Conselho Nacional de Desenvolvimento CientÃfico e TecnolÃgico / O tratamento cirÃrgico da doenÃa hemorroidÃria pela Anopexia MecÃnica (AM), utilizando grampeador circular PPH de 33mm (Ethicon EndoSurgery) pode estar relacionado a lesÃo esfincteriana perianal, com repercussÃo no padrÃo evacuatÃrio. O objetivo deste estudo à avaliar a sensibilidade e complacÃncia retal em pacientes submetidos a esta tÃcnica operatÃria. Foram estudados 10 pacientes portadores de hemorrÃidas grau III ou IV sintomÃticas. Todos os pacientes foram avaliados prÃ-operatoriamante utilizando-se um barostato (Visceral Stimulator; Synetics Medical), com base em dois protocolos de pesquisa da sensibilidade retal: um contÃnuo (Ramp Test) e outro aleatÃrio (Random test), nos quais foram aferidas as diferentes reaÃÃes dos pacientes frente à distensÃo volumÃtrica de um balÃo retal sob controle de um "software" (Polygram for Windows; Medtronic), o que permitiu a reprodutibilidade do mÃtodo no pÃs-operatÃrio. Foram observadas a sensaÃÃo retal inicial (1a. sensaÃÃo), a sensibilidade evacuatÃria (2a. sensaÃÃo) e a sensibilidade a dor (3a. sensaÃÃo). ApÃs cirurgia os pacientes foram reavaliados ao final de 2, 4 e 6 meses. Utilizou-se um grupo controle de 10 pacientes portadores de doenÃa pilonidal sacro-coccÃgea, submetidos ao mesmo protocolo de avaliaÃÃo no prà e pÃs-operatÃrio, diferenciando-os do grupo cirÃrgico pela nÃo realizaÃÃo da anopexia mecÃnica. Foram aplicados os testes estatÃsticos de Pearson e t-student para a anÃlise dos estatÃstica dos resultados. Observou-se diminuiÃÃo dos valores de complacÃncia e sensibilidade retal ao final de 2 meses de pÃs-operatÃrio no grupo submetido a AM, para todas as sensaÃÃes pesquisadas, em ambos os protocolos de insuflaÃÃo do barostato. NÃo se observou diferenÃa entre a complacÃncia e sensibilidade retal observada nas avaliaÃÃes prÃ-operatÃria e aos quatro e seis meses no grupo submetido a AM, bem como em nenhuma das avaliaÃÃes realizadas no grupo controle. Conclui-se que a Anopexia MecÃnica causa uma diminuiÃÃo transitÃria da complacÃncia e sensibilidade retal aos dois meses de pÃs-operatÃrio, valores estes que se recuperam a partir do quarto mÃs pÃs-operatÃrio. / Post-graduation Course in Surgery (Strictu Sensu), Departament of Surgery, Medicine School, Federal University of Cearà (Master in Surgery Degree). 2005, September. Professor: Prof. Dr. Lusmar Veras Rodrigues Surgical treatment of haemorrhoids by Stapled Anopexy (SA), using a circular stapler PPH - 33mm (Ethicon EndoSurgery) may damage perianal muscle fibers, with changes In defecation pattern. The aim of this study was to evaluate rectal compliance and sensitivity in patients treated by SA. Ten patients with grade III or IV sintomatic haemorrhoids were elegible for this study. All patients were studied before surgery with a barostat (Visceral Stimulator; Synetics Medical), using two research protocols for rectal sensitivity: a continuous one (Ramp Test) and another one in steps (Random test), that could record patient's perception to volumetric distention of a rectal baloon, controled by a software (Polygram for Windows, Medtronic). This software made the method reproductible to all patients in the post-operative period. The barostat was able to record the first rectal sensation (1st. sensation), urge to defecate (2nd. sensation) and rectal pain (3rd. sensation). Patients were studied following the same protocol at two, four and six months after surgery. A control group of ten patients with pilonidal sinus disease was submitted to the same protocol, except for stapled anopexy. Statistical analysis was acomplished using Pearson and Student's t test. The study found a decrease in retal compliance and sensitivity of patients treated by stapled anopexy, during the second post-operative month evaluation, for all recorded sensations, to all distension protocols. There was no difference in rectal compliance and sensitivity between pre-operative and post-operative at four and six months evaluations for patients treated by stapled anopexy. There was no difference in rectal compliance and sensitivity for any patient in control group, for any sensation recordered, using any distension protocol. The conclusion was that stapled anopexy caused a transient decrease in rectal compliance and sensitivity at the second postoperative month, that returned to normal values at the fourth post-operative month.

O objetivo do trabalho foi avaliar a técnica de biópsia retal em equinos e as alterações histopatológicas encontradas na mucosa retal em animais clinicamente saudáveis e em animais com alterações do trato gastrintestinal. Foram utilizados 32 equinos divididos em três grupos: 10 animais clinicamente saudáveis (grupo 1), sete animais com alterações do trato gastrintestinal com diagnóstico estabelecido (grupo 2) e 15 animais com manifestações clínicas inespecíficas do trato gastrintestinal (grupo 3). Os equinos do grupo 1 foram biopsiados duas vezes, a segunda biópsia sendo realizada 48 horas após a primeira. As biópsias retais foram realizadas com os animais em estação, utilizando-se pinça de biópsia tipo jacaré. As amostras de mucosa retal foram coradas por hematoxilina-eosina (HE), azul de alciano com ácido periódico de Schiff a 2,5% e azul de toluidina. No grupo 1, não foram observadas diferenças significativas entre a primeira e a segunda biópsia, mas três equinos apresentaram pequenas alterações que podem ser decorrentes da palpação retal. Na primeira avaliação, sete animais desse grupo apresentaram padrão semelhante, permitindo estabelecer um padrão de normalidade histológica para a mucosa retal: epitélio superficial preservado; criptas uniformes e alinhadas perpendicularmente à superfície com grande número de células caliciformes com mucinas ácidas em maior quantidade; linfócitos intra-epiteliais na superfície do epitélio em número de até 15 linfócitos para cada 100 colonócitos; pequeno número de linfócitos, plasmócitos e eosinófilos infiltrando a lâmina própria e a submucosa. Os outros três equinos deste grupo apresentaram um aumento na intensidade das células inflamatórias (discreto a moderado na intensidade de linfócitos e plasmócitos na lâmina própria e submucosa, e moderado na intensidade dos eosinófilos na submucosa). Os equinos do grupo 2, todos com síndrome cólica, apresentaram as seguintes alterações histopatológicas: proctite linfoplasmocítica simples (4/7) e proctite eosinofílica (1/7). No grupo 3 (12 equinos com diarreia crônica e três com emagrecimento progressivo), apenas um animal apresentou mucosa retal com padrão de normalidade. Nos outros animais foram observadas: proctite linfoplasmocítica simples (6/15), proctite erosiva (3/15), proctite linfoplasmocítica com aumento de neutrófilos (2/15), proctite eosinofílica (2/15), proctite linfoplasmocítica com aumento de neutrófilos e eosinófilos (1/15) e infiltração por linfócitos atípicos/linfoma (1/15). Concluiu-se que: a técnica de biópsia retal avaliada é de fácil execução e segura; embora algumas alterações histológicas possam ser observadas na mucosa retal de equinos clinicamente saudáveis, causadas ou não por palpação retal, há um padrão de normalidade que deve ser usado para a avaliação de equinos com alterações gastrintestinais; apenas em alguns casos as alterações histológicas encontradas na mucosa retal em equinos permitem um diagnóstico definitivo, mas elas podem direcionar o raciocínio diagnóstico em outros, sendo este um importante exame complementar a ser indicado em casos de equinos com alterações gastrintestinais inespecíficas. / The purpose of this study was to asses the rectal biopsy techique in horses and the histopathological changes found in the rectal mucosa in clinically healthy animals and in animals with clinical signs of intestinal disorders. 32 horses were divided into three groups: 10 animals clinically healthy (group 1), seven animals with gastrointestinal disorders with an established diagnosis (group 2) and 15 animals with nonspecific clinical manifestations of the gastrointestinal tract (group 3). The horses in group 1 had two biopsies, the second biopsy was performed 48 hours after the first. Rectal biopsies were performed on the animals station, using alligator biopsy forceps. The samples of rectal mucosa were stained with hematoxylin end eosin (HE), alcian blue PAS pH 2.5% and toluidine blue. In group 1, no significant differences between the first and second biopsy were observed, but three horses showed small changes that may result from rectal palpation. In the first evaluation, seven animals of this group showed a similar pattern, establishing a standard of normality for histological rectal mucosa: Surface epithelial preserved; crypts of uniform length, diameter and perpendicular arrangement to the surface with acid mucins strongly dominated over neutral mucins in the goblet cell population; intraepithelial lymphocytes in the surface of the epithelium with sparse population of approximately 15 cells per stretch of 100 epithelial cells; sparse individual lymphocytes, plasma cells and eosinophils infiltrating the lamina propria and submucosa. The other three horses in this group had an increase in the intensity of inflammatory cells (mild to moderate in intensity of lymphocytes and plasma cells in the lamina propria and submucosa, and moderate intensity of eosinophils in the submucosa). The horses in group 2, all with colic syndrome, showed the following pathological changes: simple lymphocyticplasmacytic proctitis (4/7) and eosinophilic proctitis (1/7). In group 3 (12 horses with chronic diarrhea and three with progressive weight loss), only one animal showed rectal mucosa with normal histology. It was observed in the other animals: simple lymphocytic-plasmacytic proctitis (6/15), erosive proctitis (3/15), lymphocyticplasmacytic proctitis with increased neutrophils (2/15), eosinophilic proctitis (2/15), lymphocytic-plasmacytic proctitis with increased neutrophils and eosinophils (1/15) and atypical lymphocytes infiltration/lymphoma (1/15). It was concluded that: the rectal biopsy technique evaluated is effective and safe; although some histological changes can be observed in the rectal mucosa of clinically healthy horses, whether or not caused by rectal palpation, there is a normal range that should be used to the evaluation of horses with gastrointestinal disorders; only in some cases the histological changes found in the rectal mucosa in horses allow a definitive diagnosis, but they can lead to a diagnostic logic in others, which is an important complementary test to be indicated in cases of horses with nonspecific gastrointestinal disturbances.

Introduction: Assessment of heat strain is an alternative approach to assessing heat stress exposures. Two common measures of heat strain are body core temperature (TC) and heart rate (HR). In this study TC was assessed by rectal temperature (Tre). Physiological Strain Index (PSI) was developed to combine both Tre and HR into one metric. Data collected from progressive heat stress trials were used to (1) demonstrate that PSI can distinguish between Sustainable and Unsustainable heat stress; (2) suggest values for PSI that demonstrate a sustainable level of heat stress; and (3) determine if clothing or metabolic rate were effect modifiers. Methods: Two previous progressive heat stress studies included 494 trials with 988 pairs of Sustainable and Unsustainable exposures over a range of relative humidity (rh), metabolic rates (M) and clothing using 29 participants. To assess the discrimination ability of PSI, conditional logistic regression and logistic regression were used. The accuracy of PSI was assessed using Receiver Operating Characteristic curves (ROC). Results: The present study found that primary (Tre, HR, and Tsk) and derived (PSI and ΔTre-sk) HSMs can accurately predict Unsustainable heat stress exposures based on AUCs that ranged from 0.73 to 0.86. Skin temperature had the highest AUC (0.86) with PSI in the mid-range (0.79). The values of the HSMs associated with a predicted probability of 0.25 were considered as screening values (PSI < 2.6, ΔTre-sk > 1.9 °C, Tre < 37.5, HR < 109, and Tsk < 35.8). The value of using any one of these individual indicators is that they act as a screening tool to decide if an exposure assessment is needed. Metabolic rate was found to be a confounder for all the HSMs except for RTsk. It was not statistically significant for HSMs derived models (PSI and ΔTre-sk). And its effect modification was not significant in any model. Conclusions: Based on the ROC curve, PSI can accurately predict Unsustainable heat stress exposures (AUC 0.79). HR alone has a similar capacity to distinguish Unsustainable exposures (AUC 0.78) under relatively constant exposure (metabolic rate and environment) for an hour or so. Screening limits with high sensitivity, however, have low thresholds. This limits the utility of these heat strain metrics. To the extent that the observed strain is low, there is good evidence that the exposure is Sustainable.

Anal acoustic reflectometry (AAR) is a technique that is currently under investigation for the assessment of faecal incontinence. It uses reflected sounds waves to measure cross sectional area at different pressures leading to a profile of the anal canal, and in particular the high pressure zone of the anal sphincters. The cross sectional area from the high pressure zone is then plotted on a graph to give seven characteristic parameters. AAR has been shown to be reproducible and reliable, able to distinguish between continence and incontinence, correlate with the severity of incontinence and able to discriminate between the three patterns of incontinence (urge, passive and mixed). Opening pressure has been shown to be an independent predictor of success with peripheral nerve evaluation, the trial period before sacral nerve stimulation. This thesis aimed to validate AAR against manometry and explore its physiological and clinical potential. A retrospective analysis of 265 patients who had undergone AAR was undertaken in order to develop a surrogate marker for anal canal length. The surrogate marker did find the expected difference between men and women but this was not clinically significant. Furthermore, the surrogate marker was unable to differentiate between incontinence and continence. A technical limitation (Gibbs phenomenon) of AAR was subsequently shown to explain this unexpected result. Prior manometry could possibly interfere with the interpretation of AAR, and therefore a prospective randomised cohort study of 30 patients was conducted to assess two orders of data collection. Reassuringly it does not matter which one of these investigations is undertaken first. In order to test the hypothesis that the greater the challenge to the anal sphincter, the greater the response, the effect of two rates of anal canal stretch was investigated in a prospective randomised cohort study of 50 patients with faecal incontinence. No difference was found between normal or fast rates of AAR. This study has validated a faster method of AAR that can be used alongside manometry in any order. A pudendal nerve block was used to investigate whether AAR assesses primarily internal or external sphincter function in a prospective cohort study of 15 patients using both AAR and manometry. Bilateral pudendal nerve block reduced the function of the external anal sphincter but had no effect on the internal sphincter using both techniques. This study suggests that AAR at rest is predominately an investigation of the internal anal sphincter. A prospective study of 30 patients with faecal incontinence was carried out to establish if AAR can predict the outcome from posterior tibial nerve stimulation. Posterior tibial nerve stimulation improved rectal sensation, manometry squeeze pressures, quality of life, severity of incontinence and was more effective for patients with urge incontinence. A variety of demographic, clinical and physiological measures were unable to predict the success of posterior tibial nerve stimulation. The results presented in this thesis suggest that the full clinical potential of AAR has yet to be realised and it will be necessary to compare it with high resolution anal manometry in the future. Progress in this field would be greatly facilitated by establishing the normal values for this technique and the development of a robust AAR assessment of the external anal sphincter.

O objetivo deste estudo foi investigar a qualidade de vida do paciente com estoma intestinal secundário ao câncer cólon-retal na cidade de Aracaju-Se. Trata-se de estudo descritivo-exploratório, na vertente quantitativa, utilizando-se um instrumento contendo três partes, dados sócio-demográficos e clínicos, itens referentes à Escala de Qualidade de Vida de Flanagan (EQVF), e EORTC-QLQ-C-30. A amostra constou de 18 pacientes atendidos no Centro de Oncologia Dr Oswaldo Leite, localizado na cidade de Aracaju – Sergipe no período de janeiro a dezembro de 2005. Os instrumentos mostraram propriedades psicométricas satisfatórias quanto à consistência interna e validade do construto. Quanto às características sócio-demográficas e clínicas, 50% eram do sexo feminino, e 50% masculino. A média de idade foi de 51,3 anos. Quanto à localização do tumor, 38,9% tumor de reto, seguida de cólon-retal 33,3% e cólon 27,8%. 83,3% apresentavam metástase e 16,7% não apresentavam. Em relação ao tipo de estoma, 72,2% tinham colostomia definitiva e 27,8% colostomia provisória. 77,8% dos pacientes apresentaram menos de um ano de estoma e 22,2% mais de um ano de estoma. A análise de qualidade de vida da amostra mostra para EQVF média de 52,3 (DP=1,40) para EQVF Geral. Para EORTC QLQ-C30, a média estado geral de saúde foi de 35,64 (DP=12,39). Foram estatisticamente significativos os resultados obtidos nas escalas: relações com outras pessoas, atividades sociais e desenvolvimento pessoal e realização. Pacientes com menos de um ano de estoma, apresentam maior atividade social,desenvolvimento pessoal e realização do que aqueles com mais de um ano de estoma. Foram estatisticamente significativas as escalas: função física, dor, estado geral de saúde, dificuldades financeiras, dispnéia, fadiga, náusea e vômito, constipação e função emocional. A função física teve como variável estatisticamente significante o estado civil, com maior média entre pessoas casadas, assim como a escala dor, porém com maior média entre as pessoas viúvas. A função física entre as pessoas casadas foi maior. No sintoma dor, a presença desta, foi maior entre o grupo de pessoas viúvas e separadas. Na escala estado geral de saúde, foram estatisticamente significativos o sexo e complicações do estoma, com médias superiores entre aqueles do sexo masculino e com presença de complicações. Na escala dificuldades financeiras, a procedência e as complicações do estoma foram estatisticamente significantes. Com maiores médias entre aqueles da área rural e com presença de complicações do estoma. No sintoma dispnéia, a variável estatisticamente significante foi a presença ou não de metástase, com maior média entre aqueles com metástases. Já os sintomas fadiga, náusea e vômitos e constipação, apresentou como única variável estatisticamente significante o tempo de estoma. Na escala função emocional, a variável complicações do estoma foi estatisticamente significante, havendo maior média entre aqueles com presença de complicações do estoma. A escala relações com outras pessoas foi influenciada pelas variáveis: sexo, tempo de estoma e estado de origem, conforme cálculo de Regressão Linear Múltipla. As escalas função emocional, dispnéia, dificuldade financeira e estado geral de saúde tiveram influência das variáveis sexo, estado civil, estado de procedência, metástase, tempo de estoma e complicações. / The objective of this study was to investigate the quality of life of the patient with secondary intestinal estoma to the cancer colo-retal in the city of Aracaju-Se. This is an description-exploratory study, in the quantitative source, using an instrument contends three parts, given partner-demographic and clinical, itens referring to Scale of Quality of Life of Flanagan (EQVF), and EORTC QLQ-C30. The sample consisted of 18 patients taken care of in the Center of Oncologia Dr Oswaldo Leite located in the city of Aracaju - Sergipe in the period of January to December of 2005. The instruments had shown to satisfactory psicometrics properties such as the internal consistency and validity of construct. About the partner-demographic and clinical characteristics, 50% were of the feminine sex, and 50% masculine. The age average was 51,3 years. About the localization of tumor, 38,9% tumor of rectum, followed 33,3% colo-rectum and colon 27,8%. Metastase were presented by 83,3% and 16.7% didn’t present. In relation to the type of stoma, 72,2% had definitive colostomia and 27,8% provisory colostomia. 77,8% of the patients had presented less than 1 year of stoma and 22,2% more than 1 year of stoma. The analysis of quality of life of the sample shows for average EQVF of 52,3 (DP=1,40) for general EQVF. For EORTC QLQ-C30, the been average general of health was of 35,64 (DP=12,39). The scales had been statisticaly significant: social relations with other people, activities and personal development and accomplishment. Patients with less than one year of stoma, present greater social activity, personal development and accomplishment of that those with more than one year of stoma. The scales had been statistically significant: physical function, pain, general state of health, financial difficulties, dispneia, fatigue, nausea and vomit, constipation and emotional function. The physical function had as changeable statistically significant the civil state, with average greater between married people, as well as the scale pain, however with average greater between the people widowers. The physical function between the married people was bigger. In the symptom pain, the presence of this, it was bigger enters the group of people separate widowers and. In the scale general of health, the sex and complications of stoma had been statisticaly significant, with superior averages between those of the masculine sex and with presence of complications. In the scale financial difficulties, the origin and the complications of stoma they had been statisticaly significant. With average greaters between those of the agricultural area and with presence of complications of stoma. In the dispneia symptom, the statisticaly significant variable was the presence or not of metastase, with average greater it enters those with metastases. Already the symptoms fatigue, nausea and vomits and constipation, the stoma time presented as only statisticaly significant variable. In the scale emotional function, the variable complications of stoma was statisticaly significant, having bigger average between those with presence of complications of stoma. The scale Relations with other people was influenced by the variable: sex, time of stoma and state of origin, as calculation of Multiple Linear Regression. The scales emotional function, dispneia, financial difficulty and general state of health had had influence of the variable sex, civil state, state of origin, metastase, time of stoma and complications.

京都大学 / 新制・課程博士 / 博士(医学) / 甲第23075号 / 医博第4702号 / 新制||医||1049(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 川上 浩司, 教授 近藤 尚己, 教授 小川 修 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

Objective: Access to care is key to effective rectal cancer treatment. We hypothesized that ethnic/racial minorities living in high population density areas would have the greatest delays in cancer care compared to whites living in medium population density areas. Methods: Using 2004-2016 National Cancer DataBase data, we identified stage I-III patients with invasive rectal adenocarcinoma who underwent surgery. The data were analyzed by race/ethnicity (whites, blacks, or Hispanics) and population density (metropolitan or urban/rural). Multivariable ANCOVA was performed to evaluate the duration of time from diagnosis to surgery. Results: The study population consisted of 76,131 patients: 65,172 Non-Hispanic whites (NHW; 85.6%), 6,167 Non-Hispanic blacks (NHB; 8.1%), and 4,792 Hispanics (6.3%). Of these, 61,363 patients (80.6%) lived in metropolitan areas. Among direct-to-surgery patients, the greatest difference in mean time from diagnosis to surgery was 20.3 days (urban/rural NHW, 53.3 days, vs. metropolitan Hispanics, 73.6 days). Among patients receiving neoadjuvant therapy, the greatest difference in mean time from diagnosis to surgery was 18.8 days (urban/rural NHW, 136.9 days, vs. metropolitan NHB, 155.7 days). After multivariable adjustment for several socioeconomic and clinical factors, among direct-to-surgery patients, metropolitan Hispanics had a 16.5-day delay (95% CI 12.9-20.0) compared with urban/rural NHW. In patients receiving neoadjuvant therapy, metropolitan NHB had an 18.1-day delay (95% CI 16.1-20.0) compared to urban/rural NHW. Conclusion: The combination of high population density and racial/ethnic minority status was associated with delays in rectal cancer care that persisted after adjusting for other important factors. Understanding which populations are at risk and perceived obstacles to timely care will help inform interventions to minimize treatment access disparities.

京都大学 / 0048 / 新制・論文博士 / 博士(医学) / 乙第13032号 / 論医博第2114号 / 新制||医||1016(附属図書館) / 32990 / 横浜市立大学大学院医科学専攻 / (主査)教授 増永 慎一郎, 教授 坂井 義治, 教授 小川 修 / 学位規則第4条第2項該当 / Doctor of Medical Science / Kyoto University / DFAM

京都大学 / 0048 / 新制・課程博士 / 博士(医学) / 甲第21016号 / 医博第4362号 / 新制||医||1028(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 小西 靖彦, 教授 福田 和彦, 教授 松村 由美 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

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