Conselho Nacional de Desenvolvimento Científico e Tecnológico / A fase cefálica de secreção de insulina (FCSI) ocorre dentro da fase cefálica da digestão, em aproximadamente dez minutos entre a estimulação oro-sensorial pelo alimento e o início da absorção deste e determina um incremento rápido dos níveis basais de insulina. A FCSI parece ser importante para a tolerância normal à glicose. A hipótese deste estudo é de que a insulina secretada na fase cefálica da digestão teria ações direcionadas para o tecido microvascular, com conseqüente recrutamento capilar. Estudos recentes com indivíduos sadios têm mostrado a associação entre função microvascular e componentes dietéticos. Padrões alimentares saudáveis e intervenções nutricionais com alimentos específicos representam estratégias preventivas e terapêuticas não-farmacológicas para redução da inflamação e do risco metabólico e cardiovascular associados. O estudo de consumo alimentar inserido nesta pesquisa objetivou identificar associações entre componentes dietéticos e a função microvascular em indivíduos saudáveis. Após avaliação clínica e laboratorial, 39 voluntários saudáveis foram submetidos a dois exames de videocapilaroscopia do leito ungueal, com um intervalo de dez minutos entre os mesmos. Neste intervalo, conforme randomização, uma refeição com ótima apresentação e aroma foi apresentada (estímulo sensorial) ou não (controle). Coletas sangüíneas foram realizadas aos 3, 9 e 15 minutos após a apresentação do estimulo, para avaliação dos níveis de insulina e polipeptídeo pancreático (PP), marcadores bioquímicos da fase cefálica da digestão. Durante todo o exame medidas de fluxo e vasomotricidade foram realizadas pela técnica de laser-Doppler fluxometria. Após o exame, foi realizada iontoforese transdérmica de insulina. Todos os participantes responderam a um questionário de freqüência alimentar (QFA), relativo ao hábito de consumo dietético dos últimos 12 meses. O estudo da resposta microvascular à fase cefálica comparou as diferenças de densidade capilar funcional e fluxo capilar nos grupos experimental e controle, antes e após o estímulo sensorial, e sua correlação com a variação de insulina e PP. O estudo de consumo alimentar avaliou correlações entre componentes dietéticos e recrutamento capilar no exame basal (antes do estímulo) em toda amostra. Após o intervalo, o grupo que recebeu o estímulo sensorial teve sua densidade capilar funcional (DCF) aumentada. A variação de insulina não diferiu entre os grupos e a de PP foi maior no grupo estimulado, sendo também correlacionada positivamente como aumento na DCF. A velocidade máxima de perfusão pósisquemia também aumentou no grupo estimulado, enquanto o tempo para alcançar esta velocidade máxima diminuiu. O estudo do consumo alimentar revelou associações positivas entre o consumo de cálcio, selênio e laticínios e recrutamento capilar na amostra total. Em conclusão, o consumo alimentar de cálcio, selênio e laticínios foi associado com maior recrutamento capilar em indivíduos sadios. Nestes indivíduos a microcirculação cutânea respondeu ao estímulo da fase cefálica da digestão com recrutamento capilar e aumento de fluxo sanguíneo microvascular. / The cephalic phase of insulin secretion (CPIS) occurs within the cephalic phase of digestion, in approximately ten minutes between the oral-sensorial stimulation elicited by the food to be consumed and the beginning of its absorption. It determines a rapid increase in insulin levels. The CPIS is believed to be important for normal glucose tolerance. The hypothesis of this study is that insulin secreted during cephalic phase would also have actions targeting microvascular tissue, with resulting capillary recruitment. Recent studies with healthy subjects have shown an association between microvascular function and dietary factors. Healthy eating patterns and nutritional interventions with specific food items represent non-pharmacological preventive and therapeutic strategies for reducing inflammation and cardio-metabolic associated risk factors. The study of food intake included in this research aimed to identify associations between dietary intake and microvascular function in healthy subjects. After clinical and laboratorial assessment, 39 healthy men underwent two nailfold videocapillaroscopies, with an interval of 10 minutes between them. In this interval, according to randomization, they were subjected to a great-looking breakfast tray (CPIS group) or to nothing (control group). Blood samples were drawn at 3, 9 and 15 minutes after the stimulus presentation to assess insulin and pancreatic polypeptide (PP) levels, which are markers of cephalic phae of digestion. Throughout the exam, microflow and vasomotion were measured by laser-Doppler flowmetry. After the exam insulin iontophoresis was performed. All participants answered a food-frequency questionnaire (FFQ) regarding their dietary intake in the last 12 months. The assessment of microvascular response to CPIS compared differences in functional capillary density (FCD) and microflow in the CPIS and control groups, pre- and post-stimulus and their correlations with changes in insulin and PP. The study of food intake attempted to identify correlations between dietary factors and functional capillary recruitment pre-stimulus in the total sample. After the interval, the CPIS group had significantly increased basal and peak FCD. Insulin variation was not different between groups. PP was significantly increased in the CPIS group and its variation was positively correlated with FCD increase. Resting red blood cell velocity (RBCV) and peak RBCV were also significantly increased and time taken to reach peak RBCV, decreased. The study of food intake revealed positive associations between calcium, selenium and dairy intakes and functional capillary recruitment in the total sample. In conclusion, skin microcirculation is activated during cephalic phase of digestion. Selenium, calcium and dairy intakes are positively associated with capillary recruitment in healthy men.

Conselho Nacional de Desenvolvimento Científico e Tecnológico / A fase cefálica de secreção de insulina (FCSI) ocorre dentro da fase cefálica da digestão, em aproximadamente dez minutos entre a estimulação oro-sensorial pelo alimento e o início da absorção deste e determina um incremento rápido dos níveis basais de insulina. A FCSI parece ser importante para a tolerância normal à glicose. A hipótese deste estudo é de que a insulina secretada na fase cefálica da digestão teria ações direcionadas para o tecido microvascular, com conseqüente recrutamento capilar. Estudos recentes com indivíduos sadios têm mostrado a associação entre função microvascular e componentes dietéticos. Padrões alimentares saudáveis e intervenções nutricionais com alimentos específicos representam estratégias preventivas e terapêuticas não-farmacológicas para redução da inflamação e do risco metabólico e cardiovascular associados. O estudo de consumo alimentar inserido nesta pesquisa objetivou identificar associações entre componentes dietéticos e a função microvascular em indivíduos saudáveis. Após avaliação clínica e laboratorial, 39 voluntários saudáveis foram submetidos a dois exames de videocapilaroscopia do leito ungueal, com um intervalo de dez minutos entre os mesmos. Neste intervalo, conforme randomização, uma refeição com ótima apresentação e aroma foi apresentada (estímulo sensorial) ou não (controle). Coletas sangüíneas foram realizadas aos 3, 9 e 15 minutos após a apresentação do estimulo, para avaliação dos níveis de insulina e polipeptídeo pancreático (PP), marcadores bioquímicos da fase cefálica da digestão. Durante todo o exame medidas de fluxo e vasomotricidade foram realizadas pela técnica de laser-Doppler fluxometria. Após o exame, foi realizada iontoforese transdérmica de insulina. Todos os participantes responderam a um questionário de freqüência alimentar (QFA), relativo ao hábito de consumo dietético dos últimos 12 meses. O estudo da resposta microvascular à fase cefálica comparou as diferenças de densidade capilar funcional e fluxo capilar nos grupos experimental e controle, antes e após o estímulo sensorial, e sua correlação com a variação de insulina e PP. O estudo de consumo alimentar avaliou correlações entre componentes dietéticos e recrutamento capilar no exame basal (antes do estímulo) em toda amostra. Após o intervalo, o grupo que recebeu o estímulo sensorial teve sua densidade capilar funcional (DCF) aumentada. A variação de insulina não diferiu entre os grupos e a de PP foi maior no grupo estimulado, sendo também correlacionada positivamente como aumento na DCF. A velocidade máxima de perfusão pósisquemia também aumentou no grupo estimulado, enquanto o tempo para alcançar esta velocidade máxima diminuiu. O estudo do consumo alimentar revelou associações positivas entre o consumo de cálcio, selênio e laticínios e recrutamento capilar na amostra total. Em conclusão, o consumo alimentar de cálcio, selênio e laticínios foi associado com maior recrutamento capilar em indivíduos sadios. Nestes indivíduos a microcirculação cutânea respondeu ao estímulo da fase cefálica da digestão com recrutamento capilar e aumento de fluxo sanguíneo microvascular. / The cephalic phase of insulin secretion (CPIS) occurs within the cephalic phase of digestion, in approximately ten minutes between the oral-sensorial stimulation elicited by the food to be consumed and the beginning of its absorption. It determines a rapid increase in insulin levels. The CPIS is believed to be important for normal glucose tolerance. The hypothesis of this study is that insulin secreted during cephalic phase would also have actions targeting microvascular tissue, with resulting capillary recruitment. Recent studies with healthy subjects have shown an association between microvascular function and dietary factors. Healthy eating patterns and nutritional interventions with specific food items represent non-pharmacological preventive and therapeutic strategies for reducing inflammation and cardio-metabolic associated risk factors. The study of food intake included in this research aimed to identify associations between dietary intake and microvascular function in healthy subjects. After clinical and laboratorial assessment, 39 healthy men underwent two nailfold videocapillaroscopies, with an interval of 10 minutes between them. In this interval, according to randomization, they were subjected to a great-looking breakfast tray (CPIS group) or to nothing (control group). Blood samples were drawn at 3, 9 and 15 minutes after the stimulus presentation to assess insulin and pancreatic polypeptide (PP) levels, which are markers of cephalic phae of digestion. Throughout the exam, microflow and vasomotion were measured by laser-Doppler flowmetry. After the exam insulin iontophoresis was performed. All participants answered a food-frequency questionnaire (FFQ) regarding their dietary intake in the last 12 months. The assessment of microvascular response to CPIS compared differences in functional capillary density (FCD) and microflow in the CPIS and control groups, pre- and post-stimulus and their correlations with changes in insulin and PP. The study of food intake attempted to identify correlations between dietary factors and functional capillary recruitment pre-stimulus in the total sample. After the interval, the CPIS group had significantly increased basal and peak FCD. Insulin variation was not different between groups. PP was significantly increased in the CPIS group and its variation was positively correlated with FCD increase. Resting red blood cell velocity (RBCV) and peak RBCV were also significantly increased and time taken to reach peak RBCV, decreased. The study of food intake revealed positive associations between calcium, selenium and dairy intakes and functional capillary recruitment in the total sample. In conclusion, skin microcirculation is activated during cephalic phase of digestion. Selenium, calcium and dairy intakes are positively associated with capillary recruitment in healthy men.

Embasamento racional: O uso rotineiro da cineangiocoronariografia tem demonstrado que nem todos os pacientes com suspeita clínica de doença arterial coronária (DAC) apresentam-se com lesões obstrutivas nas artérias coronárias epicárdicas. Esse achado de dor precordial associado a coronárias angiograficamente normais é relativamente comum, estando presente em aproximadamente 30 % dos pacientes que realizam cateterismo cardíaco para investigação de DAC. Em uma parcela destes pacientes a isquemia miocárdica está presente e pode ser demonstrada através de um teste ergométrico convencional ou até mesmo pela aplicação da cintilografia miocárdica de perfusão (CMP) que é um método de maior acurácia para detecção da extensão/gravidade da isquemia. Pacientes que apresentam o quadro de dor precordial associada a coronárias angiograficamente normais e defeitos perfusionais reversíveis (DPR) na CMP são diagnosticados como portadores de disfunção microvascular coronária (DMC). Ainda que muito se conheça em relação à sua fisiopatologia, essa síndrome ainda não dispõe de opções terapêuticas adequadas. Objetivo: O objetivo do presente estudo é avaliar o efeito do treinamento físico aeróbico (TFA) sobre as alterações da perfusão miocárdica, da potência aeróbica máxima (VO2 pico), da qualidade de vida e dos sintomas anginosos em pacientes com diagnóstico de DMC. Métodos: Foram estudados prospectivamente 12 indivíduos de ambos os gêneros (7 mulheres), idade média de 53,8 ± 9,7 anos, com diagnóstico de DMC dor precordial, artérias coronárias livres de lesões obstrutivas de qualquer magnitude e presença de dois ou mais segmentos miocárdicos com DPR documentados pela CMP. Os defeitos perfusionais nas imagens de repouso e esforço foram semi-quantificados, mediante atribuição de escores visuais (0 = normal; 4 = ausente) em modelo de 17 segmentos das paredes do ventrículo esquerdo. Foram calculados para cada paciente escores somados nas imagens de repouso e estresse e a extensão global da reversibilidade (isquemia) foi medida pelo escore da diferença estresse-repouso. Teste cardiopulmonar (TCP) em esteira ergométrica foi usado para obtenção do VO2 pico e prescrição da intensidade do TFA. Por fim, os pacientes responderam a um questionário de qualidade de vida SF36. Após as avaliações basais os indivíduos foram submetidos a TFA durante quatro meses em esteira ergométrica, três vezes por semana, uma hora por dia e com intensidade prescrita entre 60 % e 85 % do VO2 pico atingido no TCP. Ao final dos quatro meses os pacientes foram novamente avaliados pela CMP, TCP e SF36. Resultados: Dos 12 pacientes, 10 (83,4%) apresentaram redução dos DPR, tendo-se resolvido completamente em 8 (66,7%). Foi observada entre as avaliações basais e póstreinamento melhora estatisticamente significante na redução do DPR (10,1 ± 8,8 para 2,8 ± 4,9 p = 0,008), do número de segmentos do ventrículo esquerdo (VE) isquêmicos (7,67 ± 4,52 para 2,3 ± 4,1 p = 0,002), da porcentagem do VE com isquemia (45,1 ± 26,58 para 13,7 ± 24,1 p = 0,002), do escore somado no pico do estresse na CMP (10,8 ± 8,7 para 3,1 ± 5 p = 0,004), aumento do VO2 pico (19,4 ± 4,8 para 22,1 ± 6,2 p = 0,01), do pulso de oxigênio pico (2550 ± 1040 para 3043 ± 1332 p = 0,01), melhora nos domínios analisados pelo SF36 relacionados à capacidade funcional (44,6 ± 25,8 para 88,3 ± 9,1 p = 0,0002), ao aspecto físico (25 ± 31,9 para 89,6 ± 19,8 p = 0,002), à dor (38,4 ± 22,2 para 68,4 ± 22,3 p = 0,007), à vitalidade (49,2 ± 28,2 para 83,8 ± 12,6 p = 0,0005), aos aspectos sociais (47,9 ± 27,1 para 93,8 ± 15,5 p = 0,002), aos aspectos emocionais (30,6 ± 38,8 para 80,6 ± 33,2 p = 0,005) e à saúde mental (53 ± 22,1 para 80 ± 15,9 p = 0,001). Conclusão: Os resultados mostram que o TFA aplicado aos pacientes com DMC foi associado à significativa melhora da capacidade funcional, da qualidade de vida, incluindo melhora dos escores de dor e redução dos defeitos perfusionais reversíveis (extensão/gravidade da isquemia). Nossos achados sugerem que o TFA seja opção terapêutica válida para tratar pacientes com DMC. Esses resultados iniciais necessitam de validação mais ampla em estudo clínico randomizado e com maior número de pacientes. / Rationale: The routine use of cineangiocoronariography has demonstrated that not all patients with clinical suspicion of coronary artery disease (CAD) present with obstructive lesions in epicardial coronary arteries. This finding of chest pain associated with angiographically normal coronary arteries is relatively common, occurring in approximately 30 % of patients undergoing cardiac catheterization for investigation of CAD. In these patients the myocardial ischemia can be demonstrated by a conventional exercise stress test or by utilization of myocardial perfusion scintigraphy (MPS) which is a more accurate method to detect the extent/severity of ischemia. The diagnosis of coronary microvascular dysfunction (CMD) can be made in patients with chest pain associated to angiographically normal coronary arteries and reversible perfusion defects (RPD) in the MPS. Despite the growing knowledge about the pathophysiology of this syndrome, effective therapeutic options are still missing. Objective: The aim of this study is to evaluate the effect of aerobic exercise training (AET) on myocardial perfusion, oxygen uptake (VO2 peak), quality of life and anginal symptoms in patients with CMD. Methods: We prospectively studied 12 individuals of both gender (7 females), mean age was 53.8 ± 9.7 years, diagnosed with CMD, characterized by chest pain, coronary artery free of obstructive lesions and presence of two or more myocardial segments with RPD documented by using MPS. The perfusion defects on stress and rest images were semi-quantified by attributing visual scores (0 = normal, 4 = absent) in a 17 segment model of left ventricular wall. For each patient, we calculated score summed stress and rest scores and the global extent of reversibility (ischemia) was measured by the difference between stress-rest scores. We applied a treadmill cardiopulmonary test (CPT) obtaining VO2 peak and allowing the prescription of the AET intensity. Finally the patients answered a quality of life questionnaire SF36. After baseline assessments subjects undergone 4 months AET on a treadmill three times a week for an hour a day and prescribed intensity between 60 % and 85% of VO2 peak. At the end of four months the patients were re-evaluated by using MPS, CPT and SF36. Results: Of 12 patients, 10 (83.4 %) showed any reduction of RPD, and RPD was resolved completely in 8 (66.7 %). The comparison between baseline and post-training assessments showed statistically significant improvements in reducing the RPD (10.1 ± 8.8 to 2.8 ± 4.9 p = 0.008), number of segments of the left ventricle (LV) ischemic (7.67 ± 4.52 to 2.3 ± 4.1 p = 0.002), percentage of LV ischemia (45.1 ± 26.58 to 13.7 ± 24.1 p = 0.002), summed score at peak stress MPS (10.8 ± 8.7 to 3.1 ± 5 p = 0.004), increase VO2 peak (19.4 ± 4.8 to 22.1 ± 6.2 p = 0.01), peak oxygen pulse (2550 ± 1040 to 3043 ± 1332 p = 0.01), SF36 domains related to: functional capacity (44.6 ± 25.8 to 88.3 ± 9.1 p = 0.0002), the physical appearance (25 ± 31.9 to 89.6 ± 19.8 p = 0.002), pain (38.4 ± 22.2 to 68.4 ± 22.3 p = 0.007), vitality (49.2 ± 28.2 to 83.8 ± 12.6 p = 0.0005), social aspects (47.9 ± 27.1 to 93.8 ± 15.5 p = 0.002), emotional aspects (30.6 ± 38.8 to 80.6 ± 33.2 p = 0.005) and mental health (53 ± 22.1 to 80 ± 15.9 p = 0.001). Conclusion: The results show that AET applied to patients with CMD was associated with significant improvement in functional capacity, quality of life, including improvement in pain scores and reduction of extent/severity of reversible perfusion defects (ischemia). Our findings suggest that AET is a valid therapeutic option for treating patients with CMD. These initial results require further confirmation in a large randomized placebo controlled clinical trial.

Embasamento racional: O uso rotineiro da cineangiocoronariografia tem demonstrado que nem todos os pacientes com suspeita clínica de doença arterial coronária (DAC) apresentam-se com lesões obstrutivas nas artérias coronárias epicárdicas. Esse achado de dor precordial associado a coronárias angiograficamente normais é relativamente comum, estando presente em aproximadamente 30 % dos pacientes que realizam cateterismo cardíaco para investigação de DAC. Em uma parcela destes pacientes a isquemia miocárdica está presente e pode ser demonstrada através de um teste ergométrico convencional ou até mesmo pela aplicação da cintilografia miocárdica de perfusão (CMP) que é um método de maior acurácia para detecção da extensão/gravidade da isquemia. Pacientes que apresentam o quadro de dor precordial associada a coronárias angiograficamente normais e defeitos perfusionais reversíveis (DPR) na CMP são diagnosticados como portadores de disfunção microvascular coronária (DMC). Ainda que muito se conheça em relação à sua fisiopatologia, essa síndrome ainda não dispõe de opções terapêuticas adequadas. Objetivo: O objetivo do presente estudo é avaliar o efeito do treinamento físico aeróbico (TFA) sobre as alterações da perfusão miocárdica, da potência aeróbica máxima (VO2 pico), da qualidade de vida e dos sintomas anginosos em pacientes com diagnóstico de DMC. Métodos: Foram estudados prospectivamente 12 indivíduos de ambos os gêneros (7 mulheres), idade média de 53,8 ± 9,7 anos, com diagnóstico de DMC dor precordial, artérias coronárias livres de lesões obstrutivas de qualquer magnitude e presença de dois ou mais segmentos miocárdicos com DPR documentados pela CMP. Os defeitos perfusionais nas imagens de repouso e esforço foram semi-quantificados, mediante atribuição de escores visuais (0 = normal; 4 = ausente) em modelo de 17 segmentos das paredes do ventrículo esquerdo. Foram calculados para cada paciente escores somados nas imagens de repouso e estresse e a extensão global da reversibilidade (isquemia) foi medida pelo escore da diferença estresse-repouso. Teste cardiopulmonar (TCP) em esteira ergométrica foi usado para obtenção do VO2 pico e prescrição da intensidade do TFA. Por fim, os pacientes responderam a um questionário de qualidade de vida SF36. Após as avaliações basais os indivíduos foram submetidos a TFA durante quatro meses em esteira ergométrica, três vezes por semana, uma hora por dia e com intensidade prescrita entre 60 % e 85 % do VO2 pico atingido no TCP. Ao final dos quatro meses os pacientes foram novamente avaliados pela CMP, TCP e SF36. Resultados: Dos 12 pacientes, 10 (83,4%) apresentaram redução dos DPR, tendo-se resolvido completamente em 8 (66,7%). Foi observada entre as avaliações basais e póstreinamento melhora estatisticamente significante na redução do DPR (10,1 ± 8,8 para 2,8 ± 4,9 p = 0,008), do número de segmentos do ventrículo esquerdo (VE) isquêmicos (7,67 ± 4,52 para 2,3 ± 4,1 p = 0,002), da porcentagem do VE com isquemia (45,1 ± 26,58 para 13,7 ± 24,1 p = 0,002), do escore somado no pico do estresse na CMP (10,8 ± 8,7 para 3,1 ± 5 p = 0,004), aumento do VO2 pico (19,4 ± 4,8 para 22,1 ± 6,2 p = 0,01), do pulso de oxigênio pico (2550 ± 1040 para 3043 ± 1332 p = 0,01), melhora nos domínios analisados pelo SF36 relacionados à capacidade funcional (44,6 ± 25,8 para 88,3 ± 9,1 p = 0,0002), ao aspecto físico (25 ± 31,9 para 89,6 ± 19,8 p = 0,002), à dor (38,4 ± 22,2 para 68,4 ± 22,3 p = 0,007), à vitalidade (49,2 ± 28,2 para 83,8 ± 12,6 p = 0,0005), aos aspectos sociais (47,9 ± 27,1 para 93,8 ± 15,5 p = 0,002), aos aspectos emocionais (30,6 ± 38,8 para 80,6 ± 33,2 p = 0,005) e à saúde mental (53 ± 22,1 para 80 ± 15,9 p = 0,001). Conclusão: Os resultados mostram que o TFA aplicado aos pacientes com DMC foi associado à significativa melhora da capacidade funcional, da qualidade de vida, incluindo melhora dos escores de dor e redução dos defeitos perfusionais reversíveis (extensão/gravidade da isquemia). Nossos achados sugerem que o TFA seja opção terapêutica válida para tratar pacientes com DMC. Esses resultados iniciais necessitam de validação mais ampla em estudo clínico randomizado e com maior número de pacientes. / Rationale: The routine use of cineangiocoronariography has demonstrated that not all patients with clinical suspicion of coronary artery disease (CAD) present with obstructive lesions in epicardial coronary arteries. This finding of chest pain associated with angiographically normal coronary arteries is relatively common, occurring in approximately 30 % of patients undergoing cardiac catheterization for investigation of CAD. In these patients the myocardial ischemia can be demonstrated by a conventional exercise stress test or by utilization of myocardial perfusion scintigraphy (MPS) which is a more accurate method to detect the extent/severity of ischemia. The diagnosis of coronary microvascular dysfunction (CMD) can be made in patients with chest pain associated to angiographically normal coronary arteries and reversible perfusion defects (RPD) in the MPS. Despite the growing knowledge about the pathophysiology of this syndrome, effective therapeutic options are still missing. Objective: The aim of this study is to evaluate the effect of aerobic exercise training (AET) on myocardial perfusion, oxygen uptake (VO2 peak), quality of life and anginal symptoms in patients with CMD. Methods: We prospectively studied 12 individuals of both gender (7 females), mean age was 53.8 ± 9.7 years, diagnosed with CMD, characterized by chest pain, coronary artery free of obstructive lesions and presence of two or more myocardial segments with RPD documented by using MPS. The perfusion defects on stress and rest images were semi-quantified by attributing visual scores (0 = normal, 4 = absent) in a 17 segment model of left ventricular wall. For each patient, we calculated score summed stress and rest scores and the global extent of reversibility (ischemia) was measured by the difference between stress-rest scores. We applied a treadmill cardiopulmonary test (CPT) obtaining VO2 peak and allowing the prescription of the AET intensity. Finally the patients answered a quality of life questionnaire SF36. After baseline assessments subjects undergone 4 months AET on a treadmill three times a week for an hour a day and prescribed intensity between 60 % and 85% of VO2 peak. At the end of four months the patients were re-evaluated by using MPS, CPT and SF36. Results: Of 12 patients, 10 (83.4 %) showed any reduction of RPD, and RPD was resolved completely in 8 (66.7 %). The comparison between baseline and post-training assessments showed statistically significant improvements in reducing the RPD (10.1 ± 8.8 to 2.8 ± 4.9 p = 0.008), number of segments of the left ventricle (LV) ischemic (7.67 ± 4.52 to 2.3 ± 4.1 p = 0.002), percentage of LV ischemia (45.1 ± 26.58 to 13.7 ± 24.1 p = 0.002), summed score at peak stress MPS (10.8 ± 8.7 to 3.1 ± 5 p = 0.004), increase VO2 peak (19.4 ± 4.8 to 22.1 ± 6.2 p = 0.01), peak oxygen pulse (2550 ± 1040 to 3043 ± 1332 p = 0.01), SF36 domains related to: functional capacity (44.6 ± 25.8 to 88.3 ± 9.1 p = 0.0002), the physical appearance (25 ± 31.9 to 89.6 ± 19.8 p = 0.002), pain (38.4 ± 22.2 to 68.4 ± 22.3 p = 0.007), vitality (49.2 ± 28.2 to 83.8 ± 12.6 p = 0.0005), social aspects (47.9 ± 27.1 to 93.8 ± 15.5 p = 0.002), emotional aspects (30.6 ± 38.8 to 80.6 ± 33.2 p = 0.005) and mental health (53 ± 22.1 to 80 ± 15.9 p = 0.001). Conclusion: The results show that AET applied to patients with CMD was associated with significant improvement in functional capacity, quality of life, including improvement in pain scores and reduction of extent/severity of reversible perfusion defects (ischemia). Our findings suggest that AET is a valid therapeutic option for treating patients with CMD. These initial results require further confirmation in a large randomized placebo controlled clinical trial.

El texto completo de este trabajo no está disponible en el Repositorio Académico UPC por restricciones de la casa editorial donde ha sido publicado. / Objective: Present different flap alternatives when performing microvascular free-flap reconstruction in acute hard-to-heal wounds. Method: A retrospective review of patients whose acute hard-to-heal wounds were treated with microvascular free-flap reconstruction. Data on demographics, wound aetiology, diagnostic, previous treatment, free-flap type, free-flap size, complications and follow up were analysed. Results: A total of 20 patients received microvascular free-flap reconstruction. The median age was 39.5 years. Twenty free-flap reconstructions were performed. These included: 3 cross-leg free flap, 1 cross-leg vascular cable bridge flap, 2 fibula osteocutaneous flap, 6 anterolateral thigh (ALT) flap, 3 thoracodorsal artery perforator (TDAP) flap, 3 fasciomyocutaneous flap, and 2 femoral artery fasciocutaneous flap. A patient required microvascular anastomosis due to hematoma; the rest did not present complications during their postoperative. Previous treatment included negative pressure wound therapy (12 patients) and surgical debridement with silver hydrogel dressings (8 patients). Conclusion: Hard-to-heal wounds can be unresponsive to traditional wound healing practices or local flaps. They often require free-flap reconstruction, using tissues similar to those compromised. Microvascular techniques can be an effective alternative. CONFLICT OF INTEREST None.

Retina is a unique site in the human body where the microcirculation can be imaged directly and non-invasively, allowing us to study in vivo the structure and pathology of the human microcirculation. Retinal images can be quantitatively assessed with computerized imaging techniques, enabling us to measure several different quantitative traits derived from the retinal vasculature. Arterial and venular calibres are the most extensively studied traits of the retinal microvasculature and numerous epidemiological studies demonstrated promising associations with systemic and ocular diseases as well as with disease markers. However, there has been a lack of research into pathophysiological processes leading to retinal vascular signs, and how they link retinal microcirculation with coronary and cerebral microvasculature change. Information about genetic determinants underlying retinal vascular structure is therefore important for understanding the processes leading to microvascular pathophysiology. Two genome wide association studies have been published so far revealing four loci associated with retinal venular calibre and one locus with arteriolar calibre. Here the results from the genome-wide association analysis of 10 different retinal vessel traits in two population based cohorts are presented. Retinal images were measured in non-mydriatic fundus images from 808 subjects in the Orkney Complex Disease Study (ORCADES) and 390 subjects from the Croatian island of Korcula, using the semi-automated retinal vasculature measurement programme SIVA and VAMPIRE. Using pairwise estimates of kinship based on genomic sharing, heritability was calculated for each trait. Estimates of tortuosity measure and fractal dimensions present first published reports of heritability estimates for those traits. In addition correlation analysis with systemic risk factor was also completed, confirming already published results as well as revealing some new associations. A genome wide association analysis of retinal arteriolar width revealed a genome wide significant hit (1.8x10-7) in a region of chromosome 2q32 (within TTN gene). Replication was sought in a further independent Scottish population (LBC) and additional 400 retinal images were graded. The result did not replicate, however the direction of the effect was consistent and a larger sample size is required. Analysis of the remaining traits did not yield genome wide significant result,s and will also require larger sample sizes. Genetic analysis of a binary retinal trait was also explored in a case control study of retinal detachment, which is an important cause of vision loss. A two-stage genetic association discovery phase followed by a replication phase in a combined total of 2,833 RRD cases and 7,871 controls was carried out. None of the SNPs tested in the discovery phase reached the threshold for association. Further testing was carried out in independent case-control series from London (846 cases) and Croatia (120 cases). The combined meta-analysis identified one association reaching genome-wide significance for rs267738 (OR=1.29, p=2.11x10-8), a missense coding SNP and eQTL for CERS2 encoding the protein ceramide synthase 2. Additional genetic risk score, pathway analysis and genetic liability analysis were also carried out.

A majority of all fractures in current US armed conflicts are open fractures, in which a soft tissue injury is sustained along with the bone fracture. Even with gold standard treatment, in which muscle flaps are used to cover bony defects, patients often do not regain normal function of their extremity, highlighting the necessity for tissue engineering strategies for this complex clinical problem. Due to a substantial amount of tissue damage and debridement treatment in composite injuries, a large volume of cells and extracellular matrix (ECM) proteins that are necessary for tissue healing are removed from the body. In the replacement of large volumes of tissue, nutrient transfer necessitates a vascular supply to maintain the viability of delivered cells. The objective of this project was to examine the regenerative potential of engineered matrix constructs and stem cells on composite bone & muscle defects. We hypothesized that stem cells delivered on engineered matrix constructs into the muscle defect will aid in muscle regeneration and promote bone healing, ultimately resulting in superior functional limb recovery. These studies established multiple preclinical platforms for testing tissue engineering strategies as well as models that can be used to gain insights on the healing of VML and composite VML/bone defects. From some of the insights gained on the vascularization of the defect sites, a vascular treatment strategy was tested within these platforms and shown to have varying results in the treatment of complex multi-tissue injuries.

Cigarette smoke contributes to many diseases. The actions of second and third hand smoke, which have implications for non-smokers and the very young, are just beginning to be appreciated. The overarching hypothesis of this project is that cigarette smoke has different injurious actions on alveolar cells based on chronological age. The purpose here was to learn more about the susceptibility of alveolar cells to cigarette smoke extract (CSE)- induced injury by performing studies on pulmonary alveolar and endothelial cells derived from neonatal, young, and old rats. The aims involved: 1. Developing cell culture models to study age-related effects of cigarette smoke on alveolar type I cells and microvascular endothelial cells from the lung, and 2. Using these models to examine the effects of CSE on markers of oxidative stress, inflammation and aging in alveolar cells harvested from neonatal, young and old rats. Descriptive and experimental studies involved using a variety of cell culture, biochemical and molecular techniques, including gene expression arrays. The most significant findings were that: 1. primary proliferating alveolar type I cells were used to develop novel cell culture model systems, including single culture, co-culture and three-dimensional cultures that were used to study the effects of CSE; 2. Hydrogen peroxide production by endothelial cells was markedly reduced by co-culturing with AT I cells; 3. Gene expression profiling of oxidative stress-specific pathways suggest that genes responsible for both stopping production of H2O2 or mopping-up H2O2 are involved; and 4. Cigarette smoke shortens telomeres of cells from neonates, but unexpectedly preserves telomere length of cells from young and old rats. Data from telomeric pathway-specific gene expression arrays suggest that there are age-related differences in response to gene expression to CSE. The significant conclusions are: 1. Contrary to prior observations, alveolar type I cells demonstrate prolonged proliferative capacity; 2. Alveolar type I cells likely play an important role in ameliorating CSE-induced oxidative stress; and 3. Neonatal alveolar cells may be more susceptible to the deleterious effects of CSE including telomere shortening. These novel model systems and observations provide new ways to study cigarette smoke-associated lung dysfunction.

Previous reports have demonstrated that children’s physical activity is typically intermittent in nature. Accelerometers are reliable and valid tools for quantifying the pattern of activity in children. However, in order to interpret accelerometer output it is necessary to apply appropriate accelerometer thresholds for classifying physical activity intensity. Currently multiple accelerometer thresholds are available in the literature and it is unclear which are the most appropriate or whether thresholds should be sample specific. Additionally, there is little information regarding how the pattern of activity in children varies across groups and how activity patterns relate to health. The overall aim of the thesis was to describe the pattern of habitual physical activity, using objectively-measured physical activity data, in relation to health outcomes in pre-adolescent boys. The first objective was to characterize the pattern of boys’ habitual physical activity, using objectively-measured physical activity data. The second objective was to investigate the relationship between habitual physical activity and specific aspects of the activity pattern and health outcomes in boys. The final objective was to investigate the effects of continuously- versus intermittently- accumulated physical activity on acute health outcomes in boys, using an intermittent activity protocol based on the measured pattern of habitual activity in boys. The first four studies used a sample of 54 boys, aged 8 to 10 years. The final study used a different sample of 10 boys, aged 9 to 11 years. Both samples were from the county of Devon, UK. The first study of this thesis established sample-specific accelerometer-intensity thresholds through calibration research with ActiGraph accelerometers (counts•2s-1) in boys. The second study in the thesis demonstrated that relationships between time accumulated at different activity intensities and health (fatness, peak oxygen consumption and resting blood pressure) in boys were similar irrespective of whether sample-specific or published thresholds were employed as long as the threshold was at least equivalent to a brisk walk (i.e. >4 METs). However, the prevalence of children reported as meeting activity guidelines did differ according to thresholds employed. Study three showed that, despite little difference between overweight and normal weight boys in overall activity, time spent sedentary and minutes of light, moderate and vigorous intensity activity accumulated, aspects of the activity pattern (frequency, intensity and duration of ≥4 s (short) and ≥5-min (long) bouts of ≥light, ≥moderate, ≥vigorous and ≥hard intensity activity) differed by weight status. Overweight boys accumulated fewer and shorter bouts of activity, particularly sustained bouts of activity which were of moderate intensity or greater. Study four examined the relationship between activity pattern and health in boys further, focusing on body fatness, aerobic fitness, blood pressure and microvascular function. Results demonstrated that summary measures of activity were negatively related to body fatness, and positively related with both aerobic fitness (i.e., total, moderate, vigorous and hard activity) and endothelial function (i.e., total and light activity). Time spent sedentary was negatively related to endothelial function. The frequency and duration of activity bouts of ≥moderate intensity and the intensity of all activity bouts (i.e., ≥light intensity) were most important for body fatness and aerobic fitness. The frequency of all bouts (short and long) of at least light intensity was most important for endothelial health. Finally, study five moved away from chronic measures of health and examined the acute physiological effects of the recommended daily amount of physical activity (60 minutes of physical activity of ≥moderate intensity) on postprandial lipaemia and microvascular function in boys the following day. Furthermore, the study aimed to assess whether the effects differed depending on whether the activity was accumulated continuously or in a manner more similar to the children’s typical activity patterns identified in studies 3 and 4. In contrast to findings from adolescents and adults, 60 minutes of >moderate intensity activity did not impact on postprandial lipaemia or microvascular function the following day in healthy, active boys, regardless of how it was accumulated. The results of the present thesis indicate that aspects of the activity pattern are significantly related to health in boys and differ according to type of day and weight status. Furthermore, the benefits of sporadically-accumulated activity are equally as strong as continuously-accumulated activity to body fatness, aerobic fitness and endothelial health in boys. Since children typically accumulate short, intermittent bouts of activity, the promotion of sporadic activity (i.e., in intervention research and current physical activity guidelines for children and youth) might increase enjoyment and adherence. The benefits of acute intermittent exercise (which simulates free-living activity) on postprandial lipaemia and microvascular function in inactive children with risk factors for cardiovascular disease should be investigated. Longitudinal investigations into the activity pattern of a much larger and more age-diverse sample of boys and girls are needed to determine whether any changes in aspects of the activity pattern might alter these and other health outcomes (i.e., cardiovascular risk factors).

MMed thesis - Faculty of Health Sciences / The field of organ and tissue transplantation has necessitated an improved understanding of their associated pathophysiological pathways. Specific areas of interest involve the changes that follow ischaemia and derangement’s that accompany organ and tissue storage, reperfusion injury and the “no-reflow” phenomenon. Strategies have been devised to manipulate and modify these processes, improving tissue and organ survival and function. These have involved the use of preservation solutions. Although most research involves organ transplantation, these principles have been translated and applied to various tissues, surgical flaps and microvascular replantations. These studies have generally used the skin flap as their model with little knowledge regarding muscle flaps, the most vulnerable to the ischaemic process. This study targets the use of one such preservation system and uses skeletal muscle as its tissue model. The vascular anatomy of the rectus femoris muscle in the New Zealand white rabbit was studied anatomically and radiologically and thus described. The isolated rectus femoris muscle flap was harvested and perfused in-vitro with cooled, oxygenated University of Wisconsin solution (UWS) using a pulsatile renal perfusion pump. UWS was selected as it contains vital additives important in cryopreservation of organs. Monitoring of various physiological parameters was performed. The muscle was examined at 0, 4, 8, 12, 18 and 24 hours of extra-corporeal perfusion using warm and cold, non-perfused controls. The contralateral muscle served as the control. End-points were the percentage of muscle survival, as determined by a new grading system of muscle ischaemia, based on 3 light and 7 electron microscopic criteria. The overall percentage of muscle survival (combined light and electron microscopy scores) resulted in approximately 58% survival at 24 hours for the perfused muscle versus 31% for the cold stored muscle. The stored muscle had the same survival rate at 12 hours as did the perfused muscle at 24 hours. For all time periods beyond 4 to 8 hours, perfused muscle showed statistically improved survival rates compared to the stored muscle. Eight hours appears to be a crucial point beyond which survival in muscle deteriorates to a much greater degree without perfusion. Questions remain as to which method of preservation yields the best survival benefit and, as yet, there is no “ideal” perfusate. The future involves manipulating perfusion solutions and trying to arrest or reverse established warm ischaemia. Success of free tissue transfers and replantations of musclecontaining body parts may be enhanced. These techniques may also allow us to effectively store previously harvested flaps and eventually, to enter the realm of “banked” allograft tissue flaps.