia cubital não proporcionar fluxo sanguíneo adequado, uma possibilidade ainda muito pouco explorada nesse contexto. Objetivos: Avaliar a viabilidade de coletar CPHs pela veia jugular externa em pacientes que não tem acesso por meio da veia da fossa cubital.Métodos: Trata-se de estudo observacional do tipo transversal, com coleta retrospectiva dos dados por meio da análise das fichas médicas arquivadas no Hemonúcleo do Hospital de Câncer de Barretos. A amostra foi composta de 26 indivíduos, sendo que 13 (50%) dos participantes tiveram a punção da veia jugular externa e os outros 13 (50%) foram extraídos aleatoriamente do conjunto de 913 pacientes que tiveram a punção da veia da fossa cubital para equilíbrio numérico das amostras, no período de 2007 a 2014. Resultados: Dos 26 participantes do estudo, 19 (76,9%) foram do sexo masculino e 7 (23,1%) do sexo feminino. Entre as doenças, o mieloma foi a mais prevalente, não houve diferença quanto ao diagnóstico entre os dois grupos fossa cubital e jugular. As médias de células CD34+ coletadas no grupo fossa cubital e no grupo jugular foram de 10,0 x 106/kg e 5,1 x 106/kg, respectivamente (p=0,20). As volemias processadas foram de 4,2 e 4,4 para os grupos fossa cubital de jugular (p=0,12). O fluxo médio de aspiração do sangue foi de 69±17 mL/minuto e 62±17 mL/minuto (p=0,29). Conclusão: Há viabilidade da coleta de CPH por via jugular externa / Introduction: Autologous hematopoietic progenitor cell transplantation is indicated for the treatment of various neoplastic and non-neoplastic diseases, such as lymphoma, multiple myeloma, and autoimmune diseases. For this, it is essential to collect the hematopoietic progenitor cells (CPHs), usually mobilized into the peripheral blood, by means of apheresis devices and adequate venous access, either peripheral vein or central vein when the former is not adequate. Usually, the peripheral access is by the ulnar fossavein. However, the external jugular vein could also be an option in patients where the ulnar vein does not provide adequate blood flow, a possibility still very little explored in this context. Objectives: To evaluate the feasibility of collecting CPHs through the external jugular vein in patients who do not have access through the ulnar fossa vein. Methods: It is an observational cross-sectional study, with retrospective data collection through the analysis of the medical records filed at the Barretos Cancer Hospital. The sample consisted of 26 individuals; 13 (50%) of the participants had external jugular vein puncture and the other 13 (50%) were randomly extracted from a set of 913 patients who had ulnar fossa vein puncture to numerical equilibrium of the samples from 2007 to 2014. Results: Of the 26 participants in the study, 19 (76.9%) were male and 7 (23.1%) were female. Among the diseases, myeloma was the most prevalent; there was no difference in diagnosis between the two groups of ulnar and jugular fossa. The mean CD34 + cells collected in the cubital fossa group and in the jugular group were 10.0 x 106/kg and 5.1 x 106/kg, respectively (p=0.20). The blood volumes processed were 4.2 and 4.4 for the jugular fossa group (p=0.12). The mean blood aspiration flow was 69 ± 17 mL/min and 62 ± 17 mL/min (p=0.29). Conclusion: there is viability of the collection of CPHs by external jugular vein

Information about the central venous pressure is important in evaluating several clinical conditions including cardiac failure and volume overload. The jugular veins serve as a primary route for the indirect estimation of the central venous pressure or waveform. The conventional methods for acquiring the central venous pressure in these veins have been through neck visualization and the insertion of catheters. Even though these procedures are effective if done properly, they have various downsides such as being invasive, inaccurate and time consuming. In this research, a sensor is proposed for the noninvasive detection of central venous waveforms within the jugular veins. The sensor is a reflectance configured probe which utilizes laser based on the photoplethysmography principle. The effectiveness of the sensor was tested in-vitro using a mock circulatory loop and was also tested on a single human subject. The results from the tests indicated a very good sensor response in estimating pressure waveforms.

Made available in DSpace on 2014-06-11T19:31:09Z (GMT). No. of bitstreams: 0 Previous issue date: 2011-06-15Bitstream added on 2014-06-13T19:20:11Z : No. of bitstreams: 1 dias_dpm_dr_jabo.pdf: 1050559 bytes, checksum: 7a07158370abdb59cd93a29b2daf1a46 (MD5) / Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP) / A tromboflebite jugular é frequentemente encontrada em equinos causando comprometimento circulatório grave nas regiões cervical e cefálica. Até o presente momento, não há relatos que avaliem as alterações hemodinâmicas em equinos causadas pela obstrução venosa jugular por trombo durante o exercício. Da mesma forma, não há relatos da eficácia da terapia trombolítica regional com estreptoquinase no tratamento desta alteração vascular em equinos. Os objetivos deste trabalho foram: avaliação da técnica cirúrgica de canulação da artéria facial e manutenção prolongada do cateter com solução de heparina e ácido ascórbico, visando realizar de forma seriada colheita de amostras sanguíneas e avaliação invasiva de pressão arterial, durante o exercício em esteira rolante; estabelecimento de um modelo de indução de tromboflebite da veia jugular de equinos utilizando solução de dois agentes esclerosantes associados: oleato de etanolamina 5% e glicose 50%; avaliação da terapia trombolítica regional com estreptoquinase como tratamento da tromboflebite jugular induzida experimentalmente em equinos; avaliação hemodinâmica de equinos submetidos a oclusão unilateral da veia jugular por tromboflebite induzida. Vinte equinos adultos foram utilizados para conclusão dos protocolos. O procedimento de cateterização da artéria facial e manutenção do cateter com solução de heparina e ácido ascórbico, manteve a via arterial viável por 25 dias. O protocolo de indução não cirúrgica de tromboflebite jugular experimental foi eficaz em reproduzir a lesão de forma padronizada. Foram observadas alterações hemodinâmicas significativas nos equinos apresentando oclusão jugular por trombose induzida, durante o exercício de esforço progressivo em esteira rolante... / Thrombophlebitis of the jugular vein is commonly observed in horses leading to head and neck circulatory impairment. To date, there are no reports evaluating hemodynamic changes in horses presenting thrombus obstruction during the exercise. In addition, there are no studies about the use of streptokinase in thrombolytic therapy for treatment of jugular vein thrombophlebitis in horses. The purposes of this study were: to evaluate the technique for facial artery catheter implantation and long-term maintenance using heparin and ascorbic acid as a filling solution, to perform serial blood sampling and invasive arterial pressure measurement during the exercise on treadmill; establishment of an equine jugular vein thrombophlebitis induction model using a solution of two sclerosing agents in association: ethanolamine oleate 5% and glucose 50%; hemodynamic evalution in horses presenting unilateral occlusion of the jugular vein through experimental inducted thrombophlebitis; evaluation of regional thrombolytic therapy using streptokinase as a treatment for jugular vein inducted thrombophlebitis in horses. Twenty adult horses were assessed to conclude all the protocols. Procedures for facial artery catheterization and maintenance using heparin and ascorbic acid as a filling solution kept the arterial line open for 25 days. The nonsurgical protocol to induce experimental jugular thrombophlebitis was efficient in reproduce a standardized lesion. Significative hemodynamic changes were observed in the horses presenting jugular occlusion through induced thrombosis during the exercise on treadmill. Streptokinase thrombolytic therapy test showed that the drug exerts fibrinolytic action on horses’ thrombus, however it was not capable to permanently recanalize injuried vessels

The aim of this project is to develop and perform a first evaluation of a software, based on the active contour, which automatically computes the cross-section area of the internal jugular veins through a sequence of 90 ultrasound images. The software is intended to be useful in future research in the field of intra cranial pressure and its associated diseases. The biomechanics of the internal jugular veins and its relationship to the intra cranial pressure is studied with ultrasound. It generates data in the form of ultrasound sequences shot in seven different body positions, supine to upright. Vein movements in cross section over the cardiac cycle are recorded for all body positions. From these films, it is interesting to know how the cross-section area varies over the cardiac cycle and between body positions, in order to estimate the pressure. The software created was semi-automatic, where the operator loads each individual sequence and sets the initial contour on the first frame. It was evaluated in a test by comparing its computed areas with manually estimated areas.  The test showed that the software was able to track and compute the area with a satisfactory accuracy for a variety of sequences. It is also faster and more consistent than manual measurements. The most difficult sequences to track were small vessels with narrow geometries, fast moving walls, and blurry edges. Further development is required to correct a few bugs in the algorithm. Also, the improved algorithm should be evaluated on a larger sample of sequences before using it in research.

Traumatic arteriovenous fistulas of the neck are a relatively uncommon injury, whose ramifications can include immediate or delayed neurological insults, massive bleeding, or death. Angiography and embolization have been increasingly used to manage this complex injury pattern. In this particular case, the patient underwent management of bilateral communicating arteriovenous fistulae using a commercially available plug occlusion device. Epidemiology, with an emphasis on patient management and outcomes, is discussed.

Knowledge about biomechanical properties of veins is of importance for understanding the physiologyof the venous system. Specifically for this thesis there is a motivation based on an idea of how to usebiomechanics of the vein in the development of new non-invasive measurement techniques for assessingthe pressure in the brain. The cross sectional area of veins is known to depend on pressure changes insidethe vessel. There are many ways of provoking these pressure changes, like changing posture or creating apositive airway pressure. The hypothesis is that the positive airway pressure will increase the intrathoracic pressure and in turnincrease the pressure in the internal jugular veins by the same magnitude. The cross sectional area will from a pressure change subsequently change with respect to the biomechanical properties of the vessel walls. A first aim in this study was to determine how the cross sectional area of the internal jugular veins is altered due to changes in airway pressure. A second aim was to develop and evaluate a model where the biomechanical properties of the internal jugular veins is described, based on the relationship between pressure and area of the vein. Ultrasound measurements were performed on one healthy adult man to study the effect on the cross sectional area at different pressure provocations. Measurements on the subject was performed at four different head up tilt angles, causing a pressure decrease in the internal jugular vein. A controlled Valsalva method was performed to give the positive airway pressure giving corresponding pressure increases. With an increased airway pressure the effect on cross sectional area changes was about 23% of the effect dueto hydrostatic pressure changes, at a tilt angle from 0° to 8°. At a tilt angle from 8° to 16° the effect was about 35%. Thus the venous pressure seems to be increased due to an increased airway pressure, but not tothe same magnitude. The theoretical model was developed and subsequently evaluated using existing head down tilt magneticresonance imaging data on nine healthy volunteers. An expression for how radius of the vessel depends on pressure changes was derived and evaluated. This expression included individual biomechanical properties that were estimated on group level for the nine subjects. The resulting equation could beused to give an approximate prediction of the increase in radius to a change in venous pressure. In conclusion, the hypothesis suggesting that a positive airway pressure would give an equally increased venous pressure could not be confirmed, and this knowledge should be considered when trying to assess thepressure in the brain with this technique. The derived biomechanical model was promising for predictionof cross sectional area with respect to a change in venous pressure. / Att ha kännedom om biomekaniska egenskaper hos vener är viktigt för att kunna förstå fysiologin hos vensystemet. I den här rapporten finns det i synnerhet ett intresse av detta baserat på en idé för hur veners biomekanik kan användas för att utveckla en ny icke-invasiv mätteknik för att uppskatta trycket i hjärnan. Det är känt att tvärsnittsnittarean av vener beror på tryckförändringar inne i kärlet. Att provocera fram dessatryckförändringar går att göra på många sätt, till exempel genom en förändrad kroppsposition eller genomatt sätta ett positivt tryck på luftvägarna. Hypotesen är att ett positivt luftvägstryck kommer att höja det intratorakala trycket, vilket i sin turkommer att höja trycket inne i de interna jugularvenerna lika mycket. Tvärsnittsarean kommer därmed att ändras enligt biomekaniska egenkaper hos kärlväggen. Ett första syftet i det här arbetet var att bestämma hur tvärsnittsarean av de internal jugularvenerna varierar enligt förändringar i luftvägstryck. Det andra syftet var att utveckla en modell som beskriver de biomekaniska egenskaperna hos de interna jugularvenerna. Detta baserat på relationen mellan tryck och area hos venen. För att studera effekten på tvärsnittsarea för olika tryckprovokationer, genomfördes ultraljudsmätningar på en frisk och vuxen man. Mätningarna på subjektet genomfördes med överkroppen positionerad i fyra olika positiva vinklar relativt horisontalplanet, vilket leder till ett minskat tryck i jugularvenerna. En kontrollerad Valsalvametod användes för att skapa det positiva luftvägstrycket som då ska ge en motsvarande tryckökning. Vid en tiltvinkel på 8° var effekten på areaförändringarna som en följd av ökat luftvägstryck ca 23% av effekten som en följd av de hydrostatiska tryckförändringarna. Vid en tiltvinkel på 16° var effekten ca 35%. Det verkar som att ventrycket ökar med ökat luftvägstryck, men inte med samma storleksordning som det pålagda trycket. Den teoretiska modellen utvecklades och utvärderades sedemera med hjälp av befintligt MRI-data för nio friska och frivilliga subjekt, där överkropparna var positionerade i nedåt tilt. Modellen bestod av ettuttryck för hur radien av ett kärl beror på tryckförändringar inne i det. Modellen innehåller individspecifika egenskaper men utvärderingen gjordes på gruppnivå för de nio subjekten. Det resulterande uttrycket kunde användas för att ge en approximativ förutsägelse om hur radie förändras till följd av en variation i ventryck. Som slutsats så kunde hypotesen som föreslog att ett positivt luftvägstryck skulle ge en lika stor ökning av ventryck inte bekräftas. Om denna teknik ska användas för att försöka bestämma trycket i hjärna så måste hänsyn tas till dessa resultat. Den utvecklade biomekaniska modellen verkar lovande för att kunna förutsäga tvärsnittsarea utifrån ventrycksförändringar.

The neurological wake-up test, NWT, is a clinical monitoring tool that can be used to evaluate the level of consciousness in patients with traumatic brain injury (TBI) and subarachnoid haemorrhage (SAH) during neurocritical care (NCC). Since patients with severe TBI or SAH are often treated with mechanical ventilation and sedation, the NWT requires that the continuous sedation is interrupted. However, interruption of continuous sedation may induce a stress response and the use of the NWT in NCC is controversial. The effects of the NWT on intracranial pressure (ICP) and cerebral perfusion pressure (CPP) were evaluated in 21 patients with TBI or SAH. Compared to baseline when the patients were sedated with continuous propofol sedation, the NWT resulted in increased ICP and CPP (p<0.05). Next, the effects of the NWT on the stress hormones adrenocorticotrophic hormone (ACTH), cortisol, epinephrine and norepinephrine were evaluated in 24 patients. Compared to baseline, the NWT caused a mild stress response resulting in increased levels of all evaluated stress hormones (p<0.05). To compare the use of routine NCC monitoring tools, the choice of sedation and analgesia and the frequency of NWT in Scandinavian NCC units, a questionnaire was used. The results showed that all 16 Scandinavian NCC units routinely use ICP and CPP monitoring and propofol and midazolam were primary choices for patient sedation in an equal number of NCC units. In 2009, the NWT was not routinely used in eight NCC units whereas others used the test up to six times daily. Finally, intracerebral microdialysis (MD), brain tissue oxygenation (PbtiO2) and jugular bulb oxygenation (SjvO2) were used in 17 TBI patients to evaluate the effect of the NWT procedure on focal neurochemistry and cerebral oxygenation. The NWT did not negatively alter interstitial markers of energy metabolism or cerebral oxygenation. In conclusion, the NWT induced a mild stress response in patients with TBI or SAH that did not result in a detectable, significant secondary insult to the injured brain. These results suggest that the NWT may safely be used as a clinical monitoring tool in the NCC of severe TBI and SAH in a majority of patients.

Orientador: José Corrêa de Lacerda Neto / Banca: Julio Carlos Canola / Banca: Áureo Evangelista Santana / Banca: Olivier Lepage / Banca: Juliana Regina Peiró / Resumo: A tromboflebite jugular é frequentemente encontrada em equinos causando comprometimento circulatório grave nas regiões cervical e cefálica. Até o presente momento, não há relatos que avaliem as alterações hemodinâmicas em equinos causadas pela obstrução venosa jugular por trombo durante o exercício. Da mesma forma, não há relatos da eficácia da terapia trombolítica regional com estreptoquinase no tratamento desta alteração vascular em equinos. Os objetivos deste trabalho foram: avaliação da técnica cirúrgica de canulação da artéria facial e manutenção prolongada do cateter com solução de heparina e ácido ascórbico, visando realizar de forma seriada colheita de amostras sanguíneas e avaliação invasiva de pressão arterial, durante o exercício em esteira rolante; estabelecimento de um modelo de indução de tromboflebite da veia jugular de equinos utilizando solução de dois agentes esclerosantes associados: oleato de etanolamina 5% e glicose 50%; avaliação da terapia trombolítica regional com estreptoquinase como tratamento da tromboflebite jugular induzida experimentalmente em equinos; avaliação hemodinâmica de equinos submetidos a oclusão unilateral da veia jugular por tromboflebite induzida. Vinte equinos adultos foram utilizados para conclusão dos protocolos. O procedimento de cateterização da artéria facial e manutenção do cateter com solução de heparina e ácido ascórbico, manteve a via arterial viável por 25 dias. O protocolo de indução não cirúrgica de tromboflebite jugular experimental foi eficaz em reproduzir a lesão de forma padronizada. Foram observadas alterações hemodinâmicas significativas nos equinos apresentando oclusão jugular por trombose induzida, durante o exercício de esforço progressivo em esteira rolante ... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: Thrombophlebitis of the jugular vein is commonly observed in horses leading to head and neck circulatory impairment. To date, there are no reports evaluating hemodynamic changes in horses presenting thrombus obstruction during the exercise. In addition, there are no studies about the use of streptokinase in thrombolytic therapy for treatment of jugular vein thrombophlebitis in horses. The purposes of this study were: to evaluate the technique for facial artery catheter implantation and long-term maintenance using heparin and ascorbic acid as a filling solution, to perform serial blood sampling and invasive arterial pressure measurement during the exercise on treadmill; establishment of an equine jugular vein thrombophlebitis induction model using a solution of two sclerosing agents in association: ethanolamine oleate 5% and glucose 50%; hemodynamic evalution in horses presenting unilateral occlusion of the jugular vein through experimental inducted thrombophlebitis; evaluation of regional thrombolytic therapy using streptokinase as a treatment for jugular vein inducted thrombophlebitis in horses. Twenty adult horses were assessed to conclude all the protocols. Procedures for facial artery catheterization and maintenance using heparin and ascorbic acid as a filling solution kept the arterial line open for 25 days. The nonsurgical protocol to induce experimental jugular thrombophlebitis was efficient in reproduce a standardized lesion. Significative hemodynamic changes were observed in the horses presenting jugular occlusion through induced thrombosis during the exercise on treadmill. Streptokinase thrombolytic therapy test showed that the drug exerts fibrinolytic action on horses' thrombus, however it was not capable to permanently recanalize injuried vessels / Doutor