Les médecins de famille, les pédiatres, les chiropraticiens et les physiothérapeutes sont parmi les professionnels de la santé les plus susceptibles de rencontrer des patients atteints d’une scoliose idiopathique adolescente. Les recherches démontrent que certaines lacunes existent à l’égard des connaissances acquises, par ces professionnels, dans le domaine musculosquelettique, incluant la scoliose. De plus, il ne semble pas exister d’informations sur le niveau de connaissances et la démarche clinique de ces professionnels en matière de scoliose, bien que les bonnes pratiques actuelles dictent une détection hâtive de cette condition pour en optimiser la gestion thérapeutique. Les objectifs de notre étude visaient donc à évaluer les connaissances ainsi que les aptitudes en matière de démarche clinique des professionnels les plus susceptibles à traiter des patients atteints d’une scoliose idiopathique adolescente. À l’aide d’un questionnaire semi-structuré, 51 professionnels de la santé ont été interviewés. Parmi ces professionnels recrutés par l'entremise de leur ordre professionnel respectif, on retrouvait 21 médecins de famille, 10 pédiatres, 10 chiropraticiens et 10 physiothérapeutes. Les entrevues évaluaient les connaissances en matière de signes cliniques, de facteurs de risque, de démarche clinique et de processus référentiel vers les soins spécialisés. De plus, les préférences des professionnels à l’égard des guides de bonne pratique ont été abordées. Parmi les professionnels interviewés, 59 % étaient des femmes, 43 % étaient âgés de moins de 40 ans et la moyenne d’années de pratique était de 20,3 ans. Les résultats démontrent qu’il existe des lacunes à l’égard des connaissances des signes cliniques et des facteurs de risque : moins du tiers des professionnels interviewés pouvaient mentionner au moins 2 signes cliniques et 31 % d’entre eux ne pouvaient se souvenir des facteurs de risque associés à la scoliose idiopathique adolescente; les médecins de famille étaient les moins connaissants dans ces domaines. De plus, en présence d’une mise en contexte nécessitant une référence urgente en soins spécialisés, 70 à 90 % des professionnels auraient référé le patient en dépit du fait que seulement 38 à 60 % d’entre eux considéraient cette situation comme urgente. Près de 40 % des professionnels mentionnaient qu’ils seraient inconfortables à gérer un patient atteint d’une scoliose. Néanmoins, la majorité d’entre eux reconnaissaient qu’il existe un problème en ce qui a trait à l’accessibilité aux soins spécialisés en orthopédiatrie. Presque la totalité c’est-à-dire, 98 % étaient favorables à la production de guides de bonne pratique et les accueilleraient positivement dans leur pratique quotidienne. Les conclusions de cette étude ont montré qu’il existe des vides en matière de connaissances de signes cliniques et de facteurs de risque de progression de la scoliose idiopathique adolescente; ces lacunes ont particulièrement été remarquées chez les médecins de famille. La majorité des professionnels reconnaissent l’importance de référer les conditions urgentes en soins spécialisés. Néanmoins, tous semblent souligner des difficultés dans ce processus référentiel. Une meilleure collaboration interprofessionnelle semble prometteuse en ce qui concerne la gestion de patients atteints d’une scoliose idiopathique adolescente. / Family physicians, peadiatricians, chiropractors and physical therapists are among health professionals most likely to encounter and treat patients with adolescent idiopathic scoliosis. Research shows that there are gaps in musculoskeletal knowledge among professionals but no studies assess knowledge of scoliosis among professionals most likely to treat patients with scoliosis. Best current practice dictates that early detection of adolescent idiopathic scoliosis leads to better decision-making regarding optimal course of management. The objectives of our study were to evaluate basic knowledge and the management skills of professionals most likely to encounter adolescent idiopathic scoliosis. We developed a semi-structured questionnaire and interviewed 51 health professionals. Among these professionals, who were recruited through their professional regulatory board registries, were 21 family physicians, 10 peadiatricians, 10 chiropractors and 10 physical therapists. The interview assessed knowledge of clinical signs and risk factors, management options, including referral to specialized care. We also discussed preferences and acceptability of clinical guidelines in regard to scoliosis. Among interviewed professionals, 59 % were female, 43 % were under 40 and mean years of practice was 20.3. Our results demonstrated gaps in knowledge with respect to clinical signs and risk factors. Less than a third of professionals were able to mention at least 2 clinical signs and 31 % were unaware of any risk factors associated with scoliosis progression. Family physicians appeared least knowledgeable in these areas. When presented with a situation where urgent referral was indicated, 70 – 90 % said that they would refer the patient although only 38 – 60 % rated this case as urgent. Close to 40 % of professionals indicated that they would not be comfortable doing the follow-up of a patient with a scoliosis. Nevertheless, the majority felt that accessibility to specialized care was a problem. Almost all (98 %) mentioned that the development of clinical guidelines would positively affect their daily practice. In conclusion, our study shows that knowledge gaps exist among professionals regarding clinical signs and risk factors of curve progression in adolescent idiopathic scoliosis. Most professionals recognize the importance of referring urgent cases to specialized care although there may be problems with access to peadiatric orthopedic specialists. Interprofessional collaboration may be a promising approach to improve management of patients with adolescent idiopathic scoliosis.

A ressonância magnética (RM) é o exame de escolha para avaliar os ligamentos do cotovelo. Os dados da literatura que relatam o uso da ultrassonografia (US) avaliando os ligamentos do cotovelo são escassos. A maioria dos estudos de US avalia apenas alguns aspectos dos ligamentos do cotovelo, principalmente relacionados a tendões, espaços articulares e, eventualmente, lesões ligamentares. O objetivo é avaliar o desempenho do US em demonstrar todos ligamentos do cotovelo em comparação com os resultados da MRI. Realizamos análises qualitativas e quantitativas das imagens do ligamento do cotovelo obtidas pelo US e RM em indivíduos assintomáticos. Na abordagem qualitativa, os dados de RM e US foram analisados por quatro radiologistas especializados em sistema musculoesquelético: dois para US e dois para RM. Cada médico realizou de forma independente e individualmente usando um relatório estruturado. A abordagem quantitativa incluiu medidas da espessura das fibras anteriores do ligamento colateral ulnar mediano e os locais exatos dessas medidas, realizados por radiologistas treinados para a avaliação quantitativa. Todos os ligamentos foram identificados pelos examinadores e houve alta concordância entre os métodos nas análises qualitativas e quantitativas: ecogenicidade e espessura do ligamento em imagens de US e espessura do ligamento e sinal em imagens de RM. A medida de concordância das espessuras dos ligamentos entre os examinadores da US foi superior a 97,8%. Entre os examinadores da RM, esta medida foi superior a 99,0%. A média da diferença entre as medidas de US e de RM foi de 0,08 mm (entre 0,04 mm e 0,12 mm). Não houve diferenças estatísticas entre os 2 métodos nas medidas de concordância e espessura dos ligamentos. Concluímos que a US é capaz de identificar ligamentos íntegros em adultos com a mesma facilidade e especificidade que a RM. Acreditamos que esses resultados, juntamente com as características já conhecidas do US (avaliação dinâmica da integridade do ligamento, menos contraindicações e baixo custo) têm potencial para adicionar um valor importante ao diagnóstico musculoesquelético da doença do cotovelo em um cenário mais difundido / Magnetic resonance imaging (MRI) is the exam of choice for assessing elbow ligaments. The literature data reporting the use of Ultrasonography (US) evaluating elbow ligaments is scarce. Most US studies evaluate only a few aspects of the elbow ligaments, mostly related to tendons, joint spaces and, eventually, ligament lesions. The main goal is to assess US performance to demonstrate elbow ligaments compared to MRI performance. We have conducted qualitative and quantitative analysis of the elbow ligaments images obtained by the US and MRI in healthy volunteers. In the qualitative approach, MRI and US data was analyzed by four radiologists specialized in musculoskeletal system: two for US and two for MRI. Each physician analyzed the images independently and individually using a structured report. The quantitative approach included measurements of the thickness of the anterior fibers of the medial ulnar collateral ligament and all measures was performed by trained radiologists for quantitative assessment. All ligaments were identified by the radiologists and there was high agreement between the methods in the qualitative and quantitative analyzes: echogenicity and thickness of the ligament in US images and ligament thickness and signal in MRI images. The concordance in the measurements of the thicknesses of the ligaments between the examiners of the US was superior to 97.8%. Among the MRI examiners, it was higher than 99.0%. The mean difference between the US and MRI measurements was 0.08 mm (between 0.04 mm and 0.12 mm). There was no statistical difference either in concordance or ligament thickness between US and MRI measures. We conclude that ultrasonography is capable of identifying healthy ligaments in adults with the same usability and specificity as magnetic resonance imaging. We believe these results, together with US already known characteristics (dynamic evaluation of ligament integrity, fewer contra-indications and low cost) has potential to add an important value to musculoskeletal diagnosis of elbow disease

INTRODUÇÃO: O aumento da cavidade ou da espessura do ventrículo esquerdo (VE) e da alteração morfológica do quadríceps se dão de forma diferente dependendo do tipo de atividade esportiva realizada (aeróbica ou anaeróbica). O presente estudo se propôs em verificar o grau de desenvolvimento da hipertrofia cardíaca e da musculatura periférica (quadríceps) em atletas fundistas e rasistas. MÉTODOS: Participaram deste estudo 16 (dezesseis) atletas de alta performance, voluntários, divididos em dois grupos: 8 (oito) atletas fundistas (corredores de 10000 metros) e 8 (oito) atletas rasistas (corredores de100 metros livre). Cada atleta foi submetido a uma coleta de sangue em jejum para as análises laboratoriais de rotina. Foram submetidos a exame de ressonância magnética cardíaca e do quadríceps femoral e, por fim, realizaram teste de esforço com a utilização da ergoespirometria. Para a análise estatística foram utilizados teste de Shapiro-Wilk para normalidade, quando não confirmado a normalidade, foi realizado o teste não paramétrico de Mann-Whitney, teste de Levene para homocedasticidade, teste t student para análise descritiva e comparativa entre os grupos e o teste de correlação de Spearman. RESULTADOS: Os fundistas e rasistas, respectivamente, apresentaram semelhanças nas comparações entre as variáveis antropométricas e clinicas, apresentando diferenças significativas nas variáveis sanguíneas direcionadas à troponina (2,2±1,0 e 3,0±2,4 ng/mL) com p = 0,042, creatina quinase (CKMB) com valores de 0,007 ng/mL e 0,016 ng/mL com p=0,001 e creatina fosfoquinase (CPK) com valores de 166,3±84,1 U/L e 465,1±221,6 U/L com p = 0,017, respectivamente. Em relação a variável relacionada à capacidade aeróbica dos corredores, não se observou diferenças entre corredores fundistas e rasistas. No que tange aos resultados apresentados na ressonância magnética, verificou-se diferença estatística comparativa no volume do quadríceps entre fundistas (3263,7 cm3) e rasistas (4946,4 cm3) sendo p < 0,01. Foi apresentado correlação significante no tamanho da área do quadríceps no grupo fundista (161,8±19,6 cm2) com a variável do diâmetro diastólico final do ventrículo esquerdo (DDF do VE) (5,3±0,5 cm) e no diâmetro sistólico final (DSF do VE) (3,5±0,4 cm), com p=0,05 em ambos. Ainda no grupo fundista, observou-se uma correlação positiva do DDF do VE com o volume do quadríceps (3263,7±212,2 cm3), com p = 0,04. No grupo rasista a significância estatística (p = 0,04) foi na aorta ascendente (2,7±0,5 cm) em correlação com a área do quadríceps (198,8±21,1 cm2) e no DSF do VE (3,5±0,5 cm) com o volume do quadríceps (4946,4±470,4 cm3). CONCLUSÃO: Com esses resultados pode-se afirmar que o quadríceps e o miocárdio adaptam-se estrutural e funcionalmente ao treinamento físico, sendo essas adaptações distintas de acordo com o tipo de modalidade esportiva realizada / INTRODUCTION: the increase of the cavity or the thickness of the left ventricle (LV) and the morphological changes of the quadriceps happen differently depending on the type of sports activity performed (aerobic or anaerobic). The proposal of the present study is to verifythe degree of development of cardiac hypertrophy and peripheral muscle (quadriceps) in short and long distance running athletes. METHOD: 16 (sixteen) high performance volunteer athletes participated in this study and were divided into two groups: 8 (eight) long distance athletes (10000 meter runners) and 8 (eight) short distance athletes (100 m runners /freestyle). Each athlete was subjected to a fasting blood collection for the routine laboratory analysis. They underwent a magnetic resonance imaging examination of the heart and quadriceps femoris and finally performed a stress test using ergo-spirometry.As statistical analysis we used Shapiro-Wilk test for normality and the non-parametric Mann-Whitney when normality was not confirmed; Levene test for homoscedasticity, t student test for descriptive and comparative analysis between the groups and the Spearman correlation test. RESULTS: The long and short distance athletes, respectively, presented similarities in the comparisons between the anthropometric and clinic variables, showing significant differences in blood variables directed to troponin (2.2 ± 1.0 and 3.0 ± 2.4 ng/mL) with p = 0.042, creatine kinase (CKMB) with values of 0.007 ng/mL and 0.016 ng/mL with p = 0.001 and creatine phosphokinase (CPK) with values of 166.3 ± U/L and 84.1 ± 465.1 221.6 U/L with p = 0.017, respectively. Regarding the variable related to the aerobic capacity of the runners, no differences were observed between long and short distance running athletes. With respect to the results presented in the MRI, there was comparative statistical difference in the quadriceps volume between long distance athletes (3263.7 cm3) and short distance athletes (4946.4 cm3) being p < 0,01. There was significant correlation in the size of the quadriceps area in long-distance group (161.8 ± 19.6 cm2) with the variable of final diastolic diameter of left ventricle (FDD of LV) (5.3 ± 0.5 cm) and in the final systolic diameter (FSD of LV) (3.5 ± 0.4 cm), with p = 0.05 in both. Also in the long distance group, it was noticed a positive correlation of FDD of LV with the volume of the quadriceps (3263.7 ± 212.2 cm3), with p = 0.04. In the short distance group, the statistical significance (p = 0.04) was in the ascending aorta (2.7 ± 0.5 cm) in correlation to the quadriceps area (198.8 ± 21.1 cm2) and in the FSD of LV (3.5 ± 0.5 cm) with the volume of the quadriceps (4946.4 ± 470.4 cm3). CONCLUSION: Based on this results we can state that both quadriceps and myocardium adapt structurally and functionally to the physical training, being these distinct adaptations according to the type of sport

Made available in DSpace on 2016-01-26T12:51:36Z (GMT). No. of bitstreams: 1 elyseusicoli_tese.pdf: 2441826 bytes, checksum: 674fd5e0ef6362d6b45b1ebf11e5cfd9 (MD5) Previous issue date: 2011-02-18 / The Cumulative Trauma Disorders (CTD) hás been common in various professions that require repeating the same movement several times thoughout the day. The professionals more affected by this problem, are: workers in production lines, cash drawers operators, homemakers, dentists, and others. Also called by work Related Musculoskeletal Disorders (WRMD) or Musculoskeletal Disorders Related to Working (MDRW), these lesions are caused by the repetitive or forced use of the muscles groups or inadequate posture. The most common symptoms are ache, tingling feelings, mysterious numbness, muscle fatigue and peripheral nerves. Several factors have been making that the personal and Professional life is much affected: intense and chronic sumptoms, lack of prevention and rehabilitation policies by the companies, late diagnosis and treatment, among other. Objective: The purpose of this work was to asses the knowledge degree of the professionals ins São José do Rio Preto among the occupational diseases and improve education in the graduation about these occupational illnesses so that students in future can prevent the same problem. Methods: The learners participating in this project went to the dental clinics of São José do Rio Preto, and explained the objectives as well as the Term of Free and Informed Consent. They made the interview with the professional using a questionnaire, avoiding the interference or reading of the data by others. The listing of clinics was obtained through the Regional Council of Dentistry Station of São José do Rio Preto. The questionnaire addressed questions since the knowledge of the diseases through what the professionals do to avoid them. The questionnaire also had the objective of selecting samples. Interesting results were obtained through research, such that 42.85% of participants already had some joint pain manifestation, which may be signs of repetitive strain injury and that nearly 99% of workers had some basic ergonomics in your graduation, but only 63.63% implemented in your office. The project was submitted by the Ethical Committee, and the volunteers that agreed in participating on the study signed a free and informed consent, as resolution 196/96 of the National Council of Ethics and the search of the Health Ministry. / As L.E.R. (Lesões por Esforços Repetitivos) têm se mostrado comuns em diversas profissões que exigem a repetição do mesmo movimento diversas vezes ao longo do dia. Os profissionais mais afetados por esse mal são: operários em linhas de produção, operadores de caixas, donas de casa, Cirurgiões-Dentistas, entre outros. Também chamadas de DORT (Doenças Osteomusculares Relacionadas ao Trabalho) ou AMERT (Afecções Musculo-Esqueléticas Relacionadas ao Trabalho), estas lesões são causadas pelo uso repetitivo ou forçado de grupos musculares, ou postura inadequada. Os sintomas mais comuns são dores, sensação de formigamento, dormência, fadiga muscular, perda da força muscular em conseqüência de alteraçãoes nos tendões, musculaturas e nervos periféricos. Vários fatores acabam fazendo com que a vida pessoal e profissional seja muito afetada: sintomas intensos e crônicos, falta de uma política de prevenção e reabilitação por parte das empresas, diagnóstico tardio e tratamento inadequado, entre outros. Objetivo: O objetivo deste trabalho foi avaliar o grau de conhecimento dos Cirurgiões Dentistas de São José do Rio Preto acerca das doenças ocupacionais e melhorar o ensino na Graduação sobre enfermidades, de forma que os alunos futuramente previnam as mesmas. Casuística e Metodos: Os pesquisadores participantes do projeto foram aos consultórios odontológicos de São José do Rio Preto, e explicaram os objetivos da pesquisa, bem como o Termo de Consentimento Livre e Esclarecido. Fizeram a entrevista com o Cirurgião Dentista, através de um questionário, evitando assim que houvesse interferências ou leitura dos dados coletados por outras pessoas. A listagem dos consultórios foi obtida através do Conselho Regional de Odontologia Delegacia de São José do Rio Preto. O questionário abordou questões desde o conhecimento das enfermidades até o que o profissional faz para evitá-las. O questionário também teve por objetivo selecionar a amostra, identificando os dados necessários para a pesquisa. Resultados interessantes foram obtidos através da pesquisa, 42,85% dos participantes já tiveram alguma manifestação dolorosa nas articulações, o que pode ser indícios de lesão por esforço repetitivo e que quase 99% desses profissionais tiveram noções básicas de ergonomia na sua graduação, mas apenas 63,63% aplicaram em seu consultório. O projeto foi submetido ao Comitê de Ética, e os voluntários que concordaram em participar do estudo assinaram um termo de consentimento livre e esclarecido, conforme a resolução 196/96 do Conselho Nacional em Ética e Pesquisa do Ministério da Saúde.

INTRODUCÃO: A cirurgia de Fontan ou conexão cavo-pulmonar total é o último procedimento de uma estratégia estadiada, empregada no tratamento de cardiopatias congênitas complexas com ventrículo único anatômico ou funcional (também chamada de cardiopatia congênita com coração univentricular). Pacientes com um único ventrículo, situação incompatível com a vida, passaram a sobreviver até a idade adulta após a realização dessa cirurgia. A conexão direta da cavas com as artérias pulmonares, exclui do sistema circulatório o ventrículo subpulmonar, criando nesses indivíduos uma circulação do tipo univentricular. A falta do ventrículo subpulmonar e a subsequente ausência de fluxo sanguíneo pulsátil no pulmão, reduz o volume de enchimento do ventrículo único e consequentemente, o débito cardíaco. Mecanismos adaptativos do sistema periférico são desencadeados para garantir uma adequada redistribuição do fluxo sanguíneo para órgãos vitais, porém não são suficientes para garantir uma capacidade funcional adequada nesses indivíduos. Acreditamos que, uma análise detalhada dessas alterações e seus respectivos mecanismos adaptativos, possam contribuir na avaliação e entendimento dessa complexa fisiologia. A interferência nos componentes relacionados a baixa capacidade física, poderiam em teoria, modificar a história natural da doença nesses indivíduos, submetidos a cirurgia de Fontan. OBJETIVOS: 1. Comparar variáveis do sistema cardiovascular, pulmonar e músculo esquelético de pacientes com idade entre 12 e 30 anos, submetidos a cirurgia de Fontan com 5 anos ou mais de evolução pós-operatória com indivíduos saudáveis. 2. Correlacionar variáveis do sistema cardiovascular, pulmonar e músculo esquelético com a capacidade funcional no grupo de pacientes com cirurgia de Fontan. 3. Identificar as variáveis preditoras de baixa capacidade funcional nesta população. MÉTODOS: Estudo transversal, tipo caso-controle. Foram incluídos 30 pacientes no Grupo Fontan (GF) e 27 indivíduos saudáveis, que compuseram o grupo controle (GC). Os indivíduos foram submetidos à ressonância magnética cardiovascular, ecodopplercardiografia, teste de esforço cardiopulmonar, prova de função pulmonar completa, microneurografia direta no nervo fibular, pletismografia de oclusão venosa, dosagem plasmática de catecolaminas e peptídeo natriurético cerebral, teste de caminhada de seis minutos, espectroscopia de fósforo por ressonância magnética do quadríceps femoral, imagem musculoesquelética por ressonância magnética da musculatura da coxa e avaliação da qualidade de vida pelo questionário SF-36 (Short-Form Health Survey). Foram realizadas análises comparativas entre os grupos nos diferentes sistemas e posteriormente, testes para identificar os preditores de baixa capacidade funcional no GF. RESULTADOS: O consumo máximo de oxigênio (VO2 pico) no GF foi menor comparada ao GC, em valores absolutos, relativo ao peso corpóreo e em porcentagem do predito para sexo e idade. [1,65 (±0,54) vs 2,81 (±0,77) L/min p < 0,001]; [29,3 (±6,0) vs 41,5 (±9,2) mL/kg/min p < 0,001] e [70 (±14) vs 100% do predito (±20) p < 0,001] respectivamente. Os volumes e capacidades pulmonares foram significativamente menores no GF comparados ao GC, e demonstraram correlação positiva com o VO2 absoluto [capacidade vital forçada (CVF) r=0,836 p < 0,001; capacidade pulmonar total (CPT) r=0,730 p < 0,001 e capacidade de difusão do monóxido de carbono (DLCO) r=0,539 p=0,002], mas foram preditores de baixa capacidade funcional, a CVF (Constante= -0,306; B=0,393; IC=0,272-0,513 e p<0,001) e a DLCO (Constante= - 0,306; B=0,042; IC= 0,018-0,067; e p=0,002). O diâmetro da artéria pulmonar esquerda, também foi identificado como preditor de baixo VO2 (Constante=0,274; B=0,111; IC=0,061-0,161 e p < 0,001). E pela análise de periférica, a área seccional transversa da musculatura da coxa foi significativamente menor no GF, demonstrando ser mais um preditor de baixa capacidade funcional nesta população (Constante: 0,380; B=0,024; IC=0,018-0,030; p < 0,001). A atividade nervosa simpática muscular foi maior no GF [30 (±4) vs 22 (±3) disparos/min p < 0,001] e o fluxo sanguíneo muscular menor [1,59 (±0,3) vs 2,17 (±0,5) mL/min/100mL p < 0,001] comparados ao GC, porém estas variáveis não foram preditoras de baixa capacidade funcional. Em relação ao metabolismo oxidativo muscular, o GF apresentou menor amplitude de pico da fosfocreatina comparado ao GC [0,43 (0,41-0,45) vs 0,45 (0,42-0,50) p=0,023]. Porém essas alterações não se correlacionaram com o VO2 pico. CONCLUSÕES: Concluímos que a função pulmonar, o controle neurovascular e a capacidade funcional de pacientes com ventrículo único funcional, clinicamente estáveis, encontram-se comprometidas quando comparadas com indivíduos saudáveis. O menor diâmetro da artéria pulmonar esquerda, a capacidade vital forçada diminuída, a capacidade de difusão do monóxido de carbono comprometida e a área seccional transversa da musculatura da coxa reduzida foram os preditores de baixa capacidade funcional na população estudada / BACKGROUND: The Fontan operation or total cavo-pulmonary connection is the last procedure of a staged strategy, performed to treat complex congenital heart diseases in patients with a functional or anatomic single ventricle, also known as a univentricular heart. After the inception of the Fontan procedure, patients are surviving to adulthood due this remarkable technique. This operation, creates a direct connection of the superior and inferior vena cava with the pulmonary arteries, excluding the subpulmonary ventricle of the circulatory system an univentricular circulation. The lack of a subpulmonary ventricle and subsequent absence of pulsatile blood flow in the lungs, reduce the filling volume of the single ventricle and consequently the cardiac output. Although some adaptive mechanisms at the peripheral system are triggered to ensure an adequade blood flow to vital organs, they are not enough for an adequate functional capacity in these patients. A detailed analysis and evaluation of these changes and their respective mechanisms may contribute to understand this complex physiology. Hopefully, it might be possible to modify and improve the long term outcomes of these individuals. The aims of the study were: 1. To compare the variables of the cardiovascular, pulmonary and musculoskeletal systems in clinically stable Fontan patients with a control group. 2. To correlate the variables of the cardiovascular, pulmonary and skeletal muscle with the functional capacity in Fontan patients. 3. To identify predictors of low functional capacity in this population. METHODS: A prospective cross-sectional study of 30 FP of (20 +/- 6 years) and 10 (8-15) years of follow-up and 27 healthy controls (HC) (22 +/- 5years) was performed. They underwent cardiovascular magnetic resonance, echocardiography, cardiopulmonary exercise test, complete lung function, catecholamine and B-type natriuretic peptide (BNP) plasmatic levels, microneurography, venous occlusion plethismography, six-minute walk test, phosphorus magnetic resonance spectroscopy (31P MRS) and magnetic resonance imaging (MRI) of skeletal muscle and quality of life (QoL) using the Short Form Health Survey (SF36). Comparative analyzes of the different systems of two groups were done as well as tests to identify the predictors of low functional capacity in Fontan groups (FG). RESULTS: The maximal oxygen consumption (VO2) in the FG was lower compared to control group (CG), in absolute values, relative to body weight and percentage predicted for gender and age [1,65 (±0,54) vs 2,81 (±0,77) L/min p < 0,001]; [29,3 (±6,0) vs 41,5 (±9,2) mL/kg/min p < 0,001] e [70 (±14) vs 100% of the predicted value (±20) p < 0,001] respectively. Pulmonary volumes and capacities were also significantly lower in FG compared to CG, and demonstrated a positive correlation with absolute peak VO2 [Forced vital capacity (FVC) r=0,836 p < 0,001; total lung capacity (TLC) r=0,730 p < 0,001 and carbon monoxide diffusion capacity (DLCO) r=0,539 p=0,002]. But, the FVC and DLCO were predictors of reduced VO2 (Constant= -0,306; B=0,393; CI=0,272-0,513 e p < 0,001) and (Constant= -0,306; B=0,042; CI=0,018-0,067; e p=0,002) respectively. The diameter of the left pulmonary artery was also other of the predictors of low functional capacity (Constant=0,274; B=0,111; CI=0,061-0,161 e p < 0,001). Analyzing the volume of the thigh muscles, a significant difference between the groups was found, and the transversal sectional area of this muscle was a predictor of low functional capacity (Constant: 0,380; B=0,024; CI=0,018-0,030; p < 0,001). Muscle sympathetic nerve activity was higher in FG [30 (±4) vs 22 (±3) burst/min p < 0,001] and forearm blood flow was lower [1,59 (±0,3) vs 2,17 (±0,5) mL/min/100mL p < 0,001] compared with CG, however, these variables were not predictive of low functional capacity. Muscle oxidative metabolism showed difference in the intracellular pH value and the peak amplitude of phosphocreatine between the groups. The peak amplitude of phosphocreatine was lower in FG compared CG [0,43 (0,41-0,45) vs 0,45 (0,42-0,50) p=0,023] however, there were no correlation with the functional capacity. CONCLUSIONS: Pulmonary function, neurovascular control and functional capacity of clinically stable Fontan patients were impaired when compared to healthy subjects. Lower diameter of the left pulmonary artery, decreased forced vital capacity, impaired carbon monoxide diffusion capacity, and reduced transverse sectional area of the thigh musculature were the predictors of low functional capacity in the study population

Khoo, Chyi Chyi. / Thesis (M.Phil.)--Chinese University of Hong Kong, 2010. / Includes bibliographical references (leaves 177-204). / Abstracts in English and Chinese; appendix in Chinese. / Abstract(English version) --- p.i / Abstract(Chinese version) --- p.iii / Acknowledgements --- p.iv / List of Tables --- p.vii / List of Figures --- p.ix / List of Abbreviations --- p.x / Publications from this Thesis --- p.xi / Chapter Chapter 1 --- Introduction and Objectives / Chapter 1.1 --- Introduction --- p.1 / Chapter 1.2 --- Objectives --- p.3 / Chapter Chapter 2 --- Literature Review / Chapter 2.1 --- Definitions --- p.4 / Chapter 2.2 --- Epidemiology of Osteoporosis and Fracture --- p.5 / Chapter 2.3 --- Burden --- p.7 / Chapter 2.4 --- Osteoporosis in Men --- p.9 / Chapter 2.5 --- Risk factor of Osteoporosis --- p.11 / Chapter 2.6 --- Prediction of Osteoporosis --- p.13 / Chapter 2.7 --- Risk Factors of Osteoporotic Fracture --- p.15 / Chapter 2.8 --- Prediction of Fracture --- p.28 / Chapter 2.9 --- Difference between men and women --- p.29 / Chapter 2.10 --- DXA and Fracture --- p.31 / Chapter 2.11 --- QUS and Fracture --- p.32 / Chapter 2.12 --- pQCT and Fracture --- p.35 / Chapter 2.13 --- Self-report of Fracture --- p.37 / Chapter Chapter 3 --- Research Outline / Chapter 3.1 --- Non-spine fracture of older men --- p.39 / Chapter 3.2 --- Subjects --- p.40 / Chapter 3.3 --- Measurements of study --- p.41 / Chapter 3.4 --- Record of Fracture --- p.50 / Chapter 3.5 --- Statistical Methods --- p.51 / Chapter Chapter 4 --- Predictors of Non-spine Fracture of Hong Kong Elderly Chinese Men / Chapter 4.1 --- Introduction --- p.52 / Chapter 4.2 --- Subjects and Methods --- p.54 / Chapter 4.3 --- Results --- p.61 / Chapter 4.4 --- Discussions --- p.74 / Chapter 4.5 --- Conclusions --- p.80 / Chapter 4.6 --- Key Points --- p.81 / Chapter Chapter 5 --- Predictive values of QUS for non-spine fracture / Chapter 5.1 --- Introduction --- p.82 / Chapter 5.2 --- Subjects and Methods --- p.84 / Chapter 5.3 --- Results --- p.87 / Chapter 5.4 --- Discussions --- p.92 / Chapter 5.5 --- Conclusions --- p.97 / Chapter 5.6 --- Key Points --- p.98 / Chapter Chapter 6 --- Predictive values of pQCT for non-spine fracture / Chapter 6.1 --- Introduction --- p.99 / Chapter 6.2 --- Subjects and Methods --- p.101 / Chapter 6.3 --- Results --- p.103 / Chapter 6.4 --- Discussions --- p.109 / Chapter 6.5 --- Conclusions --- p.112 / Chapter 6.6 --- Key Points --- p.113 / Chapter Chapter 7 --- Accuracy of self-report of fracture in Asian elderly men / Chapter 7.1 --- Introduction --- p.114 / Chapter 7.2 --- Subjects and Methods --- p.115 / Chapter 7.3 --- Results --- p.116 / Chapter 7.4 --- Discussions --- p.118 / Chapter 7.5 --- Conclusions --- p.121 / Chapter 7.6 --- Key Points --- p.122 / Chapter Chapter 8 --- Conclusions / Chapter 8.1 --- Predictors of Non-spine Fracture of Hong Kong Elderly Chinese Men --- p.123 / Chapter 8.2 --- Predictive values of QUS for non-spine fracture --- p.124 / Chapter 8.3 --- Predictive values of pQCT for non-spine fracture --- p.125 / Chapter 8.4 --- Accuracy of self-report of fracture in Asian elderly men --- p.126 / Chapter 8.5 --- Strength and limitations --- p.127 / Chapter 8.6 --- Implications of the results --- p.129 / Chapter 8.7 --- Future research --- p.130 / Appendix A --- p.131 / Bibliography --- p.178

INTRODUCTION: Cerebral Palsy (CP) is a sensorimotor disorder characterized by dysfunctional motor coordination, balance problems, and loss of selective motor control. Motor coordination exhibited as co-contraction, has been subjectively quantified using gait analysis, but recent studies have begun to objectively analyze the amount of co-contraction by collecting electromyography (EMG) data. Center of pressure excursion (COPE) measurements collected during a single leg standing test (SLST) have shown to be more valid measurements of balance in populations with motor disabilities than a SLST alone. A recent study has correlated increased COPE velocity with a lower fall risk as determined by reported fall frequency, suggesting a more objective measure of fall risk. The current study aimed to determine if the fall risk calculated by COPE velocity in children with CP is correlated with co-contraction index value in various muscle synergy groups. It was hypothesized that i) co-contraction index values will differ between high and low fall risk groups, ii) there will be preferential activation of different synergy groups within the high and low fall risk groups, and iii) there will be a negative and direct correlation between COPE velocity and co-contraction index values for all synergy groups. METHODS: Fall risk grouping was determined by average COPE velocity values calculated from previously reported fall frequency groups. Balance ability was determined by COPE measurements during a SLST on a force plate. Muscle synergy groups were determined by common muscle pairings at the hip, knee and ankle. Co-contraction indices were determined from linear envelopes plotted from muscle group EMG data. An independent t-test was run on muscle synergy groups between high and low fall risk groups. Nonparametric Analysis of Variance (ANOVA) and Tukey post-hoc tests were run on the high and low fall risk groups separately to determine differences in co-contraction index value within high and low fall risk groups. A Pearson correlation analyzed COPE velocity and co-contraction index value. RESULTS: No significant differences in muscle synergy between the high and low fall risk groups were found (p = 0.476, 0.076, 0.064, 0.364). The ANOVA and Tukey post-hoc tests for high fall risk group found significant differences in co-activation index value between the sagittal hip and frontal hip groups (p = 0.022) and sagittal hip and ankle groups (p = 0.016). Low fall risk group was found to have significant differences between the sagittal hip and frontal hip groups (p = 0.038) and frontal hip and knee groups (p = 0.012). Weak and negative correlations were found between COPE velocity and both knee and ankle groups (r = -0.309, -0.323, p = 0.059, 0.050). Negligible and insignificant correlations were found between frontal hip and sagittal hip synergies and COPE velocity ((r = 0.013, -0.068, p = 0.475, 0.367). CONCLUSION: There is insufficient evidence to claim that muscle group activations are different depending on fall risk grouped by COPE velocity. It is not currently possible to correlate COPE velocity to a specific synergy group recruitment. However, data do suggest that sagittal hip and knee strategies are recruited more than ankle and frontal hip strategies during SLST.

Les médecins de famille, les pédiatres, les chiropraticiens et les physiothérapeutes sont parmi les professionnels de la santé les plus susceptibles de rencontrer des patients atteints d’une scoliose idiopathique adolescente. Les recherches démontrent que certaines lacunes existent à l’égard des connaissances acquises, par ces professionnels, dans le domaine musculosquelettique, incluant la scoliose. De plus, il ne semble pas exister d’informations sur le niveau de connaissances et la démarche clinique de ces professionnels en matière de scoliose, bien que les bonnes pratiques actuelles dictent une détection hâtive de cette condition pour en optimiser la gestion thérapeutique. Les objectifs de notre étude visaient donc à évaluer les connaissances ainsi que les aptitudes en matière de démarche clinique des professionnels les plus susceptibles à traiter des patients atteints d’une scoliose idiopathique adolescente. À l’aide d’un questionnaire semi-structuré, 51 professionnels de la santé ont été interviewés. Parmi ces professionnels recrutés par l'entremise de leur ordre professionnel respectif, on retrouvait 21 médecins de famille, 10 pédiatres, 10 chiropraticiens et 10 physiothérapeutes. Les entrevues évaluaient les connaissances en matière de signes cliniques, de facteurs de risque, de démarche clinique et de processus référentiel vers les soins spécialisés. De plus, les préférences des professionnels à l’égard des guides de bonne pratique ont été abordées. Parmi les professionnels interviewés, 59 % étaient des femmes, 43 % étaient âgés de moins de 40 ans et la moyenne d’années de pratique était de 20,3 ans. Les résultats démontrent qu’il existe des lacunes à l’égard des connaissances des signes cliniques et des facteurs de risque : moins du tiers des professionnels interviewés pouvaient mentionner au moins 2 signes cliniques et 31 % d’entre eux ne pouvaient se souvenir des facteurs de risque associés à la scoliose idiopathique adolescente; les médecins de famille étaient les moins connaissants dans ces domaines. De plus, en présence d’une mise en contexte nécessitant une référence urgente en soins spécialisés, 70 à 90 % des professionnels auraient référé le patient en dépit du fait que seulement 38 à 60 % d’entre eux considéraient cette situation comme urgente. Près de 40 % des professionnels mentionnaient qu’ils seraient inconfortables à gérer un patient atteint d’une scoliose. Néanmoins, la majorité d’entre eux reconnaissaient qu’il existe un problème en ce qui a trait à l’accessibilité aux soins spécialisés en orthopédiatrie. Presque la totalité c’est-à-dire, 98 % étaient favorables à la production de guides de bonne pratique et les accueilleraient positivement dans leur pratique quotidienne. Les conclusions de cette étude ont montré qu’il existe des vides en matière de connaissances de signes cliniques et de facteurs de risque de progression de la scoliose idiopathique adolescente; ces lacunes ont particulièrement été remarquées chez les médecins de famille. La majorité des professionnels reconnaissent l’importance de référer les conditions urgentes en soins spécialisés. Néanmoins, tous semblent souligner des difficultés dans ce processus référentiel. Une meilleure collaboration interprofessionnelle semble prometteuse en ce qui concerne la gestion de patients atteints d’une scoliose idiopathique adolescente. / Family physicians, peadiatricians, chiropractors and physical therapists are among health professionals most likely to encounter and treat patients with adolescent idiopathic scoliosis. Research shows that there are gaps in musculoskeletal knowledge among professionals but no studies assess knowledge of scoliosis among professionals most likely to treat patients with scoliosis. Best current practice dictates that early detection of adolescent idiopathic scoliosis leads to better decision-making regarding optimal course of management. The objectives of our study were to evaluate basic knowledge and the management skills of professionals most likely to encounter adolescent idiopathic scoliosis. We developed a semi-structured questionnaire and interviewed 51 health professionals. Among these professionals, who were recruited through their professional regulatory board registries, were 21 family physicians, 10 peadiatricians, 10 chiropractors and 10 physical therapists. The interview assessed knowledge of clinical signs and risk factors, management options, including referral to specialized care. We also discussed preferences and acceptability of clinical guidelines in regard to scoliosis. Among interviewed professionals, 59 % were female, 43 % were under 40 and mean years of practice was 20.3. Our results demonstrated gaps in knowledge with respect to clinical signs and risk factors. Less than a third of professionals were able to mention at least 2 clinical signs and 31 % were unaware of any risk factors associated with scoliosis progression. Family physicians appeared least knowledgeable in these areas. When presented with a situation where urgent referral was indicated, 70 – 90 % said that they would refer the patient although only 38 – 60 % rated this case as urgent. Close to 40 % of professionals indicated that they would not be comfortable doing the follow-up of a patient with a scoliosis. Nevertheless, the majority felt that accessibility to specialized care was a problem. Almost all (98 %) mentioned that the development of clinical guidelines would positively affect their daily practice. In conclusion, our study shows that knowledge gaps exist among professionals regarding clinical signs and risk factors of curve progression in adolescent idiopathic scoliosis. Most professionals recognize the importance of referring urgent cases to specialized care although there may be problems with access to peadiatric orthopedic specialists. Interprofessional collaboration may be a promising approach to improve management of patients with adolescent idiopathic scoliosis.

[Truncated abstract] Around 50,000 hip and knee replacements are performed every year in Australia and this number has been increasing by around 13% annually since 1998 (Transplantation Society 2006). The incidence and number of revision surgery has increased by a similar proportion. Autogenous bone or allograft is still the gold standard grafting material and is currently used in a variety of reconstructive surgical procedures. The use of any allograft material carries with it the risk of transfer of disease from donor to recipient. These tissues can transmit the same viral and bacterial infections as blood, and the products of a single donation may be transplanted to several recipients. In contrast to blood, musculoskeletal tissues may come from surgical and cadaveric donation. Overall, the prevention of infection relies on the maintenance of rigid protocols for procurement, donor and allograft testing, secondary sterilisation, and the adherence to internal safety standards within the tissue banks. This thesis aims to determine the risk of viral infection among musculoskeletal tissue donors in Australia. We retrieved and analysed data retrospectively from three large tissue banks in Australia (Perth, Queensland, Victoria). This includes 12,415 musculoskeletal tissue donors, 10,937 of which are surgical donors and 1,478 of which are deceased donors, for the period of 1993 -2004. This data was analysed to determine the prevalence and incidence of viral infections such as human immunodeficiency virus (HIV), hepatitis B virus (HBV), hepatitis C virus (HCV) and human T-lymphotropic virus (HTLV) in musculoskeletal allografts. The results indicate that the risk of viral infection from musculoskeletal tissue transplantation in Australia is low. ... The results indicate that the overall prevalence of screened transfusion-transmitted viral infections did not vary significantly for musculoskeletal donors over the study period, despite falling in the general population and first-time blood donors. In tissue donors, HIV incidence significantly decreased over time, and HBV decreased significantly during 1999-2001; however, there was an apparent increase in the estimated incidence of HCV in 2002-2004 compared with earlier years. Furthermore the residual risk estimate of HIV in the period 2002-2004 has declined 5-fold compared to estimates in the period 1993-1995. This is perhaps due to greater awareness of high risk behaviours among donors, improvement in donor recruitment and an overall decrease in infection levels in the general population. Musculoskeletal tissue is second only to blood as the most frequent transplanted human tissue. Viral infection is a potential complication of tissue transplantation. In this thesis the rates of HIV, HBV, HCV and HTV infection in musculoskeletal donors in Australia were identified and then compared with results in published data from Canada, Scotland and the United States. The study also compared that result with first-time blood donors because they have satisfied similar donor selection criteria (Galea et al. 2006). The results indicate that prevalence and incidence estimates for viral infection in Australian tissue donors are higher than those in blood donors. This was also reported in studies from other countries. Accordingly, it is crucial that viral prevalence and incidence be monitored to evaluate the safety of tissue supply and to improve donor selection processes.

[Truncated abstract] In this work a computer simulation program, similar to a finite element program, is used to study the relationship between skeletal tissue structure and function. Though other factors affect the shape of bone (e.g., genetics, hormones, blood supply), the skeleton adapts its shape mainly in response to the mechanical environment to which it is exposed throughout life. The specific relationship between the mechanical environment and the mechanical adaptation response of the skeleton is reviewed. Theories of mechanical adaptation are applied to the sites of tendon attachment to bone (entheses), the adaptation of generalised trabecular bone (i.e., Wolff’s Law of trabecular architecture), sesamoid bones that are often found where a tendon wraps around a bony pulley, and the internal trabecular structure of a whole bony sesamoid such as the patella. The relative importance of compression rather than tension in bone adaptation theories is still not fully understood. Some mechanical adaptation theories suggest that an overwhelming tensile stress at a skeletal location does not stimulate bone deposition, but would instead lead to bone resorption. The skeletal locations studied in this work were chosen because they have been proposed to be in tension. Computer simulations involving models are an ideal method to analyse the mechanical environment of a skeletal location. They are able to determine the mechanical stresses at, and the stress patterns around, complex biological situations. This study uses a two dimensional computer simulation program, Fast Lagrangian Analysis of Continua (Flac), to analyse the stress at the skeletal locations, and to test theories of mechanical adaptation over time by simulating physiological adaptation. The initial purpose of this study is to examine the stress in the skeletal tissue in generalised trabeculae, anatomical sites where a tendon wraps around a bony pulley, in the trabecular networks that fill the patella, and at tendon attachments. A secondary purpose, that follows directly from the first, is to relate the results of these initial stress analyses to existing and hypothetical skeletal tissue remodelling theories, to suggest how the complex skeletal structures might be generated solely in response to their mechanical environment. The term “remodelling” is used throughout this work to refer to mechanical adaptation of bone, usually at a surface of bone, rather than the internal regeneration of osteons (Haversion systems)